What could be causing pain above the Cesarean section (C-section) scar 3 months post-delivery?

Pain Above the C-Section Scar at 3 Months Postpartum

The most likely causes of pain above the cesarean scar at 3 months are adhesions between the abdominal wall and uterus (captive uterus syndrome), musculoskeletal pain from the surgical incision, or nerve entrapment, with adhesions being particularly important to consider given the chronic nature and location of symptoms. 1

Primary Differential Diagnosis

Adhesion-Related Pain (Most Important to Consider)

• Adhesions between the abdominal wall and uterus can cause severe chronic pelvic pain that appears in the early postoperative period and persists for months to years after cesarean section. 1
• This condition, termed "captive uterus syndrome," creates traction and fixes the uterus to the abdominal wall, causing pain specifically above the incision line. 1
• Physical examination typically reveals a subinvoluted uterus with a high fixed cervix. 1
• Ultrasound may show clues of adhesions manifested by points of traction and irregular uterine borders. 1

Musculoskeletal/Incisional Pain

• Musculoskeletal pain from sternotomy and surgical incisions is the most common cause of post-surgical chest/abdominal wall pain, affecting 7-66% of patients after major surgery. 2
• Post-surgical pain may be due to scar pain, nerve regeneration, or focal nerve injury due to ischemia or tissue trauma. 2
• Pain related to previous surgery is more common in patients who had postoperative infection or hematoma. 2

Nerve Entrapment

• Entrapment of the lateral cutaneous branch of intercostal nerves can lead to chronic abdominal wall pain that mimics intra-abdominal pathology. 2
• The nerve supply to the lower abdominal wall is from the anterolateral and anteromedial branches of the intercostal nerves, and irritation anywhere along their course can lead to pain. 2

Epidemiology and Risk Factors

Incidence of Persistent Pain

• Persistent pain one year after cesarean section occurs in 18% of women, which is significantly higher than the 10% rate after vaginal birth (OR 2.1,95% CI 1.2-3.7). 3
• Approximately 10-15% of women suffer chronic persistent pain after cesarean section. 4
• The incidence of moderate-severe acute postoperative pain after cesarean section is 78.4%. 5

Key Risk Factors

• Women who recall significantly more pain on the day after cesarean section are at higher risk for developing persistent pain. 3
• Previous history of chronic pain or back pain significantly increases risk (P=0.016 and P=0.013 respectively). 3
• Preoperative anxiety increases the risk of moderate-severe postoperative pain (OR = 1.60,95% CI: 1.22-2.30). 5
• Any chronic disease increases risk of persistent pain (P=0.016). 3

Diagnostic Approach

Initial Clinical Assessment

• Perform focused physical examination looking specifically for:
  • Fixed, high cervix on bimanual examination suggesting uterine adhesions 1
  • Point tenderness that is precisely localizable and reproducible 2
  • Signs of nerve entrapment (pain with specific movements or positions) 2

Imaging Studies

• Transvaginal ultrasound should be the first imaging study performed to evaluate for adhesions, looking for points of traction and irregular uterine borders. 1
• Ultrasound can reveal clues of adhesions that may not be apparent on physical examination alone. 1

When to Consider Surgical Evaluation

• Diagnostic laparoscopy should be considered when:
  • Pain is severe and persistent despite conservative management 1
  • Physical examination and ultrasound suggest adhesions 1
  • Other diagnoses such as endometriosis, pelvic inflammatory disease, or ovarian pathology need to be excluded 1

Management Strategy

Conservative Management First

• Multimodal analgesia with acetaminophen (650 mg every 6 hours or 975 mg every 8 hours) as first-line treatment. 2, 6
• Ibuprofen 600 mg every 6 hours for anti-inflammatory effect if not contraindicated. 2
• Minimize opioid use; reserve only for severe pain not controlled by non-opioid analgesics. 2

Definitive Treatment for Adhesions

• Laparoscopic adhesion lysis provides complete resolution of pain in patients with confirmed adhesive disease. 1
• All 10 patients in the captive uterus syndrome case series who underwent laparoscopic adhesion lysis or hysterectomy noted complete resolution of pain that lasted during follow-up of at least 5 years. 1

Critical Clinical Pitfalls to Avoid

Do Not Dismiss Persistent Pain as "Normal"

• Persistent severe pain at 3 months post-cesarean is NOT normal and requires thorough evaluation. 2
• The intensity of persistent pain is mild in only 55% of affected patients; it can be intense or unbearable in others. 3

Do Not Delay Evaluation

• Early postoperative period pain that persists beyond expected healing time (typically 2-6 weeks) warrants investigation. 1
• Waiting to see if pain resolves spontaneously can allow complications like adhesions to become more established. 1

Consider Multiple Etiologies

• Recognize that multiple pain mechanisms can coexist (adhesions plus nerve entrapment plus musculoskeletal pain). 2
• A negative ultrasound does not completely exclude adhesions, as diagnostic laparoscopy remains the gold standard. 1

Long-Term Implications

• Persistent pain after cesarean section can impair not only the ability of women to care for their child in the immediate postpartum period, but also their own well-being for a long period of time. 4
• Chronic pain may affect future pregnancies and delivery planning. 7
• Early identification and treatment of the underlying cause can prevent progression to chronic pain syndrome. 7