1
|
Nunes I, Nicholson W, Theron G. FIGO good practice recommendations on surgical techniques to improve safety and reduce complications during cesarean delivery. Int J Gynaecol Obstet 2023; 163 Suppl 2:21-33. [PMID: 37807585 DOI: 10.1002/ijgo.15117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
FIGO is actively contributing to the global effort to reduce maternal morbidity, mortality, and disability worldwide. Cesarean delivery rates are increasing globally, without signs of slowing down. Bleeding associated with cesarean delivery has become an important cause of hemorrhage-related maternal deaths in many low- and middle-income countries. Correct surgical techniques to improve safety and reduce complications of cesarean delivery is of the utmost importance. This article presents FIGO's good practice recommendations for effective surgical techniques to reduce cesarean complications. Evidence-based information is included where data are available. An expanded WHO Surgical Safety Checklist for maternity cases is suggested. Different incision techniques through the layers of the abdominal wall with appropriate indications are discussed. Hysterotomy through a transverse incision is described, as are indications for low vertical and classical incisions. Important precautions when extracting the fetus are explained. Uterine closure includes a safe method ensuring adequate reapproximation of the upper segment if a vertical incision is made. The paper concludes with the management of two common bleeding problems following delivery of the placenta.
Collapse
Affiliation(s)
- Inês Nunes
- Centro Hospitalar Vila Nova de Gaia/Espinho, Department of Obstetrics and Gynaecology, CINTESIS - Center for Health Technology and Services Research, University of Porto, Porto, Portugal
| | - Wanda Nicholson
- George Washington University Milken School of Public Health, Washington, District of Columbia, USA
| | - Gerhard Theron
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| |
Collapse
|
2
|
Stegwee SI, Verberkt C, Huirne JA. Letter on Genovese et al.'s "Impact of Hysterotomy Closure Technique on Subsequent Cesarean Scar Defects Formation: A Systematic Review". Gynecol Obstet Invest 2023; 88:322-324. [PMID: 37647882 PMCID: PMC10659000 DOI: 10.1159/000533688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/15/2023] [Indexed: 09/01/2023]
Affiliation(s)
- Sanne I. Stegwee
- Department of Obstetrics and Gynaecology, Research Institute ‘Amsterdam Reproduction and Development’, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Carry Verberkt
- Department of Obstetrics and Gynaecology, Research Institute ‘Amsterdam Reproduction and Development’, Amsterdam UMC, Amsterdam, The Netherlands
| | - Judith A.F. Huirne
- Department of Obstetrics and Gynaecology, Research Institute ‘Amsterdam Reproduction and Development’, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Amsterdam, The Netherlands
| |
Collapse
|
3
|
Verberkt C, Lemmers M, de Vries R, Stegwee SI, de Leeuw RA, Huirne JAF. Aetiology, risk factors and preventive strategies for niche development: A review. Best Pract Res Clin Obstet Gynaecol 2023; 90:102363. [PMID: 37385157 DOI: 10.1016/j.bpobgyn.2023.102363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/03/2023] [Accepted: 05/14/2023] [Indexed: 07/01/2023]
Abstract
The increase in caesarean sections (CS) has resulted in an increase in women with a uterine niche. The exact aetiology of niche development has yet to be elucidated but is likely multifactorial. This study aimed to give a systematic overview of the available literature on histopathological features, risk factors and results of preventive strategies on niche development to gain more insight into the underlying mechanisms. Based on current published data histopathological findings associated with niche development were necrosis, fibrosis, inflammation, adenomyosis and insufficient approximation. Patient-related risk factors included multiple CS, BMI and smoking. Labour-related factors were CS before onset of labour, extended cervical dilatation, premature rupture of membranes and presenting part of the fetus at CS below the pelvic inlet. Preventive strategies should focus on the optimal level of incision, training of surgeons and full-thickness closure of the myometrium (single or double-layer) using non-locking sutures. Conflicting data exist concerning the effect of endometrial inclusion. Future studies without heterogeneity in population, using standardized performance of the CS after proper training and using standardized niche evaluation with a relevant core outcome set are required to allow meta-analyses and to develop evidence-based preventive strategies. These studies are needed to reduce the prevalence of niches and prevent complications in subsequent pregnancies such as caesarean scar pregnancies.
Collapse
Affiliation(s)
- C Verberkt
- Department of Obstetrics and Gynecology, Research Institute "Amsterdam Reproduction and Development", Amsterdam UMC, Location VU Medical Center, Amsterdam, the Netherlands
| | - M Lemmers
- Department of Obstetrics and Gynecology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - R de Vries
- Medical Library, Vrije Universiteit, 1081 HV, Amsterdam, the Netherlands
| | - S I Stegwee
- Department of Obstetrics and Gynecology, Research Institute "Amsterdam Reproduction and Development", Amsterdam UMC, Location VU Medical Center, Amsterdam, the Netherlands; Department of Obstetrics and Gynaecology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - R A de Leeuw
- Department of Obstetrics and Gynecology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands
| | - J A F Huirne
- Department of Obstetrics and Gynecology, Amsterdam UMC, Location AMC, Amsterdam, the Netherlands.
| |
Collapse
|
4
|
Qayum K, Kar I, Sofi J, Panneerselvam H. Single- Versus Double-Layer Uterine Closure After Cesarean Section Delivery: A Systematic Review and Meta-Analysis. Cureus 2021; 13:e18405. [PMID: 34729282 PMCID: PMC8555931 DOI: 10.7759/cureus.18405] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2021] [Indexed: 11/05/2022] Open
Abstract
Cesarean section (CS) delivery is a common procedure, and its incidence is increasing globally. To compare single-layer (SL) with double-layer (DL) uterine closure techniques after cesarean section in terms of ultrasonographic findings and rate of CS complications. PubMed, Scopus, Web of Science, and Cochrane Library were searched for relevant randomized clinical trials (RCTs). Retrieved articles were screened, and relevant studies were included in a meta-analysis. Continuous data were pooled as mean difference (MD) with 95% confidence interval (CI), and dichotomous data were pooled as relative risk (RR) and 95% CI. Analysis was conducted using RevMan software (Version 5.4). Eighteen RCTs were included in our study. Pooled results favored DL uterine closure in terms of residual myometrial thickness (MD = -1.15; 95% CI -1.69, -0.60; P < 0.0001) and dysmenorrhea (RR = 1.36; 95% CI 1.02, 1.81; P = 0.04), while SL closure had shorter operation time than DL closure (MD = -2.25; 95% CI -3.29, -1.21; P < 0.00001). Both techniques had similar results in terms of uterine dehiscence or rupture (RR = 1.88; 95% CI 0.63, 5.62; P = 0.26), healing ratio (MD = -5.00; 95% CI -12.40, 2.39; P = 0.18), maternal infectious morbidity (RR = 0.94; 95% CI 0.66, 1.34; P = 0.72), hospital stay (MD = -0.12; 95% CI -0.30, 0.06; P = 0.18), and readmission rate (RR = 0.95; 95% CI 0.64, 1.40; P = 0.78). Double-layer uterine closure shows more residual myometrial thickness and lower incidence of dysmenorrhea than single-layer uterine closure of cesarean section scar. But single-layer closure has the advantage of the shorter operation time. Both methods have comparable blood loss amount, healing ratio, hospital stay duration, maternal infection risk, readmission rate, and uterine dehiscence or rupture risk.
Collapse
Affiliation(s)
- Kaif Qayum
- General Surgery, Wye Valley NHS Foundation Trust, Hereford, GBR
| | - Irfan Kar
- General Surgery, Wye Valley NHS Foundation Trust, Hereford, GBR
| | - Junaid Sofi
- General Surgery, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, IND
| | | |
Collapse
|
5
|
Kaps C, Schwickert A, Dimitrova D, Nonnenmacher A, Siedentopf JP, Henrich W, Braun T. Online survey on uterotomy closure techniques in caesarean section. J Perinat Med 2021; 49:809-817. [PMID: 34229368 DOI: 10.1515/jpm-2021-0118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/19/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Uterine closure technique in caesarean section (CS) influences the rate of late complications in subsequent pregnancies. As no common recommendation on suture techniques exists, we developed a questionnaire to determine the techniques currently used and the frequencies of late complications. METHODS The online questionnaire consisted of 13 questions and was sent to 648 obstetric hospitals (level I-IV) in Germany. Number of CS, rate of vaginal birth after caesarean section (VBAC), the type of uterus suturing technique and the frequency of uterine dehiscences, ruptures and placenta accreta spectrum (PAS) were queried. The answers were anonymous, and results were evaluated descriptively. RESULTS The response rate was 24.7%. The mean CS rate was 27.3% (±6.2), the repeat CS rate 33.2% (±18.1). After CS, 46.2% (±20.2) women delivered vaginally. To close the uterotomy, 74.4% of hospitals used single layer continuous sutures, 16.3% single layer locked sutures, 3.8% interrupted sutures, 3.1% double layer continuous sutures and 2.5% used other suture techniques. The percentages of observed uterine dehiscences did not differ significantly between the different levels of care nor did the uterotomy suture techniques. CONCLUSIONS There is no uniform suturing technique in Germany. A detailed description of suture technique in surgery reports is required to evaluate complications in subsequent pregnancies. National online surveys on obstetric topics are feasible and facilitate the discussion on the need to define a standardized uterine closure technique for CS.
Collapse
Affiliation(s)
- Celine Kaps
- Department of Obstetrics and Division of 'Experimental Obstetrics', Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Alexander Schwickert
- Department of Obstetrics and Division of 'Experimental Obstetrics', Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Desislava Dimitrova
- Department of Obstetrics and Division of 'Experimental Obstetrics', Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Andreas Nonnenmacher
- Department of Obstetrics and Division of 'Experimental Obstetrics', Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Jan-Peter Siedentopf
- Department of Obstetrics and Division of 'Experimental Obstetrics', Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Wolfgang Henrich
- Department of Obstetrics and Division of 'Experimental Obstetrics', Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| | - Thorsten Braun
- Department of Obstetrics and Division of 'Experimental Obstetrics', Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany.,Division of 'Experimental Obstetrics', Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Virchow-Klinikum, Berlin, Germany
| |
Collapse
|
6
|
Elkhouly NI, Abdelaal NK, Solyman AE, Elkelani OA, Elbasueny BF, Elhalaby AF. A new technique for uterine incision closure at the time of cesarean section: does it make a difference? J OBSTET GYNAECOL 2021; 42:416-423. [PMID: 34155957 DOI: 10.1080/01443615.2021.1910636] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The purpose of this study was to compare the short-term operative outcomes of three different surgical techniques for uterine incision closure during caesarean section (CS). This trial enrolled 120 patients scheduled for primary caesarean delivery. Patients were randomised into either classical double-layer uterine closure, purse-string double-layer uterine closure (Turan), or our new approach of uterine closure (double layer step up-step down technique). For short-term comparison, transvaginal ultrasonography was planned for all patients 6 weeks after surgery. Compared to group II and Group III, residual myometrial thickness was significantly thinner in group I (p < .001). The number of patients with uterine niche was 10 (50% of all scar defects) in group I whereas it was 4 (20%) in group II and 6 (30%) in group III. Operative time was significantly longer in group II (p < .001). This led to our conclusion that Turan technique and our new approach are associated with thicker myometrial thickness and less frequency of uterine scar defect than classical double-layer uterine incision closure; however, our approach takes less operative time. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT04681378Impact statementWhat is already known on this subject? Many variations in CS technique have been studied. For example, single-layer uterine incision closure has been compared to double-layer uterine incision closure. Purse string double layer (Turan) has been also compared to the traditional double-layer technique. Double layer unlocked closure has been shown to result in a thicker residual myometrium and as a consequence can possibly lead to the decrease of niche development after a CS compared to single-layer closure with lower frequency of uterine scar defect with Turan technique.What do the results of this study add? Here we introduce a new uterine closure technique, which we have named double-layer step up-step down technique, as an alternative method. With this technique, the uterine incision contract more than with the traditional double layer technique and has similar results to the Turan technique; however, our approach takes less operative time.What are the implications of these findings for clinical practice and/or further research? These alternative techniques of uterine incision closure decrease the frequency of uterine niche that may be associated with many clinical problems such as ectopic pregnancy at the CS scar, placenta accreta, rupture of the uterus during a subsequent pregnancy. Future studies are needed to investigate the frequency of uterine rupture in a subsequent pregnancy following different uterine incision closure techniques.
Collapse
Affiliation(s)
- Nabih I Elkhouly
- Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Shibin Elkom, Egypt
| | - Nasser K Abdelaal
- Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Shibin Elkom, Egypt
| | - Ayman E Solyman
- Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Shibin Elkom, Egypt
| | - Osama A Elkelani
- Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Shibin Elkom, Egypt
| | - Bahi F Elbasueny
- Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Shibin Elkom, Egypt
| | - Alaa F Elhalaby
- Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Shibin Elkom, Egypt
| |
Collapse
|
7
|
Abstract
In this Commentary, we explain the case for a standardized cesarean delivery surgical technique. There are three strong arguments for a standardized approach to cesarean delivery, the most common major abdominal surgery performed in the world. First, standardization within institutions improves safety, efficiency, and effectiveness in health care delivery. Second, surgical training among obstetrics and gynecology residents would become more consistent across hospitals and regions, and proficiency in performing cesarean delivery measurable. Finally, standardization would strengthen future trials of cesarean delivery technique by minimizing the potential for aspects of the surgery which are not being studied to bias results. Before 2013, more than 155 randomized controlled trials, meta-analyses or systematic reviews were published comparing various aspects of cesarean delivery surgical technique. Since 2013, an additional 216 similar studies have strengthened those recommendations and offered evidence to recommend additional cesarean delivery techniques. However, this amount of cesarean delivery technique data creates a forest for the trees problem, making it difficult for a clinician to synthesize this volume of data. In response to this difficulty, we propose a comprehensive, evidence-based and standardized approach to cesarean delivery technique.
Collapse
|
8
|
Alalfy M, Osman OM, Salama S, Lasheen Y, Soliman M, Fikry M, Ramadan M, Alaa D, Elshemy S, Abdella R. Evaluation of the Cesarean Scar Niche In Women With Secondary Infertility Undergoing ICSI Using 2D Sonohysterography Versus 3D Sonohysterography and Setting a Standard Criteria; Alalfy Simple Rules for Scar Assessment by Ultrasound To Prevent Health Problems for Women. Int J Womens Health 2020; 12:965-974. [PMID: 33177887 PMCID: PMC7650036 DOI: 10.2147/ijwh.s267691] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 09/07/2020] [Indexed: 11/30/2022] Open
Abstract
Background Many expressions were used to define the defect that is seen by ultrasound after cesarean section (CS) namely scar defect, niche, isthmocele, uterine pouch or diverticula. Objective To compare the accuracy of 2 dimensional sonohysterography (2D SHG) to 3 dimensional sonohysterography (3D SHG) in evaluating cesarean section uterine scar depth (D), base width (BW), width (W) and residual myometrial thickness (RMT) in women with secondary infertility and establishment of a standard criteria; Alalfy simple rules for scar assessment. Patients and Methods This was an observational cross-sectional comparative study that was conducted on women who presented with secondary infertility and were candidates for intracytoplasmic sperm injection (ICSI) and giving a history of a previous cesarean section. Assessment of uterine scar in each woman was performed using 2D transvaginal ultrasound with sonohysterography (SHG) followed by 3D transvaginal with SHG with evaluation of niche depth, width, RMT, niche BW and RMT/depth ratio. The study was conducted at Algezeera hospital, Egypt. Results The present study revealed that 3D ultrasound with SHG is superior in evaluation of the RMT and niche width prior to ICSI providing better characterization of the scar niche. Conclusion Scar niche should be assessed by a combined integrated 2D SHG and 3D SHG scan with the specific geometrical and anatomical considerations, Alalfy simple rules for scar niche assessment that involvemeasurement of niche depth, (Base width) BW, width, RMT and RMT/depth ratio in sagittal plane, RMT in coronal plane / niche width in coronal plane ratio (ratio less than 1 denotes scar weakness with more liability for dehiscence). Trial Registration Clinical Trials.gov Id NCT04076904.
Collapse
Affiliation(s)
- Mahmoud Alalfy
- Reproductive Health and Family Planning Department, National Research Centre, Dokki, Cairo, Egypt
| | - Omneya M Osman
- Obstetrics and Gynecology Department, Kasr Alainy, Faculty of Medicine, Cairo University, Egypt, Algezeera Hospital, Egypt
| | - Sameh Salama
- Reproductive Health and Family Planning Department, National Research Centre, Dokki, Cairo, Egypt
| | - Yossra Lasheen
- Obstetrics and Gynecology Department, Kasr Alainy, Faculty of Medicine, Cairo University, Egypt, Algezeera Hospital, Egypt
| | - Mahmoud Soliman
- Obstetrics and Gynecology Department, Kasr Alainy, Faculty of Medicine, Cairo University, Egypt, Algezeera Hospital, Egypt
| | - Mohamed Fikry
- Obstetrics and Gynecology Department, Kasr Alainy, Faculty of Medicine, Cairo University, Egypt, Algezeera Hospital, Egypt
| | - Mohamed Ramadan
- Obstetrics and Gynecology Department, Kasr Alainy, Faculty of Medicine, Cairo University, Egypt, Algezeera Hospital, Egypt
| | - Doaaa Alaa
- Obstetrics and Gynecology Department, Kasr Alainy, Faculty of Medicine, Cairo University, Egypt, Algezeera Hospital, Egypt
| | - Shaimaa Elshemy
- Obstetrics and Gynecology Department, Kasr Alainy, Faculty of Medicine, Cairo University, Egypt, Algezeera Hospital, Egypt
| | - Rana Abdella
- Obstetrics and Gynecology Department, Kasr Alainy, Faculty of Medicine, Cairo University, Egypt, Algezeera Hospital, Egypt
| |
Collapse
|
9
|
Stegwee SI, van der Voet LF, Ben AJ, de Leeuw RA, van de Ven PM, Duijnhoven RG, Bongers MY, Lambalk CB, de Groot C, Huirne J. Effect of single- versus double-layer uterine closure during caesarean section on postmenstrual spotting (2Close): multicentre, double-blind, randomised controlled superiority trial. BJOG 2020; 128:866-878. [PMID: 32892392 PMCID: PMC7983985 DOI: 10.1111/1471-0528.16472] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate whether double-layer uterine closure after a first caesarean section (CS) is superior compared with single-layer uterine closure in terms of postmenstrual spotting and niche development in the uterine caesarean scar. DESIGN Multicentre, double-blind, randomised controlled superiority trial. SETTING Thirty-two hospitals in the Netherlands. POPULATION A total of 2292 women aged ≥18 years undergoing a first CS were randomly assigned to each procedure (1:1): 1144 women were assigned to single-layer uterine closure and 1148 women were assigned to double-layer uterine closure. METHODS Single-layer unlocked closure and double-layer unlocked closure, with the second layer imbricating the first. MAIN OUTCOME MEASURES Number of days with postmenstrual spotting during one menstrual cycle 9 months after CS. SECONDARY OUTCOMES perioperative and menstrual characteristics; transvaginal ultrasound measurements. RESULTS A total of 774 (67.7%) women from the single-layer group and 770 (67.1%) women from the double-layer group were evaluable for the primary outcome, as a result of drop-out and amenorrhoea. The mean number of postmenstrual spotting days was 1.33 (bootstrapped 95% CI 1.12-1.54) after single-layer closure and 1.26 (bootstrapped 95% CI 1.07-1.45) after double-layer closure (adjusted mean difference -0.07, 95% CI -0.37 to 0.22, P = 0.810). The operative time was 3.9 minutes longer (95% CI 3.0-4.9 minutes, P < 0.001) and niche prevalence was 4.7% higher (95% CI 0.7-8.7%, P = 0.022) after double-layer closure. CONCLUSIONS The superiority of double-layer closure compared with single-layer closure in terms of postmenstrual spotting after a first CS was not shown. Long-term obstetric follow-up of our trial is needed to assess whether uterine caesarean closure guidelines should be adapted. TWEETABLE ABSTRACT Double-layer uterine closure is not superior for postmenstrual spotting after a first caesarean; single-layer closure performs slightly better on other outcomes.
Collapse
Affiliation(s)
- S I Stegwee
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - L F van der Voet
- Department of Obstetrics and Gynaecology, Deventer Hospital, Deventer, the Netherlands
| | - A J Ben
- Department of Health Sciences, Amsterdam Public Health, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - R A de Leeuw
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, the Netherlands
| | - P M van de Ven
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - R G Duijnhoven
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, the Netherlands
| | - M Y Bongers
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Research School Grow Maastricht University, Veldhoven, the Netherlands
| | - C B Lambalk
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Cjm de Groot
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, the Netherlands
| | - Jaf Huirne
- Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Department of Obstetrics and Gynaecology, Amsterdam Reproduction & Development, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, the Netherlands
| | | |
Collapse
|
10
|
Stegwee SI, Jordans I, van der Voet LF, van de Ven PM, Ket J, Lambalk CB, de Groot C, Hehenkamp W, Huirne J. Uterine caesarean closure techniques affect ultrasound findings and maternal outcomes: a systematic review and meta-analysis. BJOG 2018; 125:1097-1108. [PMID: 29215795 DOI: 10.1111/1471-0528.15048] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Caesarean section (CS) rates are rising globally. Long-term adverse outcomes after CS might be reduced when the optimal uterine closure technique becomes evident. OBJECTIVE To determine the effect of uterine closure techniques after CS on maternal and ultrasound outcomes. SEARCH STRATEGY Literature search in electronic databases. SELECTION CRITERIA Randomised controlled trials (RCTs) or prospective cohort studies that evaluated uterine closure techniques and reported on ultrasound findings, perioperative or long-term outcomes. DATA COLLECTION AND ANALYSIS Twenty studies (15 053 women) were included in our meta-analyses for various outcomes. We calculated pooled risk ratios (RR) and weighted mean differences (WMD) with 95% CI through random-effect analysis. MAIN RESULTS Residual myometrium thickness (RMT), reported in eight studies (508 women), decreased by 1.26 mm after single- compared with double-layer closure (95% CI -1.93 to -0.58), particularly when locked sutures were used. Healing ratio [RMT/adjacent myometrium thickness (AMT)] decreased after single-layer closure (WMD -7.74%, 95% CI -13.31 to -2.17), particularly in the case of locked sutures. Niche prevalence increased (RR 1.71, 95% CI 1.11-2.62) when the decidua was excluded. Dysmenorrhea occurred more often in the single-layer group (RR 1.23, 95% CI 1.01-1.48), whereas incidence of uterine rupture was similar (RR 1.91, 95% CI 0.63-5.74). CONCLUSION Double-layer unlocked sutures are preferable to single-layer locked sutures regarding RMT, healing ratio and dysmenorrhoea. Excluding the decidua seems to result in higher niche prevalence. As thin residual myometrium or niches may serve as intermediates for gynaecological and reproductive outcomes, future studies should focus on these outcomes. TWEETABLE ABSTRACT: #Uterineclosuretechniques after #caesarean affect #longtermoutcomes.
Collapse
Affiliation(s)
- S I Stegwee
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
| | - Ipm Jordans
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
| | - L F van der Voet
- Department of Obstetrics and Gynaecology, Deventer Hospital, Deventer, the Netherlands
| | - P M van de Ven
- Department of Epidemiology and Biostatistics, VU University, Amsterdam, the Netherlands
| | - Jcf Ket
- Medical Library, VU University, Amsterdam, the Netherlands
| | - C B Lambalk
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
| | - Cjm de Groot
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
| | - Wjk Hehenkamp
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
| | - Jaf Huirne
- VU University Medical Centre, Department of Obstetrics and Gynaecology, Research Institutes 'ICaR-VU' and 'Reproduction and Development', Amsterdam, the Netherlands
| |
Collapse
|
11
|
Di Spiezio Sardo A, Saccone G, McCurdy R, Bujold E, Bifulco G, Berghella V. Risk of Cesarean scar defect following single- vs double-layer uterine closure: systematic review and meta-analysis of randomized controlled trials. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:578-583. [PMID: 28070914 DOI: 10.1002/uog.17401] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 12/17/2016] [Accepted: 01/01/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVE There is a growing body of evidence that suggests that the surgical technique for uterine closure following Cesarean delivery influences the healing of the Cesarean scar, but there is still no consensus on the optimal technique. The aim of this systematic review and meta-analysis was to compare the effect of single- vs double-layer uterine closure on the risk of uterine scar defect. METHODS MEDLINE, Scopus, ClinicalTrials.gov, PROSPERO, EMBASE and the Cochrane Central Register of Controlled Trials were searched from inception of each database until May 2016. All randomized controlled trials (RCTs) evaluating the effect of single- vs double-layer uterine closure following low transverse Cesarean section on the risk of uterine scar defect were included. The primary outcome was the incidence of uterine scar defects detected on ultrasound. Secondary outcomes were residual myometrial thickness evaluated by ultrasound and the incidence of uterine dehiscence and/or rupture in subsequent pregnancy. Summary measures were reported as relative risk (RR) or mean difference (MD), with 95% CIs. Quality of the evidence was assessed using the GRADE approach. RESULTS Nine RCTs (3969 participants) were included in the meta-analysis. The overall risk of bias of the included trials was low. Statistical heterogeneity within the studies was low, with no inconsistency in the primary and secondary outcomes. Women who received single-layer uterine closure had a similar incidence of uterine scar defects as did women who received double-layer closure (25% vs 43%; RR, 0.77 (95% CI, 0.36-1.64); five trials; 350 participants; low quality of evidence). Compared with double-layer uterine closure, women who received single-layer closure had a significantly thinner residual myometrium on ultrasound (MD, -2.19 mm (95% CI, -2.80 to -1.57 mm); four trials; 374 participants; low quality of evidence). No difference was found in the incidence of uterine dehiscence (0.4% vs 0.2%; RR, 1.34 (95% CI, 0.24-4.82); three trials; 3421 participants; low quality of evidence) or uterine rupture (0.1% vs 0.1%; RR, 0.52 (95% CI, 0.05-5.53); one trial; 3234 participants; low quality of evidence) in a subsequent pregnancy. CONCLUSIONS Single- and double-layer closure of the uterine incision following Cesarean delivery are associated with a similar incidence of Cesarean scar defects, as well as uterine dehiscence and rupture in a subsequent pregnancy. However, the quality level of summary estimates, as assessed by GRADE, was low, indicating that the true effect may be, or is even likely to be, substantially different from the estimate of the effect. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- A Di Spiezio Sardo
- Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy
| | - G Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - R McCurdy
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - E Bujold
- Department of Obstetrics and Gynecology, Faculty of Medicine, Laval University, Québec, Canada
| | - G Bifulco
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - V Berghella
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| |
Collapse
|
12
|
Huirne JAF, Stegwee SI, van der Voet LF, de Groot CJM, Hehenkamp WJK, Brölmann HAM. Re: Risk of Cesarean scar defect following single- vs double-layer uterine closure. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:664-666. [PMID: 29105218 DOI: 10.1002/uog.18901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- J A F Huirne
- Department of Obstetrics and Gynaecology and Research Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, De Boelelaan, 1117, 1081 HV, Amsterdam, The Netherlands
| | - S I Stegwee
- Department of Obstetrics and Gynaecology and Research Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, De Boelelaan, 1117, 1081 HV, Amsterdam, The Netherlands
| | - L F van der Voet
- Department of Obstetrics and Gynaecology, Deventer Ziekenhuis, Nico Bolkesteinlaan, 75, Deventer, The Netherlands
| | - C J M de Groot
- Department of Obstetrics and Gynaecology and Research Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, De Boelelaan, 1117, 1081 HV, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology and Research Institute Amsterdam Reproduction & Development, VU University Medical Center, Amsterdam, The Netherlands
| | - W J K Hehenkamp
- Department of Obstetrics and Gynaecology and Research Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, De Boelelaan, 1117, 1081 HV, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam, The Netherlands
| | - H A M Brölmann
- Department of Obstetrics and Gynaecology and Research Institute for Cardiovascular Research (ICaR-VU), VU University Medical Center, De Boelelaan, 1117, 1081 HV, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
13
|
Marino R, Capriglione S, Morosetti G, Di Angelo Antonio S, Miranda A, Pazzola M, Lopez S, Patrizi L, Angioli R, Stella P. May intraperitoneal irrigation with Betadine improve cesarean delivery outcomes? Results of a 6 years’ single centre experience. J Matern Fetal Neonatal Med 2017; 31:670-676. [DOI: 10.1080/14767058.2017.1293036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Riccardo Marino
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, San Camillo-Forlanini Hospital, Rome, Italy
| | - Stella Capriglione
- Department of Obstetrics and Gynaecology Campus Bio-Medico, University of Rome, Rome, Italy
| | - Giulia Morosetti
- Department of Biomedicine and Prevention, Section of Gynecology and Obstetrics, University of Rome Tor Vergata, Rome, Italy
| | - Silvia Di Angelo Antonio
- Department of Biomedicine and Prevention, Section of Gynecology and Obstetrics, University of Rome Tor Vergata, Rome, Italy
| | - Andrea Miranda
- Department of Obstetrics and Gynaecology Campus Bio-Medico, University of Rome, Rome, Italy
| | - Marta Pazzola
- Department of Biomedicine and Prevention, Section of Gynecology and Obstetrics, University of Rome Tor Vergata, Rome, Italy
| | - Salvatore Lopez
- Department of Obstetrics and Gynaecology Campus Bio-Medico, University of Rome, Rome, Italy
| | - Lodovico Patrizi
- Department of Biomedicine and Prevention, Section of Gynecology and Obstetrics, University of Rome Tor Vergata, Rome, Italy
| | - Roberto Angioli
- Department of Obstetrics and Gynaecology Campus Bio-Medico, University of Rome, Rome, Italy
| | - Paolo Stella
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, San Camillo-Forlanini Hospital, Rome, Italy
| |
Collapse
|