Banerjee, Amrita; Solda, Roberta; Ivan, Maria; Colley, Charlotte; Jurkovic, Davor; David, Anna L; Napolitano, Raffaele; (2026) A systematic review of transvaginal ultrasound assessment of cesarean scar characteristics and prediction of adverse obstetric outcomes. American Journal of Obstetrics & Gynecology MFM , 8 (1) , Article 101839. 10.1016/j.ajogmf.2025.101839. (In press).

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Abstract

OBJECTIVE: This study aimed to investigate the association between preconception and antenatal ultrasound characteristics of cesarean delivery scars and adverse obstetrical outcomes in subsequent pregnancies. DATA SOURCES: Literature searches were performed in MEDLINE, Embase, and Cochrane databases from inception to January 31, 2024. STUDY ELIGIBILITY CRITERIA: Eligible studies included studies that evaluated cesarean delivery scar and niche characteristics using transvaginal ultrasound during preconception and/or antenatally and described subsequent adverse obstetrical outcomes (placenta accreta spectrum, preterm birth, uterine dehiscence/rupture, and unsuccessful vaginal birth after cesarean delivery). METHODS: A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (International Prospective Register of Systematic Reviews registration number: CRD 42019121523). Of note, 2 reviewers independently screened records and assessed eligible articles. The quality of publication was assessed using the Cochrane Collaboration tool and Newcastle-Ottawa Scale. The data were summarized using descriptive statistics. RESULTS: In 19 included studies, the definition of niche, large niche, and cesarean delivery scar assessment timing varied widely. Scar visibility was reported to be between 78% and 100% in the first trimester of pregnancy and between 68% and 91% in the second trimester of pregnancy. The prevalence rates of niche detection were 65% to 97% before conception and 52% to 58% during pregnancy. Uterine dehiscence/rupture was the most common adverse outcome reported (13 studies) and was associated with a large niche, a higher niche depth-to-residual myometrial thickness ratio (≥0.785), a thin residual myometrial thickness, and a higher average decrease in residual myometrial thickness between the first and second trimesters of pregnancy. Owing to methodological study heterogeneity and insufficient description of definitions, optimal cutoffs could not be defined. Of note, 3 studies evaluated the screening for placenta accreta spectrum using first-trimester cesarean delivery scar characteristics. An exposed cesarean delivery scar above the cervicoisthmic canal with placental implantation over the scar or within the niche had high sensitivity (75.0%-100.0%) and negative predictive value (99.6%-100.0%) for placenta accreta spectrum. Of note, 1 study found that a low scar after full dilatation cesarean delivery (a scar within the cervix or <5.0 mm above the internal cervical os) was associated with an increased risk of shortening cervical length and/or spontaneous preterm birth (adjusted odds ratio, 12.7 [95% confidence interval, 4.5-36.0]; P≤.0001). CONCLUSION: This systematic review found that cesarean delivery scar characteristics are associated with adverse obstetrical outcomes, including uterine rupture/dehiscence, placenta accreta spectrum, and spontaneous preterm birth. Multicenter prospective studies using standardized cesarean delivery scar assessment are needed to establish predictive data for optimal management and pregnancy counseling.

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