Platelet-Rich Plasma in Postpartum Wound and Scar Repair: A Narrative Review of Clinical Evidence, Patient-Centered Outcomes, and Translational Challenges

Abstract

Platelet-rich plasma (PRP) is an autologous blood-derived product containing concentrated platelets and platelet-associated mediators involved in hemostasis, inflammation, angiogenesis, epithelialization, fibroblast activity, and extracellular matrix remodeling. In obstetric practice, cesarean abdominal wounds, perineal injury, pelvic floor trauma, and uterine scars represent distinct repair settings with different clinical consequences. This narrative review evaluates current evidence for PRP in postpartum wound and scar repair, with emphasis on patient-centered outcomes and the distinction between superficial abdominal healing and uterine scar remodeling. Evidence is most developed for cesarean abdominal wounds, where several small controlled studies and two recent meta-analyses suggest modest improvement in selected early wound and scar measures; postoperative pain intensity is not consistently reduced. Evidence for perineal repair is more heterogeneous: uncontrolled and case-based reports suggest feasibility, a small comparative study in severe perineal rupture suggests possible functional benefit, and a randomized trial of levator ani injury did not demonstrate improved muscle recovery. Uterine scar application remains exploratory and rests mainly on one small pilot trial. Changes in residual myometrial thickness or niche morphology are surrogate imaging findings and do not establish greater scar strength, improved fertility, lower uterine rupture risk, or safer subsequent pregnancy. Clinical translation is further limited by heterogeneity in PRP source, preparation, platelet dose, leukocyte content, activation, anatomical application site, outcome assessment, and follow-up. Better characterized products, indication-specific trials, patient-reported outcomes, and long-term reproductive follow-up are required before routine postpartum use can be recommended.

Introduction

Obstetric Wounds and Scars as women’s Health Outcomes

Cesarean delivery is among the most frequently performed obstetric operations worldwide, and global estimates show a continuing increase in cesarean section rates over recent decades.¹ The World Health Organization has emphasized that cesarean delivery is beneficial when medically indicated, but unnecessary cesarean section may expose women and infants to avoidable short- and long-term risks.² As cesarean delivery becomes more common, postoperative recovery, wound healing, scar quality, and long-term reproductive consequences have become increasingly relevant clinical outcomes.

Post-cesarean surgical site infection remains an important complication because it may delay recovery, prolong hospitalization, and increase healthcare costs.³ In a hospital-based case-control study, emergency cesarean delivery, pregestational obesity, blood transfusion during or after delivery, and signs of infection during labor were associated with increased risk of surgical site infection after cesarean delivery.⁴ These observations are clinically relevant because several of these factors overlap with broader host-related determinants of impaired wound healing, including metabolic disease, tissue oxygenation, infection, medication exposure, smoking, and nutritional status.⁵

Scar-related outcomes are increasingly recognized as part of postoperative recovery rather than merely cosmetic concerns. The Patient and Observer Scar Assessment Scale was developed to evaluate scar quality from both clinician and patient perspectives.⁶ A later review of scar assessment tools emphasized that scar evaluation should include appearance, pliability, symptoms, and patient-reported burden.⁷ These considerations are relevant after cesarean delivery because the abdominal scar may affect discomfort, pruritus, body image, and satisfaction with postpartum recovery.

Vaginal birth may result in spontaneous perineal tears, episiotomy wounds, and third- or fourth-degree perineal tears that require structured diagnosis, repair, and follow-up.⁸ Anal sphincter disruption during vaginal delivery is clinically important because it can lead to fecal urgency, anal incontinence, and long-term pelvic floor dysfunction.⁹ Severe perineal trauma can also affect sexual function, body image, and emotional well-being during the postpartum period.¹⁰ Perineal wound breakdown has been associated with wound infection and obstetric factors such as operative delivery and higher-grade lacerations.¹¹ A prospective cohort study further identified wound infection and dehiscence as clinically meaningful complications after obstetric perineal tears.¹² These findings support the need to evaluate postpartum perineal repair through pain, continence, sexual function, and quality of life, rather than anatomical closure alone.

Uterine Scar Remodeling and Reproductive Implications

The uterine incision after cesarean delivery represents a deeper repair site that is not adequately reflected by the appearance of the abdominal incision. A cesarean scar defect, also known as a niche or isthmocele, is commonly evaluated using transvaginal ultrasound parameters such as residual myometrial thickness and niche depth.¹³ A modified Delphi procedure proposed standardized sonographic assessment of uterine niches in non-pregnant women.¹⁴ A subsequent practical tutorial further emphasized reproducible measurement of niche depth, length, width, and residual myometrium in clinical research.¹⁵

Cesarean scar defects may be associated with postmenstrual spotting and other long-term gynecological symptoms.¹⁶ A systematic review and meta-analysis reported an association between cesarean scar defects and abnormal uterine bleeding.¹⁷ A European consensus study defined cesarean scar disorder as a symptomatic condition associated with a niche rather than as an ultrasound finding alone.¹⁸ Donnez emphasized that cesarean scar defects should be suspected in women with spotting, dysmenorrhea, pelvic pain, or infertility after cesarean delivery.¹⁹ Vissers et al proposed several mechanisms by which niche-related changes may contribute to impaired fertility, including retained blood, chronic inflammation, altered cervical mucus transport, and disturbed embryo implantation.²⁰ Uterine scar repair should therefore be considered a long-term reproductive issue rather than only an intraoperative closure problem.

Why PRP is Being Considered

Conventional obstetric wound management relies on surgical technique, tissue approximation, infection prevention, analgesia, wound hygiene, and follow-up. These measures remain essential, but they do not directly supply bioactive mediators that regulate the cellular phases of wound repair. Normal wound healing requires coordinated hemostasis, inflammation, proliferation, and remodeling.²¹ Classic wound-healing work has emphasized the challenge of achieving organized repair rather than excessive scarring in adult tissues.²² Wound repair also depends on interactions among epithelial cells, fibroblasts, endothelial cells, immune cells, and extracellular matrix components.²³ When these cellular programs are dysregulated, repair may be delayed or progress toward chronic inflammation and pathological scarring.²⁴

PRP is being explored because platelets release mediators involved in hemostasis, inflammation, angiogenesis, epithelialization, and tissue remodeling.²⁵ In obstetrics, this biological rationale is relevant to cesarean wounds, perineal trauma, postpartum wound dehiscence, and uterine scar remodeling. The current evidence, however, is uneven. Cesarean wound healing has the most direct clinical evidence, whereas perineal and uterine scar applications remain early-stage indications. This distinction is important because postpartum tissue repair involves several anatomically and biologically different tissue targets rather than a single wound type.

Literature Search Strategy

We searched PubMed/MEDLINE, Web of Science, Scopus, and ClinicalTrials.gov from database inception to August 31, 2026. The core search combined platelet-product terms with terms for postpartum tissue injury and scar repair: (“platelet-rich plasma” OR PRP OR “platelet concentrate”) AND (cesarean OR caesarean OR postpartum OR perineal OR episiotomy OR “wound dehiscence” OR “uterine scar” OR niche OR isthmocele OR “scar healing” OR “wound healing”). Database-specific variants and spelling alternatives were used where appropriate. Reference lists of eligible primary studies and recent reviews were hand-searched, and registry records were cross-checked when trial identifiers were available.

We prioritized clinical studies in which PRP was applied during or after cesarean delivery, perineal repair, postpartum wound dehiscence, pelvic floor injury, or uterine scar treatment. Randomized trials, non-randomized comparative studies, prospective observational studies, case reports, systematic reviews, consensus statements, and registered trials were considered when directly relevant to the review question. General wound-healing, scar, and PRP-methodology studies were retained only when they informed biological rationale, outcome assessment, product characterization, or safety. Studies focused on fertility treatment, ovarian rejuvenation, or non-obstetric PRP indications without direct relevance to tissue repair were excluded from the clinical evidence synthesis. Retracted publications were excluded from efficacy assessment, and trial registrations were treated as evidence of study activity or protocol details rather than clinical benefit. Titles and abstracts were screened for relevance, followed by full-text review of potentially eligible reports. Because this was a narrative review, we did not perform a protocol-driven dual-reviewer selection process or formal risk-of-bias meta-analysis; study limitations were instead appraised qualitatively and are summarized in Table 1.

Table 1.

Primary Clinical Evidence for Platelet-Rich Plasma in Postpartum Wound, Perineal, Pelvic-Floor, and Cesarean Scar Repair

Study/Design/Sample	Comparator/Blinding	PRP Preparation/Characterization	Application/Follow-Up	Outcomes/Main Findings	Critical Appraisal
A. Cesarean abdominal wound and postoperative scar outcomes
Tehranian et al, 201626 Randomized controlled trial; 140 enrolled/randomized as reported; 138 analyzed (67 PRP, 71 control)	Usual care with saline irrigation Outcome assessor blinding reported	Maternal autologous PRP Blood ~55 mL; citrate anticoagulant Single spin: 3200 rpm, 15 min Final PRP: 4–5 mL; sodium-bicarbonate buffered Platelet count/dose, leukocytes, RBC contamination: NR	Applied to subcutaneous wound tissue before skin closure; single intraoperative application Follow-up: day 1, day 5, 8 weeks	Primary: REEDA Secondary: VSS, VAS REEDA and VSS improved more with PRP; pain scores also decreased over follow-up	Single center; heterogeneous high-risk population; 2 participants not included in final analysis PRP cellular composition/delivered platelet dose not quantified 8 weeks is short for mature scar assessment
Wanas et al, 201727 Randomized 3-arm controlled study; n=90 (30/group), high-risk cesarean delivery	PRP/fibrin gel activated with CaCl2 vs PRP/fibrin gel activated with medical ozone vs control Randomization method and blinding: NR	Maternal autologous PRP + autologous fibrin gel Blood ~50 mL with 3.8% citrate + 10 mL for autologous thrombin Spins: 704×g 3 min, then 1252×g (reported with inconsistent timing); ~5 mL PRP + 15 mL PPP Activation: 10% CaCl2 or ozone Platelet/leukocyte/RBC counts: NR	PRP injected subcutaneously; PPP/fibrin preparation applied to subcutaneous wound site Follow-up: days 1, 7, 21	REEDA, VSS, VAS Both active groups generally outperformed control; ozone-activated arm reported greater improvements on several time points	Intervention combines PRP with fibrin gel and activation strategy, so effect of PRP alone cannot be isolated Randomization/blinding details limited; no platelet-dose characterization Short follow-up
Kamel, 201828 Reported randomized controlled study; n=120 diabetic women (60/group)	Standard cesarean closure/care Randomization method and blinding: NR	Maternal autologous PRP Blood 30 mL in anticoagulant tubes Spins: 1200 rpm 12 min, then 3300 rpm 7 min Lower fraction homogenized; 5 mL PRP used No exogenous activator specified Platelet/leukocyte/RBC counts: NR	Spread/injected subcutaneously before skin closure; single application Follow-up: days 1, 7, 30	Primary: REEDA, VSS; secondary: VAS More inflammatory signs in PRP group on day 1, followed by better wound/scar scores later; wound gapping reported only in control	Internal reporting inconsistency (“30 in each group” vs 60/group) Randomization/blinding poorly described; no cellular PRP characterization Author notes variable PRP yield/laboratory processing; single-center study
Barwijuk et al, 202429 Single-blind randomized placebo-controlled study; n=46 (23/group)	0.9% NaCl placebo Participants blinded; allocation concealment with opaque envelopes	Maternal autologous activated PRP Blood 24–30 mL Separator-gel system; single spin 1500×g 5 min Final PRP ~8–10 mL; thrombin activation Platelet recovery 90±5%; PDGF-AB 140±14 ng/mL Cell counts/leukocytes/RBCs: NR	Microinjections into abdominal fascia and subcutaneous tissue during closure; single application Pain: immediate, 6 h, 12 h; scar: days 8, 30, 90	Planned primary outcome: wound dehiscence (none occurred) POSAS favored PRP; VAS pain intensity not significantly different Paracetamol use was lower; SF-12 similar	Small sample with zero primary events Analgesic consumption must not be equated with lower pain intensity No standardized platelet/leukocyte cell counts
Thanachaiviwat et al, 202430 Randomized controlled trial; 60 allocated, 52 analyzed (26/group)	Standard closure/control Masking did not use a sham PRP procedure	Cord-blood PRP (biologically distinct from maternal autologous PRP) Cord blood 30 mL; ACD anticoagulant Spins: 250×g 12 min, then 1000×g 3 min CaCl2 activation (PRP:CaCl2 10:1); final PRP 5 mL Measured platelets ~288,916→579,250/µL (~2.03-fold)	4 mL subcutaneous + 1 mL to surgical wound before skin closure; single application Follow-up: days 1, 3; 8 weeks	REEDA, VSS, VAS Better early REEDA and 8-week VSS with cord-blood PRP No significant VAS pain reduction	Cord-blood PRP cannot be assumed equivalent to maternal PRP Attrition from 60 allocated to 52 analyzed; small sample and short follow-up Leukocyte content and total delivered platelet dose incompletely reported
Brezeanu et al, 2025 (RCT)31 Single-center, single-blind randomized pilot; n=100 (50/group)	Standard care/no PRP Computer-generated 1:1 randomization; sealed opaque envelopes Outcome assessors not blinded; statistician blinded	Maternal autologous PRP Blood 20 mL Single spin: 4000 rpm 7 min Final PRP ~10 mL; no exogenous activator reported Platelet concentration/dose, leukocytes, RBCs: NR	5 mL along uterine incision margins before hysterorrhaphy + 5 mL subcutaneously before skin closure Follow-up: days 7 and 40	POSAS, VSS, MSS, REEDA, VAS/NRS Favorable trends in several scar scores; patient POSAS significantly lower at day 40 No treatment-related adverse events reported	Pilot/short follow-up; unblinded outcome assessment PRP applied to two anatomical sites, but outcomes focused on abdominal scar; no uterine imaging Cannot infer uterine scar integrity or reproductive safety
Brezeanu et al, 2025 (observational)32 Prospective single-arm pilot; n=50	No concurrent control	Maternal autologous PRP Blood 20 mL; 3.2% sodium citrate Double spin: 1600 rpm 10 min + 3500 rpm 7 min Reported final PRP yield ~6–8 mL; no commercial kit Platelet concentration/dose, leukocytes, RBCs: NR	Article describes uterine-incision-margin and subcutaneous application; administration described as 5 mL + 5 mL Follow-up: days 7 and 40	POSAS, VSS, MSS, REEDA, VAS/NRS Scar and pain scores improved between day 7 and day 40	No control: natural healing cannot be separated from PRP effect Internal inconsistency between reported final yield (~6–8 mL) and described total administered volume (10 mL) Short follow-up; multilayer treatment
B. Perineal wound, chronic perineal scar, and pelvic-floor injury
Soliman, 201933 Uncontrolled observational study; n=210 postpartum women	No comparator; blinding: NR	Maternal autologous PRP Blood 8–9 mL Centrifugation: 5 min (force/speed NR) Final PRP ~4.5–5 mL Platelet/leukocyte/RBC composition and activation: NR	Injected into subcutaneous and subvaginal tissues after vaginal/perineal repair; application schedule incompletely described	“Vaginal tear recovery”/clinical healing reported; authors described uniformly favorable recovery	Very high risk of bias: uncontrolled observational design, poorly defined outcomes/follow-up, no standardized effect estimates PRP product incompletely characterized; claims cannot establish efficacy
Akhoundova et al, 202234 Case report; postpartum perineal wound dehiscence	No comparator Concomitant irrigation, antibiotics, sterile honey and analgesia	Autologous PRP fibrin glue (RegenKit-Surgery) Two citrate PRP tubes (~10 mL blood each); ~5 mL PRP/tube (~10 mL total) Activated at application with autologous thrombin serum + 10% calcium gluconate Platelet dose: NR	Single ~10 mL fibrin-glue application to wound edges and bed; office procedure Weekly follow-up; complete healing ~3 weeks; pain resolved by day 30	Favorable wound closure and symptom recovery	Single case; concurrent antibiotics/honey/irrigation and natural healing confound attribution No standardized comparator; no long-term functional outcome
Kabakcı and Bozkır, 202135 Case report; chronic symptomatic second-degree episiotomy scar	No comparator	Maternal autologous PRP (VACUSERA PRP Tube Set) Blood 10 mL Spin: 5000 rpm 5 min Final volume, platelet dose, leukocytes/RBCs, activation: NR	Injected into right lateral vaginal wall Three sessions at 3-week intervals Assessments through week 9	VAS pain 10→2; VSS 12→4 by final assessment	Single chronic case (~10-year symptom history); no comparator Placebo/regression-to-mean effects cannot be excluded PRP composition and injected dose not reported
Moegni et al, 202236 Prospective single-blind randomized controlled trial; 58 analyzed	Control: 1% lidocaine infiltration Participants, outcome examiners and birth assistants blinded; injectors not blinded	Maternal autologous PRP Blood ~40 mL (8×5-mL tubes) First spin: 3000 rpm 10 min; second high-speed spin: 10 min (rpm NR) ~5 mL PRP prepared; platelet/leukocyte/RBC characterization not reported sufficiently for classification	5–10 mL injected at three sites: bilateral levator ani origin/insertion + perineorrhaphy area; single treatment Follow-up: 40 days and 3 months	Primary: levator hiatal area and muscle strength No significant between-group improvement at 3 months No infection/allergy reported	Pelvic-floor muscle injury is distinct from superficial perineal wound healing Only 58 of a much larger recruited cohort were eligible/analyzed; short follow-up PRP cellular composition and exact second-spin speed not reported
Kurniawati et al, 202637 Comparative post-test-only study; grade III–IV perineal rupture; n=30 (15/group)	Standard repair/control; group assignment described by odd/even drawing Participant masking reported	Maternal autologous PRP Blood 30 mL; ACD anticoagulant Spins: 1500 rpm 6 min, then 2500 rpm 15 min Final delivered volume and platelet/leukocyte/RBC composition: incompletely reported	Intramuscular injection in repaired perineum/anal-sphincter region; single adjunct Follow-up: 8 weeks	Wound defect, Wexner score, resting tone, squeeze score No wound defects in either group; continence/sphincter-tone measures favored PRP	Small two-center study; post-test-only design; short follow-up Several outcomes are examiner-dependent; activity/nutrition/hygiene not fully controlled PRP dose/composition incompletely reported
C. Uterine incision and cesarean scar morphology
Chaichian et al, 202238 Randomized double-blinded placebo/control pilot; 40 included, 30 analyzed (15/group)	Routine uterine closure/no PRP Computer-generated blocked randomization; sequential coded envelopes Radiologist blinded; surgeon not blinded	Maternal autologous PRP Blood 8.5 mL + 1.5 mL anticoagulant Double spin: 1600 rpm 10 min + 3500 rpm 6 min Final PRP ~2–3 mL; no exogenous activator reported Platelet/leukocyte/RBC counts: NR	After uterine closure, injected along upper/lower hysterotomy between decidua and myometrium; single application TVUS follow-up: 12 weeks	Primary imaging outcomes: niche frequency/height, RMT, AMT Lower niche frequency/height and greater RMT reported; AMT similar	Very small pilot with attrition; 12-week imaging only RMT/niche are surrogate outcomes, not scar tensile strength or reproductive safety Published niche-rate P value (2/15 vs 7/15 reported P=0.002) is not readily reproducible from displayed counts and warrants caution

Notes: Only primary clinical studies are shown. Systematic reviews/meta-analyses are discussed in the manuscript text. Retracted publications were excluded. Study-design labels reflect the original reports; the final column provides critical appraisal of important reporting and interpretive limitations.

Abbreviations: AMT, adjacent myometrial thickness; ACD, acid citrate dextrose; CaCl2, calcium chloride; MSS, Manchester Scar Scale; NR, not reported; NRS, Numeric Rating Scale; PDGF-AB, platelet-derived growth factor AB; POSAS, Patient and Observer Scar Assessment Scale; PPP, platelet-poor plasma; PRP, platelet-rich plasma; RBC, red blood cell; REEDA, redness, edema, ecchymosis, discharge, approximation; RMT, residual myometrial thickness; VAS, Visual Analog Scale; VSS, Vancouver Scar Scale.

Biological Basis of PRP in Postpartum Tissue Repair

PRP Composition and Biological Activity

PRP is generally defined as a plasma fraction containing a platelet concentration above baseline whole-blood levels.³⁹ Activated platelets release growth factors, cytokines, chemokines, adhesive proteins, and coagulation-related molecules.⁴⁰ These mediators include platelet-derived growth factor, transforming growth factor-beta, vascular endothelial growth factor, epidermal growth factor, fibroblast growth factor, and insulin-like growth factor.⁴¹ Platelet-derived mediators participate in fibroblast recruitment, endothelial proliferation, epithelial migration, collagen deposition, and matrix remodeling.²⁵

The fibrin component of PRP provides a provisional matrix that may support local retention of bioactive molecules and cellular migration.⁴² PRP-derived extracellular vesicles have also been proposed as mediators of intercellular communication in regenerative medicine.⁴³ Direct evidence for PRP-derived extracellular vesicles in cesarean, perineal, or uterine wound repair is not yet available. Their relevance to postpartum repair should therefore be viewed as mechanistic rather than clinical.

PRP is Not a Uniform Product

A central limitation of PRP research is that PRP is not a single standardized intervention. Preparation methods differ in blood volume, anticoagulant, centrifugation protocol, platelet recovery, leukocyte concentration, red blood cell contamination, activation method, and final volume.⁴⁴ These differences can alter the biological composition and clinical effect of the final PRP product.

The platelet, activation, and white blood cell (PAW) classification system categorizes PRP according to platelet number, activation method, and white blood cell content.⁴⁵ The dose, efficiency, purity, and activation (DEPA) classification emphasizes the dose of injected platelets, efficiency of production, purity of PRP, and activation status.⁴⁶ The MARSPILL classification incorporates additional variables such as preparation method, red blood cell content, spin protocol, leukocyte content, and activation approach.⁴⁷ These classification systems were not developed specifically for obstetrics, but they are useful reminders that obstetric PRP studies should report product characteristics rather than using PRP as a generic term.

Commercial preparation systems may yield PRP products with different platelet and leukocyte concentrations.⁴⁸ Inter-individual variability can further influence PRP composition even when the same preparation system is used.⁴⁹ Sex-related differences in PRP biochemical composition have also been reported, although the implications for pregnant and postpartum women are not established.⁵⁰ Platelet and growth-factor quantification studies further support the view that PRP dose and composition should be reported rather than assumed.⁵¹ These issues are particularly relevant because pregnancy and the postpartum period involve changes in coagulation, platelet activity, vascular physiology, and inflammatory balance.

Activation, Leukocyte Content, and Release Kinetics

PRP activation affects both the physical form of the product and the release kinetics of bioactive mediators. Roh et al showed that cytokine-release profiles differ according to activation protocol.⁵² Cavallo et al reported that calcium chloride, thrombin, calcium chloride plus thrombin, and collagen type I activation generate different growth factor release patterns.⁵³ These findings matter because obstetric studies have used different activation methods or failed to report activation details.

Leukocyte content is another important variable. Leukocyte-rich PRP may increase antimicrobial and immune-related activity, but it may also increase inflammatory cytokine exposure. Leukocyte-poor PRP may be preferable when the goal is controlled inflammation and scar quality, but this assumption has not been adequately tested in postpartum wound repair. Future obstetric trials should report leukocyte concentration rather than assuming that all PRP preparations are interchangeable.

Extracellular Matrix Remodeling and Scar Formation

Extracellular matrix remodeling is central to the transition from early wound closure to mature scar formation. Xue and Jackson emphasized that abnormal extracellular matrix reorganization, particularly disordered collagen remodeling, contributes to abnormal scarring.⁵⁴ Marshall et al described cutaneous scarring as the expected outcome of adult wound repair, with long-term functional and psychological implications for some patients.⁵⁵ These principles are directly relevant to cesarean abdominal scars and may also be relevant to perineal scar symptoms.

The uterus adds another level of complexity because the cesarean scar must preserve myometrial continuity and mechanical integrity in future pregnancies. Improvements in superficial scar appearance cannot be assumed to reflect improved uterine scar strength. This distinction should guide both interpretation of current PRP studies and design of future obstetric trials.

Clinical Framework for Postpartum Applications

The potential role of PRP in postpartum wound and scar repair can be understood as a link between platelet-derived biological activity and clinically distinct repair scenarios. Cesarean abdominal wounds require epithelialization, control of local inflammation, and acceptable scar formation; perineal wounds heal in a mechanically active and contamination-prone site; pelvic floor muscle injury represents a deeper functional injury; and uterine scars require myometrial remodeling and evaluation of tissue integrity. These settings should therefore not be grouped as a single indication. The proposed framework and the relative maturity of evidence across these applications are summarized in Figure 1.

Figure 1.

Clinical framework for prp in postpartum wound and scar repair. Platelet-rich plasma (prp) contains concentrated platelets and platelet-associated mediators that may influence inflammation, cellular activity, angiogenesis, extracellular matrix remodeling, and the local tissue microenvironment. Postpartum prp applications involve distinct anatomical targets, including cesarean abdominal wounds, perineal wounds, pelvic floor muscle injury, and uterine scar remodeling, with different biological processes and clinical endpoints. Current evidence is most developed for cesarean abdominal wound and scar outcomes, whereas evidence for perineal repair, pelvic floor muscle injury, and uterine scar remodeling remains limited or exploratory. For uterine applications, residual myometrial thickness and niche morphology should be interpreted as surrogate imaging outcomes rather than direct evidence of improved scar strength, fertility, reduced uterine rupture risk, or subsequent pregnancy safety.

Outcome Assessment in Postpartum Wound and Scar Repair

Scar Assessment

Validated scar assessment is necessary because scar quality includes both objective appearance and patient symptoms. The Patient and Observer Scar Assessment Scale evaluates scar characteristics from both clinician and patient perspectives.⁶ Scar assessment tools differ in structure, clinical sensitivity, and emphasis on patient-reported outcomes.⁷ For cesarean scars, these differences are important because women may value pain, itching, pigmentation, thickness, pliability, and appearance differently from clinicians.

A meta-analysis of PRP for post-burn and surgical scars suggested that PRP may improve selected scar parameters, but the included trials were heterogeneous in scar type, PRP protocol, and follow-up duration.⁵⁶ A broader review of PRP in scar management reached a similar conclusion: available evidence is promising but not yet sufficiently standardized for definitive clinical recommendations.⁵⁷ These scar-focused studies support the plausibility of studying PRP after cesarean delivery, but they do not replace obstetric-specific evidence.

Wound Healing and Patient-Centered Assessment

The REEDA (redness, edema, ecchymosis, discharge, and approximation) scale assesses redness, edema, ecchymosis, discharge, and approximation. Alvarenga et al reported acceptable reliability of the REEDA scale for episiotomy healing assessment.⁵⁸ A scoping review found that REEDA remains the most commonly used tool in research on perineal and cesarean wound healing after childbirth.⁵⁹

REEDA is useful for early wound evaluation, but it does not capture long-term scar quality, dyspareunia, pelvic floor symptoms, body image, or patient satisfaction. The same caution applies to scar scales: a statistically significant difference in the Patient and Observer Scar Assessment Scale (POSAS), REEDA, or Vancouver Scar Scale (VSS) does not necessarily represent a benefit that is noticeable or important to the patient. In the obstetric PRP studies reviewed here, postpartum-specific minimal clinically important differences were generally not prespecified. Effect size and confidence intervals should therefore be interpreted alongside pain intensity, analgesic use, itching, satisfaction, body image, sexual function, continence, and quality of life rather than relying on clinician-assessed scar scores alone.

PRP in Cesarean Abdominal Wound and Scar Healing

Early Studies in High-Risk Women

Cesarean delivery provides a practical setting for local PRP application because the abdominal wound is created under controlled conditions and is accessible before closure. The clinically relevant questions are nevertheless specific: whether PRP improves early wound approximation, reduces wound complications, changes long-term scar quality, or improves patient recovery. These outcomes should be distinguished from uterine scar remodeling, even when PRP is administered during the same operation.

Tehranian et al randomized high-risk women undergoing cesarean delivery to local maternal autologous PRP or usual care. PRP was applied to the subcutaneous wound before skin closure, and greater improvement in selected REEDA and VSS scores was reported during follow-up.²⁶ The trial remains important because it enrolled a population at increased risk of impaired healing, but its PRP product was incompletely characterized and scar follow-up was limited to eight weeks.

Two additional early studies broadened the evidence base but also illustrate why the intervention cannot be treated as uniform. Wanas et al used a three-arm design in 90 high-risk women, comparing autologous PRP plus fibrin gel activated with calcium chloride, the same preparation activated with medical ozone, and a control arm.²⁷ Both active groups generally showed better REEDA, VSS, and pain scores, but the combined fibrin-gel intervention and differing activation methods prevent attribution of the findings to PRP alone. Kamel evaluated subcutaneous autologous PRP in diabetic women undergoing cesarean delivery and reported better later wound and scar scores than standard care.²⁸ However, the report contains inconsistencies in stated group size and provides limited information on randomization, blinding, and cellular PRP composition, which reduces confidence in the effect estimate.

Placebo-Controlled and Cord-Blood Studies

Barwijuk et al conducted a single-blind, placebo-controlled randomized study in 46 women.²⁹ PRP was delivered by microinjection into the abdominal fascia and subcutaneous tissue. Patient- and observer-rated POSAS scores favored PRP through 90 days, whereas VAS pain intensity did not differ significantly between groups. Paracetamol consumption was lower in the PRP arm, but this should be interpreted as a separate outcome rather than as evidence of lower pain intensity.

Thanachaiviwat et al studied cord-blood PRP rather than maternal autologous PRP.³⁰ In 52 analyzed participants, cord-blood PRP was associated with better early REEDA scores and better Vancouver Scar Scale scores at eight weeks, without a significant reduction in VAS pain. Because cord-blood PRP differs in source, biological composition, processing, and regulatory requirements, these findings should not be pooled conceptually with maternal autologous PRP without qualification.

Recent Randomized and Observational Pilot Studies

Brezeanu et al subsequently reported a single-center randomized pilot trial in 100 women undergoing elective cesarean delivery.³¹ Maternal autologous PRP was applied both along the uterine incision margins and in the subcutaneous layer. At day 40, patient-reported POSAS scores were lower in the PRP group, while several other between-group differences were small or not statistically significant. No treatment-related adverse events were reported. Because the intervention was delivered to two anatomical sites but the principal outcomes concerned the abdominal scar, these findings cannot be used to infer a specific effect on uterine scar integrity.

The same group also published a prospective single-arm observational pilot study of 50 women receiving intraoperative PRP at the uterine margins and subcutaneously.³² Scar and pain scores improved between days 7 and 40, but without a concurrent control group the observed change cannot be separated from normal postoperative healing. The report also contains an internal inconsistency between the stated final PRP yield and the total administered volume. It is therefore best regarded as descriptive feasibility evidence rather than independent confirmation of efficacy.

Evidence Synthesis and Clinical Interpretation

Two systematic reviews published in 2026 reached broadly similar conclusions. Şen and Şen synthesized five randomized trials involving 366 women and reported modest improvements in patient- and clinician-assessed scar quality and early REEDA scores, with no significant reduction in early postoperative VAS pain.⁶⁰ A second meta-analysis likewise found a favorable signal for scar quality and early wound healing but judged the evidence heterogeneous and the uterine-scar domain limited and imprecise.⁶¹ Both reviews excluded the 2021 Elkhouly trial from their quantitative evidence base; the article had been formally retracted in 2025, and the retracted study is not included in the present clinical evidence synthesis.

Taken together, the cesarean literature supports a possible effect on early wound and scar measures rather than a demonstrated reduction in major wound complications or a clearly established patient-important benefit. Most studies are single-center, sample sizes are modest, follow-up is short, and PRP preparation differs substantially across trials. Several studies report final PRP volume but omit leukocyte concentration, red-cell contamination, or total delivered platelet dose. The current signal is therefore encouraging but not sufficient to support routine use. Study-level details and limitations are summarized in Table 1.

PRP in Perineal Wound Repair and Pelvic Floor Injury

Perineal Wound Healing and Postpartum Dehiscence

Perineal wounds differ from cesarean abdominal wounds because they heal in a moist, mechanically active and contamination-prone environment. Outcomes also extend beyond wound closure to pain, sitting and mobility, dyspareunia, continence, sexual function, and body image.

Soliman reported an uncontrolled observational series of 210 postpartum women who received autologous PRP injections into subcutaneous and subvaginal tissues after vaginal or perineal repair.³³ The authors described uniformly favorable recovery, but the absence of a comparator, poorly defined outcome criteria, incomplete follow-up reporting, and limited PRP characterization create a very high risk of bias. The study supports feasibility but cannot establish efficacy.

Akhoundova et al described autologous PRP fibrin glue in a woman with postpartum perineal wound dehiscence.³⁴ Wound closure and symptom recovery were favorable, but PRP was used alongside irrigation, antibiotics, sterile honey, analgesia, and ongoing wound care. The contribution of PRP therefore cannot be isolated from concomitant treatment or natural healing.

Chronic Perineal Scar Symptoms

Kabakcı and Bozkır reported repeated autologous PRP injections in a woman with a chronic symptomatic episiotomy scar.³⁵ Pain and Vancouver Scar Scale scores improved over nine weeks. The long symptom history makes the observation clinically interesting, but a single uncontrolled case remains highly susceptible to placebo effects, regression to the mean, and selective reporting.

Pelvic Floor Muscle Injury and Severe Perineal Tears

Pelvic floor muscle injury should be considered separately from superficial perineal wound healing. In a prospective single-blind randomized trial, Moegni et al evaluated PRP injection for postpartum levator ani trauma.³⁶ The study did not demonstrate significant improvement in levator hiatal area or muscle strength at three months. This negative result argues against extrapolating favorable superficial wound findings to deeper pelvic floor muscle recovery.

Kurniawati et al studied PRP as an adjunct to repair of third- and fourth-degree perineal rupture in a small comparative study.³⁷ No wound defects occurred in either group, while continence and sphincter-tone measures favored PRP at eight weeks. The study is hypothesis-generating because of its small sample, post-test-only design, short follow-up, examiner-dependent outcomes, and incomplete characterization of the delivered PRP.

Interpretation and Ongoing Research

The perineal evidence therefore remains substantially less mature than the cesarean abdominal-wound literature. Uncontrolled series and case reports suggest that local PRP can be delivered to postpartum perineal tissues, but they do not establish comparative effectiveness. The randomized levator ani study was negative for muscle recovery, while the severe-tear study requires independent replication. A triple-blind randomized placebo-controlled trial registered in 2026 (RELIEVE; NCT07727213) is designed to test whether a single injection of autologous non-activated PRP during primary repair of a perineal tear or episiotomy reduces postpartum pain. Until such controlled data are available, routine PRP use for uncomplicated episiotomy or perineal tears is not supported.⁶²

PRP in Uterine Incision Healing and Cesarean Scar Remodeling

Biological and Clinical Rationale

Uterine incision healing is conceptually and clinically distinct from abdominal wound healing. The cesarean uterine scar must restore myometrial continuity and later tolerate substantial mechanical loading during pregnancy. Residual myometrial thickness (RMT), niche depth, and related sonographic measurements describe scar morphology, but they are surrogate outcomes rather than direct measures of scar strength. Improvement in these measurements cannot be assumed to reduce uterine rupture, cesarean scar pregnancy, placenta accreta spectrum, infertility, or other subsequent-pregnancy complications.

Postmenstrual spotting has been associated with a uterine niche after cesarean delivery,¹⁶ and cesarean scar defects have been associated with abnormal uterine bleeding in systematic review evidence.¹⁷ These associations provide a clinical rationale for studying uterine scar-directed interventions, but they also underline the need to evaluate symptoms and reproductive outcomes rather than imaging alone.

Direct PRP Evidence

Chaichian et al conducted a randomized double-blinded pilot study in women undergoing their first cesarean delivery.³⁸ Autologous PRP was injected along the hysterotomy between the decidua and myometrium, making this the principal clinical study that directly targeted uterine scar morphology. At 12 weeks, the PRP group had a lower reported niche frequency and niche height and a greater RMT. The study was small, only 30 women were included in the final analysis, and the reported niche-frequency P value is not readily reproduced from the displayed counts. Recent meta-analytic re-analysis also found the binary niche outcome imprecise.^60,61 The findings should therefore be considered hypothesis-generating rather than evidence of improved uterine scar strength.

The two Brezeanu studies applied part of the PRP dose along uterine incision margins, but they assessed postoperative abdominal scar and pain outcomes rather than uterine scar morphology.^31,32 They should therefore not be counted as direct evidence that PRP improves hysterotomy healing. No study identified in this review has demonstrated a reduction in uterine rupture, placenta accreta spectrum, cesarean scar pregnancy, infertility, or adverse outcomes in a subsequent pregnancy.

Indirect Mechanistic Support from Uterine Injury Models

Evidence from endometrial and intrauterine adhesion models provides indirect support for PRP-related uterine tissue repair. Kim et al reported improved endometrial regeneration and pregnancy outcomes after intrauterine PRP in a murine model of Asherman syndrome.⁶³ Cheng et al found that PRP combined with extracorporeal shock-wave therapy improved endometrial repair and reduced fibrosis in a rat model of intrauterine adhesion.⁶⁴ Kuroda et al showed that autologous PRP altered transcriptomic profiles of human endometrial stromal cells.⁶⁵

These data inform biological plausibility but not clinical uterine-scar efficacy. Endometrial regeneration, intrauterine adhesion repair, and healing of a full-thickness myometrial incision involve different tissues and mechanical demands. Future uterine studies should therefore prespecify imaging and symptom outcomes, follow fertility, and extend surveillance into subsequent pregnancies whenever feasible.

Methodological and Clinical Translation Challenges

PRP Characterization and Reproducibility

The main methodological obstacle is that PRP is not a single reproducible intervention. As Table 1 shows, several obstetric studies report blood volume and final PRP volume but omit leukocyte concentration, red-cell contamination, platelet recovery, or total delivered platelet dose. Future studies should report blood source, anticoagulant, centrifugation force and duration, baseline and final platelet counts, platelet dose, leukocyte and red-cell content, activation method, final volume, product form, anatomical site, tissue layer, timing, and number of applications. Reporting revolutions per minute alone is insufficient unless rotor characteristics are also provided; relative centrifugal force is preferable for reproducibility.

Patient factors also require attention. Diabetes, obesity, anemia, hypertensive disorders, infection, smoking, antiplatelet or anticoagulant therapy, and baseline platelet count may affect wound healing or PRP composition. These variables should be measured prospectively and considered in stratification or prespecified subgroup analyses rather than introduced after results are known.

Outcomes That Matter for women’s Health

Outcome selection should follow the tissue and clinical question. Cesarean abdominal-wound studies should separate early inflammation and wound complications from longer-term scar quality. Pain intensity and analgesic consumption should be reported independently. Perineal studies should include wound separation and infection together with pain, dyspareunia, continence, sexual function, pelvic floor symptoms, and quality of life. Uterine-scar studies should combine RMT and niche morphology with abnormal uterine bleeding, postmenstrual spotting, pelvic pain, fertility, and subsequent pregnancy outcomes. Recommended reporting items are summarized in Table 2.

Table 2.

Recommended Reporting and Outcome Framework for Future Obstetric PRP Studies

Domain	Minimum Data to Report	Preferred Outcomes/Timing	Interpretation and Clinical Relevance
Patient profile	Age; BMI; diabetes; anemia; hypertensive disorders; smoking; infection risk; anticoagulant/antiplatelet exposure; baseline platelet count; other major healing modifiers.	Baseline characteristics and prespecified high-risk subgroups when clinically justified.	Baseline imbalance can alter wound healing and PRP composition. Subgroup claims should be prespecified rather than generated post hoc.
PRP product characterization	Blood source; blood volume; anticoagulant; device/rotor; centrifugation force (preferably ×g), time and number of spins; baseline/final platelet count; platelet recovery/fold enrichment; leukocytes; RBC contamination; activation; final volume; total delivered platelet dose.	Report batch-level product data when feasible, or central tendency and dispersion across batches. If rpm is reported, provide centrifuge/rotor details to permit reproducibility.	PRP is not a uniform intervention. Missing product data make positive and negative studies difficult to reproduce or compare.
Application protocol	Anatomical site/layer; route; dose per site/layer; timing relative to closure; number of applications; formulation (liquid, gel/fibrin matrix, spray, injection); co-interventions.	Record abdominal fascia/subcutaneous tissue, perineal wound, levator ani and uterine incision separately.	When PRP is applied to several tissue layers, clinical effects cannot be attributed to a specific target. Co-interventions should be separated from PRP itself.
Cesarean abdominal wound	Dehiscence, infection, discharge, approximation, time to epithelialization, readmission/reintervention.	REEDA or another validated wound tool at standardized early time points plus clinically important wound complications.	Small score changes should not be interpreted as fewer clinically important complications unless dehiscence, infection, recovery or reintervention also improve.
Pain and analgesic use	Pain intensity; analgesic drug/dose; rescue medication; standardized postoperative analgesia protocol.	VAS/NRS at prespecified early time points; cumulative/daily analgesic consumption reported separately.	Lower analgesic consumption does not prove lower pain intensity. These outcomes should be analyzed and discussed independently.
Scar quality/patient experience	Observer- and patient-reported scar symptoms; itching; pain; appearance; body image; satisfaction.	POSAS when both patient and observer perspectives are relevant; VSS/MSS as appropriate; include follow-up beyond early wound closure. Report effect sizes and 95% CIs.	Statistical significance is not automatically clinical importance. Use an MCID only when validated for the instrument and relevant population; otherwise avoid claiming patient-important benefit from small score differences.
Perineal wound/dehiscence	Wound closure; infection; pain; dyspareunia; need for resuturing; time to healing; return to normal activity.	Clinical healing plus patient-reported pain, sexual function and quality of life; follow-up beyond initial closure.	Perineal wound dehiscence, chronic scar pain and pelvic-floor muscle injury are distinct indications and should not be pooled.
Pelvic floor/levator ani	Levator hiatal area; muscle strength; avulsion status; pelvic-floor symptoms; urinary/anal continence.	Transperineal ultrasound and/or perineometry at standardized postpartum intervals (eg, ~6 weeks and ≥3 months), with validated symptom measures.	Muscle-recovery outcomes should not be extrapolated from superficial wound-healing studies.
Uterine incision/scar morphology	Niche presence/dimensions; RMT; adjacent myometrial thickness; abnormal uterine bleeding; postmenstrual spotting; pelvic pain.	Standardized transvaginal ultrasound after a defined remodeling interval, with symptom outcomes measured in parallel.	RMT and niche morphology are surrogate imaging outcomes. They do not establish greater scar tensile strength, lower uterine-rupture risk, improved fertility or safer subsequent pregnancy.
Safety	Infection; hematoma; bleeding; fever; excessive inflammation; injection-site reactions; readmission; unexpected events. For uterine application: adhesion formation, abnormal fibrosis/myometrial remodeling and later obstetric events.	Prespecified adverse-event definitions and systematic surveillance. Separate superficial/perineal safety from uterine-incision safety.	Absence of complications in small pilot studies cannot establish safety, particularly for uterine-incision applications.
Long-term reproductive outcomes	Menstrual symptoms; fertility/conception; cesarean scar pregnancy; placenta accreta spectrum; uterine rupture/dehiscence; mode and outcome of later delivery.	Prospective long-term follow-up or linkage to subsequent pregnancy records when the uterine incision is treated.	These are clinically decisive outcomes for uterine applications and should remain distinct from short-term imaging changes.
Study design/reporting	Randomization; allocation concealment; blinding; comparator; prespecified primary outcome; sample-size rationale; attrition; analysis population; trial registration/protocol; funding and conflicts of interest.	Adequately powered controlled trials; predefined assessment schedule; report absolute effects, effect sizes and uncertainty (eg, 95% CIs).	Clinical translation depends on effect magnitude, precision and patient importance—not P values alone. Improvement over time in uncontrolled studies cannot be attributed to PRP.

Abbreviations: BMI, body mass index; CI, confidence interval; MCID, minimal clinically important difference; MSS, Manchester Scar Scale; NRS, Numeric Rating Scale; POSAS, Patient and Observer Scar Assessment Scale; PRP, platelet-rich plasma; RBC, red blood cell; REEDA, redness, edema, ecchymosis, discharge, approximation; RMT, residual myometrial thickness; VAS, Visual Analog Scale; VSS, Vancouver Scar Scale.

Statistical significance should not be conflated with clinical significance. Small numerical differences in POSAS, REEDA, VSS, or related scales may not correspond to a perceptible improvement in recovery or quality of life. Because postpartum-specific minimal clinically important differences have not been established or prespecified in most PRP trials, future studies should report absolute effects and confidence intervals and should prioritize patient-reported outcomes alongside clinician-rated scales.

Safety, Feasibility, and Regulation

Autologous PRP is expected to have low immunogenicity, but safety requirements differ by anatomical site. For abdominal and perineal application, relevant events include contamination, infection, hematoma or seroma, dehiscence, excessive local inflammation, injection-site pain, and readmission. Uterine application requires additional caution because small short-term studies cannot exclude adhesion formation, abnormal fibrosis, disturbed myometrial remodeling, or adverse effects on implantation and placentation. Absence of adverse events in pilot studies should therefore not be interpreted as evidence of long-term reproductive safety. Cord-blood PRP raises additional issues related to donor source, collection, processing, sterility, compatibility, and traceability.

Feasibility also differs by clinical setting. PRP preparation is easier to standardize during scheduled cesarean delivery than during emergency cesarean delivery or acute perineal repair. Preparation time, operating-room workflow, cost, staff training, sterility control, and local regulation all influence implementation. Regulatory frameworks for regenerative interventions in obstetrics and gynecology vary between jurisdictions.⁶⁶ Orthobiologic procedures, including PRP, also face broader challenges related to product standardization, clinical claims, and oversight.⁶⁷

Biomaterial-Assisted Delivery

Local retention is another unresolved issue. PRP-derived factors can disperse rapidly from a wound bed, prompting interest in gels, fibrin matrices, hydrogels, collagen scaffolds, and other delivery systems. Evidence from chronic wounds and other tissues suggests that formulation and delivery can influence exposure to platelet-derived mediators, although the underlying studies remain heterogeneous.^68,69 Platelet-rich fibrin provides a related but distinct scaffold-based approach to soft-tissue repair.⁷⁰

For postpartum use, however, added material complexity must be justified by a clear clinical advantage. Uterine delivery systems would require specific evaluation for infection, adhesion formation, bleeding, fibrosis, and effects on later implantation and placentation. Perineal systems would need to remain flexible, biocompatible, and compatible with sexual and pelvic floor function. These strategies are therefore better viewed as future translational directions than as extensions of the current clinical evidence.

Limitations of This Review

This article is a narrative review and does not provide a formal quantitative synthesis or a protocol-driven risk-of-bias assessment of every included report. Study selection was not performed by two independent reviewers, and the small literature includes older single-center studies, uncontrolled reports, inconsistent descriptions of randomization and blinding, and incomplete PRP characterization. Some mechanistic arguments also rely on general wound-healing literature or uterine injury models rather than direct postpartum trials. We therefore emphasize the direction, consistency, and limitations of the evidence rather than a single pooled treatment estimate. Recent systematic reviews are used to contextualize the randomized cesarean literature, while retracted evidence is excluded from efficacy interpretation.

Conclusions

PRP has a plausible biological rationale for postpartum wound and scar repair, but the clinical evidence is uneven and tissue-specific. Cesarean abdominal wound healing has the largest comparative evidence base and shows a modest signal for improvement in selected early wound and scar measures. The evidence is less convincing for pain intensity and does not yet show a clear reduction in major wound complications. Perineal evidence is limited by uncontrolled studies and case reports; a small severe-tear study suggests possible benefit, whereas randomized data do not show improved levator ani muscle recovery. Uterine scar application is the least established and remains based on a small pilot study using surrogate sonographic outcomes.

The next phase of research should focus less on whether a product labelled “PRP” was used and more on what product was delivered, to which tissue, at what dose, and for which clinically meaningful outcome. Standardized product characterization, adequately powered indication-specific trials, patient-reported outcomes, and longer follow-up are priorities. For uterine interventions, subsequent fertility and pregnancy outcomes are essential safety endpoints. On current evidence, PRP should remain an investigational adjunct rather than a routine component of postpartum wound or scar care.

Disclosure

The authors report no conflicts of interest.