Definition and Criteria for Diagnosing Cesarean Scar Disorder
Authors: Klein Meuleman Saskia J. M. , Murji Ally , van den Bosch Thierry , Donnez Oliver , Grimbizis Grigoris , Saridogan Ertan , Chantraine Frederick , Bourne Tom , Timmerman Dirk , Huirne Judith A. F. , de Leeuw Robert A. ,   CSDi Study Group, Barri Pere , Cok Tayfun , Grimbizis Grigoris , Clark Justin , Helmy-Bader Samir , Jurkovic Davor , di Spiezio Sardo Attilio , Tanahatoe Sandra , Rijken Marcus , Timmerman Dirk , Chantraine Frederic , Murji Ally , Tsuji Shuichiro , Timor Ilan , Connor Mary , Kaelin Agten Andrea , Laure Noel , Hehenkamp Wouter , Mashiach Roy , Sentilhes Loïc , Promorski Michal , Naji Osama , Manegold-Brauer Gwendolin , Morlando Maddalena , van den Bosch Thierry , Collins Sally , Zhang Jian , Donnez Olivier , Cohen Shlomi , Huirne Judith 
Published: March 2023

ImportanceApproximately 60% of women develop a uterine niche after a cesarean delivery (CD). A niche is associated with various gynecological symptoms including abnormal uterine bleeding, pain, and infertility, but there is little consensus in the literature on the distinction between the sonographic finding of a niche and the constellation of associated symptoms.ObjectiveTo achieve consensus on defining the clinical condition that constitutes a symptomatic uterine niche and agree upon diagnostic criteria and uniform nomenclature for this condition.Design, Setting, and ParticipantsA consensus based modified electronic Delphi (eDelphi) study, with a predefined Rate of Agreement (RoA) of 70% or higher. Experts were selected according to their expertise with niche-related consultations, publications, and participation in expert groups and received online questionnaires between November 2021 and May 2022.Main Outcomes and MeasuresDefinition, nomenclature, symptoms, conditions to exclude, and diagnostic criteria of an illness caused by a symptomatic uterine niche.ResultsIn total, 31 of the 60 invited experts (51.7%) participated, of whom the majority worked in university-affiliated hospitals (28 of 31 [90.3%]), specialized in benign gynecology (20 of 31 [64.5%]), and worked in Europe (24 of 31 [77.4%]). Three rounds were required to achieve consensus on all items. All participants underlined the relevance of a new term for a condition caused by a symptomatic niche and its differentiation from a sonographic finding only. Experts agreed to name this condition cesarean scar disorder, defined as a uterine niche in combination with at least 1 primary or 2 secondary symptoms (RoA, 77.8%). Defined primary symptoms were postmenstrual spotting, pain during uterine bleeding, technical issues with catheter insertion during embryo transfer, and secondary unexplained infertility combined with intrauterine fluid. Secondary symptoms were dyspareunia, abnormal vaginal discharge, chronic pelvic pain, avoiding sexual intercourse, odor associated with abnormal blood loss, secondary unexplained infertility, secondary infertility despite assisted reproductive technology, negative self-image, and discomfort during participation in leisure activities. Consensus was also achieved on certain criteria that should be met and conditions that should be excluded before making the diagnosis.Conclusions and RelevanceIn this modified Delphi study, a panel of 31 international niche experts reached consensus for the constellation of symptoms secondary to a uterine niche and named it cesarean scar disorder.