Gestational diabetes mellitus as a risk factor for uterine scar defects (literature review)

Introduction. This literature review presents current views on the pathogenesis of uterine scar defects in patients with gestational diabetes mellitus.
The objective of this review was to summarize the literature on uterine scar status, delivery characteristics, and the postoperative course in patients with carbohydrate metabolism disorders, particularly gestational diabetes mellitus, from the perspective of the pathogenesis of this complication.
Materials and Methods. The review includes published data from the past 25 years. A literature search was conducted in Elibrary, Medline, Scopus, Web of Science, Google Scholar, PubMed, Wiley, and the Cochrane Library.
Results. The rate of cesarean section delivery in patients with gestational diabetes mellitus is significantly higher than the general population. Furthermore, carbohydrate metabolism disorders impair uterine scar formation by increasing inflammation, impairing adipocyte migration from the myometrium, and forming a coarse connective tissue scar. This is due not only to inflammatory changes but also to metabolic disturbances at the cellular level, as well as vascular disorders due to endothelial dysfunction. Gestational diabetes is not a direct contraindication to vaginal delivery in patients with a uterine scar, although the risk of uterine rupture in this category of patients is higher than in women without carbohydrate metabolism disorders. It is necessary to carefully consider the range of contraindications to labor induction, particularly macrosomia and obesity, as well as the risk of uterine dysfunction, which collectively worsen the prognosis for vaginal delivery. In the postpartum period, personalized prevention of inflammatory diseases and the formation of an inadequate uterine scar is essential.
Conclusion. A review of the literature revealed that most authors consider carbohydrate metabolism disorders as a risk factor for uterine scar insufficiency/incompetence. However, further research is needed to ensure safe delivery for both mother and fetus in patients with a uterine scar after a previous abdominal delivery and gestational diabetes.

1. Lapolla A., Dalfra M.G., Ragazzi E., De Cata A.P., Fedele D. New International Association of the Diabetes and Pregnancy Study Groups (IADPSG) recommendations for diagnosing gestational diabetes compared with former criteria: a retrospective study on pregnancy outcome. Diabet Med. 2011;28(9): 1074-1077. https://doi.org/10.1111/j.1464-5491.2011.03351.x

2. Dedov I.I., Krasnopol’skiy V.I., Sukhikh G.T. Russian National Consensus Statement on gestational diabetes: diagnostics, treatment and postnatal care. Diabetes mellitus. 2012;15(4):4-10. (In Russ.) https://doi.org/10.14341/2072-0351-5531

3. Negmatullaeva MN, Tuksanova DI, Nasyrova ShSh. Modern aspects of gestational diabetes mellitus: definition, risk factors. Russian Bulletin of Obstetrician-Gynecologist. 2025;25(2):35–41. (In Russ.). https://doi.org/10.17116/rosakush20252502135

4. Andreeva EN, Arbatskaya NYu, Arzhanova ON, Bashmakova NV, Borovik NV, Burumkulova FF, Gals­ tyan GR, Grigoryan OR, Grineva EN, Deryabina EG, Dedov II, Demidova IYu, Dreval AV, Esayan RM, Zazerskaya IE, Ibragimova LI, Kapustin RV, Lukanoskaya OB, Malgina GB, Melnichenko GA, Pertukhin VA, Putilova NV, Ragoszin AK, Radzinsky VE, Serov VN, Startseva NM, Tisleko AV, Fadeev VV, Khodzhaeva ZS, Shestakova MV, Shmakov RG, Yarygina TA. Clinical recommendations «Gestational diabetes mellitus» of the Russian ministry of Health. Version of the year 2024. Bulletin of reproductive health. 2025;4(1):12-24. (In Russ.). https://doi.org/10.14341/brh12758

5. Petrukhin VA, Burumkulova FF, Titova TV, Golovchenko MA, Kotov IuB. Prevalence of gestational diabetes in the Moscow Region: screening results. Russian Bulletin of ObstetricianGynecologist. 2012;12(4):81‑84. (In Russ.) URL: https://www.mediasphera.ru/issues/rossijskij-vestnik-akushera-ginekologa/2012/4/031726-61222012415 (19.05.2026)

6. Ushanova FO, Lobanova KG, Perekhodov SN. Gestational diabetes mellitus: peculiarities of course and pregnancy outcomes in real clinical practice. Medical Council. 2021;(7):184-191. (In Russ.) https://doi.org/10.21518/2079-701X-2021-7-184-191

7. Mittal R, Prasad K, Lemos JRN, Arevalo G, Hirani K. Unveiling Gestational Diabetes: An Overview of Pathophysiology and Management. Int J Mol Sci. 2025;26(5):2320. https://doi.org/10.3390/ijms26052320

8. Torres-Torres J, Monroy-Muñoz IE, Perez-Duran J, Solis-Paredes JM, Camacho-Martinez ZA, Baca D, Espino-Y-Sosa S, Martinez-Portilla R, Rojas-Zepeda L, Borboa-Olivares H, Reyes-Muñoz E. Cellular and Mol ecular Pathophysiology of Gestational Diabetes. Int J Mol Sci. 2024;25(21):11641. https://doi.org/10.3390/ijms252111641

9. Abell SK, De Courten B, Boyle JA, Teede HJ. Inflamma­ tory and Other Biomarkers: Role in Pathophysiology and Prediction of Gestational Diabetes Mellitus. Int J Mol Sci. 2015;16(6):13442-73. https://doi.org/10.3390/ijms160613442

10. de Mendonça ELSS, Fragoso MBT, de Oliveira JM, Xavier JA, Goulart MOF, de Oliveira ACM Gestational Diabetes Mellitus: The Crosslink among Inflammation, Nitroxidative Stress, Intestinal Microbiota and Alternative Therapies.Antioxidants (Basel). 2022;11(1):129. https://doi.org/10.3390/antiox11010129

11. Lekva T, Norwitz ER, Aukrust P, Ueland T. Impact of Systemic Inflammation on the Progression of Gestat ional Diabetes Mellitus. Curr Diab Rep. 2016;16(4):26. https://doi.org/10.1007/s11892-016-0715-9

12. Jensen LA, Chik CL, Ryan EA. Review of gestational diabetes mellitus effects on vascular structure and function. Diab Vasc Dis Res. 2016;13(3):170-82. https://doi.org/10.1177/1479164115624681

13. Bajaj HS, Ye C, Hanley AJ, Sermer M, Zinman B, Retnakaran R Biomarkers of vascular injury and endothelial dysfunction after recent glucose intolerance in pregnancy. Diab Vasc Dis Res. 2018;15(5):449-457. https://doi.org/10.1177/1479164118779924

14. Zhang Z, Zhang Y, Huang S, Li M, Li L, Qi L, He Y, Xu Z, Tang J.Influence of gestational diabetes mellitus on the cardiovascular system and its underlying mechanisms. Front Endocrinol (Lausanne). 2025;16:1474643. https://doi.org/10.3389/fendo.2025.1474643

15. Feleke BE, Feleke TE, Adane WG, Kassahun MB, Girma A, Alebachew A, Misgan E, Mekonnin AW, Guadie W, Engedaw HA, Gebeyehu M, Biadglegne F. Maternal and newborn effects of gestational diabetes mellitus: A prospective cohort study. Prim Care Diabetes. 2022;16(1):89- 95. https://doi.org/10.1016/j.pcd.2021.09.007

16. Muche AA, Olayemi OO, Gete YK. Effects of gestational diabetes mellitus on risk of adverse maternal outcomes: a prospective cohort study in Northwest Ethiopia. BMC Pregnancy Childbirth. 2020;20(1):73. https://doi.org/10.1016/j.pcd.2021.09.007

17. Olerich KLW, Souter VL, Fay EE, Katz R, Hwang JK. Cesarean delivery rates and indications in pregnancies complicated by diabetes. Matern Fetal Neonatal Med. 2022;35(26):10375-10383. https://doi.org/10.1080/14767058.2022.2128653

18. Budny-Wińska J., Zimmer-Stelmach A., Pomorski M. Impact of selected risk factors on uterine healing after cesarean section in women with single-layer uterine closure: A prospective study using two- and three-dimensional transvaginal ultrasonography. Adv Clin Exp Med. 2022;31(1):41-48. https://doi.org/10.17219/acem/142519

19. Doğru Ş, Ezveci H, Akkuş F, Yaman FK, Alp EC, Gezginç K.J Effects of diabetes mellitus and cervical changes on scar healing after cesarean section.Ultrason. 2024;24(99):1-7. https://doi.org/10.15557/jou.2024.0035

20. El-Monsif AA, Galal Mahran TH, Ebid Mansour AA, Alshehri A. Effect of pulsed high intensity laser therapy on delayed caesarean section healing in diabetic women. J Phys Ther Sci. 2018;30(4):570–575. https://doi.org/10.1589/jpts.30.570

21. Antila-Långsjö RM, Mäenpää JU, Huhtala HS, Tomás EI, Staff SM. Cesarean scar defect: a prospective study on risk factors. Am J Obstet Gynecol. 2018;219(5):458.e1-458. e8. https://doi.org/10.1016/j.ajog.2018.09.004

22. Tikhonova N, Milovanov AP, Aleksankina VV, Kulikov IA, Fokina TV, Aleksankin AP, Belousova TN, Mikhaleva LM, Niziaeva NV. Adipocytes in the Uterine Wall during Experimental Healing and in Cesarean Scars during Pregnancy. Int J Mol Sci. 2023;24(20):15255. https://doi.org/10.3390/ijms242015255

23. Zehravi M, Maqbool M, Ara I. Correlation between obesity, gestational diabetes mellitus, and pregnancy outcomes: an overview. Int J Adolesc Med Health. 2021;33(6):339-345. https://doi.org/10.1515/ijamh-2021-0058

24. Poblete JA, Olmos P. Obesity and Gestational Diab etes in Pregnant Care and Clinical Practice. Curr Vasc Pharmacol. 2021;19(2):154-164. https://doi.org/10.2174/1570161118666200628142353

25. Roman H, Robillard PY, Hulsey TC, Laffitte A, Kouteich K, Marpeau L, Barau G. Obstetrical and neonatal outcomes in obese women.West Indian Med J. 2007;56(5):421- 6. URL: https://pubmed.ncbi.nlm.nih.gov/18303754/ (19.05.2026)

26. Bernard C, Agostini A, Bretelle F, Blanc J, Netter A. Risk factors and influence of surgical technique on the risk of caesarean scar defect formation: A systematic review of the literature.J Gynecol Obstet Hum Reprod. 2025;54(1):102870. https://doi.org/10.1016/j.jogoh.2024.102870

27. Oliveira APV, Zaccara TA, Bernardi MDC, Paganoti CF, Mikami FCF, Francisco RPV, Costa RAD. Risk factors and primary indications for cesarean section in women with gestational diabetes mellitus according to Robson classification. Clinics (Sao Paulo). 2025;80:100705. https://doi.org/10.1016/j.clinsp.2025.100705

28. Belyaeva E.K., Startseva N.M., Markaryan N.M., Khamoshina M.B., Loginova E.V., Mikhaleva L.M., Biryukov A.E. Clinical and morphological parallels of the consistency of the uterine scar after cesarean section. Akusherstvo i ginekologiya: novosti, mneniya, obuchenie [Obstetrics and Gynecology: News, Opinions, Training. 2024; 12. Supplement: 13–9. https://doi.org/10.33029/2303-9698-2024-12-suppl-13-19 (in Markaryan N.M., Vandysheva R.A., Nizyaeva N.V., Gioeva Z.V., Mikhalev S.A., Khamoshina M.B., Mikhaleva L.M. Clinical and morphological assessment of uterine scars after caesarean section in patients with gynecological and extragenital diseases. Clin. exp. morphology (In Russ.). 2023;12(1):34–45. https://doi.org/10.31088/CEM2023.12.1.34-45

29. Saucedo AM, Macones GA, Cahill AG, Harper LM.Elective Induction of Labor following Prior Cesarean Delivery. Am J Perinatol. 2024;41(15):2033-2039. https://doi.org/10.1055/a-2310-9817

30. Familiari A, Neri C, Caruso A, Airoldi C, Barone-Adesi F, Zanconato G, Bolomini G, Presti F. Vaginal birth after caesarean section: a multicentre study on prognostic factors and feasibility. Arch Gynecol Obstet. 2020;301(2):509- 515. https://doi.org/10.1007/s00404-020-05454-0

31. Lyell DJ, Caughey AB, Hu E, Daniels K.Peritoneal closure at primary cesarean delivery and adhesions. Obstet Gynecol. 2005;106(2):275-80. https://doi.org/10.1097/01.AOG.0000171120.81732.4c

32. Martel MJ, MacKinnon CJ. Guidelines for vaginal birth after previous Caesarean birth. Clinical Practice Obstetrics Committee, Society of Obstetricians and Gynaecologists of Canada. J Obstet Gynaecol Can. 2005;27(2):164-88. https://doi.org/10.1016/s1701-2163(16)30188-8

33. Brill Y, Windrim R. Vaginal birth after Caesarean section: review of antenatal predictors of success. J Obstet Gynaecol Can. 2003;25(4):275-86. https://doi.org/10.1016/s1701-2163(16)31030-1

34. Herman HG, Kogan Z, Bar J, Kovo M. Trial of labor after cesarean delivery for pregnancies complicated by gestational diabetes mellitus. Int J Gynaecol Obstet. 2017;138(1):84-88. https://doi.org/10.1002/ijgo.12164

35. Marchiano D, Elkousy M, Stevens E, Peipert J, Macones G. Diet-controlled gestational diabetes mellitus does not influence the success rates for vaginal birth after cesarean delivery. Am J Obstet Gynecol. 2004;190(3):790-6. https://doi.org/10.1016/j.ajog.2003.09.068

36. Matsuo K, Shimoya K, Shinkai T, Ohashi H, Koyama M, Yamasaki M, Murata Y.J. Uterine rupture of cesarean scar related to spontaneous abortion in the first trimester. Obstet Gynaecol Res. 2004;30(1):34-6. https://doi.org/10.1111/j.1341-8076.2004.00152.x

37. Tao J, Mu Y, Chen P, Xie Y, Liang J, Zhu J. Pregnancy complications and risk of uterine rupture among women with singleton pregnancies in China. BMC Pregnancy Childbirth. 2022;22(1):131. https://doi.org/10.1186/s12884-022-04465-w

38. Zhan W, Zhu J, Hua X, Ye J, Chen Q, Zhang J. Epidemiology of uterine rupture among pregnant women in China and development of a risk prediction model: analysis of data from a multicentre, cross-sectional study. BMJ Open. 2021;11(11):e054540. https://doi.org/10.1136/bmjopen-2021-054540

39. Košir Pogačnik R, Krajec M, Batkoska M, Trojner Bregar A. Gestational diabetes and fetal macrosomia: a dissenting opinion. J Perinat Med. 2025;54(1):129-138. https://doi.org/10.1515/jpm-2025-0247

40. Ye W, Luo C, Huang J, Li C, Liu Z, Liu F. Gestational diabetes mellitus and adverse pregnancy outcomes: systematic review and meta-analysis. BMJ. 2022;377:e067946. https://doi.org/10.1136/bmj-2021-067946

41. Aboulfalah A, Abbassi H, El Karroumi M, Morsad F, Samouh N, Matar N, El Mansouri A. Delivery of large baby after cesarean section: role of trial of labor. Apropos of 355 cases.J Gynecol Obstet Biol Reprod (Paris). 2000;29(4):409-13. https://pubmed.ncbi.nlm.nih.gov/10844329/ (дата обращения 19.05.2026)

42. Chiu HY, Chen HH, Wang CW, Lu H, Wu CH, Yang CC, Lee SL, Cheng-Yen Lai J. The risks of emergency C-section, infant health conditions and postpartum complications in Taiwanese primiparous women with gestational diabetes mellitus: A propensity matched cohort study.Taiwan J Obstet Gynecol. 2024;63(6):880-886. https://doi.org/10.1016/j.tjog.2024.01.039

43. Fischer MB, Vestgaard M, Ásbjörnsdóttir B, Mathiesen ER, Damm P. Predictors of emergency cesarean section in women with preexisting diabetes.Eur J Obstet Gynecol Reprod Biol. 2020;248:50-57. https://doi.org/10.1016/j.ejogrb.2020.03.014

44. Al-Qahtani S, Heath A, Quenby S, Dawood F, Floyd R, Burdyga T, Wray S. Diabetes is associated with impairment of uterine contractility and high Caesarean section rate. Diabetologia. 2012;55(2):489-98. https://doi.org/10.1007/s00125-011-2371-6

45. Alves FCB, Oliveira RG, Reyes DRA, Garcia GA, Floriano JF, Shetty RHL, Mareco EA, Dal-Pai-Silva M, Payão SLM, Souza FP, Witkin SS, Sobrevia L, Barbosa AMP, Rudge MVC. Transcriptomic Profiling of Rectus Abdominis Muscle in Women with Gestational DiabetesInduced Myopathy: Characterization of Pathophysiology and Potential Muscle Biomarkers of Pregnancy-Specific Urinary Incontinence. Int J Mol Sci. 2022;23(21):12864. https://doi.org/10.3390/ijms232112864

46. Gam CMBF, Mortensen OH, Larsen LH, Poulsen SS, Qvortrup K, Mathiesen ER, Damm P, Quistorff B.Diabetes, myometrium, and mitochondria in pregnant women at term. Acta Diabetol. 2018;55(10):999-1010. https://doi.org/10.1007/s00592-018-1171-6

47. Zhou J, Zhang P, Tan Z, Li C, Yao L, He T, Hou H, Yin Y. Enhanced recovery after surgery in elective cesarean section patients with gestational diabetes mellitus does not lead to glucose-related maternal and neonatal complications.Front Endocrinol (Lausanne). 2024;15:1403754. https://doi.org/10.3389/fendo.2024.1403754

48. Lu J, Guo Y, Yang Z, Xie M, Zhang S, Li K, Yang J, Xue S, Xu D, Yan K, Liu Y. Calycosin-7-glucoside-Loaded Hydrogel Promotes Wound Healing in Gestational Diabetes Mellitus. ACS Appl Bio Mater. 2025;8(5):4186- 4199. https://doi.org/10.1021/acsabm.5c00290

49. Thabet AAE, Mahran HG, Ebid AA, Alshehri MA. Effect of pulsed high intensity laser therapy on delayed caesarean section healing in diabetic women. J Phys Ther Sci. 2018;30(4):570-575. https://doi.org/10.1589/jpts.30.570

50. Liu Y, Wang Y, Gao SH, Wu H, Zhang CY, Yao JL, Cai PX. Evaluation of risk factors for poor wound healing after cesarean delivery in patients with gestational diabetes mellitus: a retrospective study. BMC Surg. 2025;25(1):344. https://doi.org/10.1186/s12893-025-03086-2