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Shakki Katouli F, Zebardast J, Tavoli Z, Bayani L, Azizinik F, Moradpour M, Mardani R, Meimani N, Fathi S. Evaluation of Association Between Adenomyosis and Cesarean Scar Defect. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:553-560. [PMID: 38088498 DOI: 10.1002/jum.16388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 10/04/2023] [Accepted: 11/25/2023] [Indexed: 02/08/2024]
Abstract
PURPOSE This study aims to investigate and compare quantitative factors of the cesarean scar defect (CSD) in symptomatic patients with and without uterine adenomyosis. METHOD This study was conducted as a case-control study. Patients who met the inclusion criteria were divided into two groups: with adenomyosis (case) and without adenomyosis (control). The demographic data, medical history, and sonohysterography findings were extracted from the patient's documents and archived images. RESULT During 2 years, 310 symptomatic women with a history of previous cesarean section underwent sonohysterography. Among them, 204 patients met the inclusion criteria. The most common chief complaints were post-menstrual bleeding (34.3%) and prolonged bleeding (27%). Cesarean scar depth and width significantly differed between these two groups, and patients with underlying adenomyosis had significantly larger defects (P-value of .009 and .005, respectively). Mean RMT/AMT ratio was 31.83% in the case group and 42.88% in the control group. In our study, RMT/AMT ratios were significantly lower in the case group (P-value of .001). In addition, we performed analysis on a subgroup of patients with one prior cesarean section. Similar results were achieved with a lower RMT/AMT ratio in case group (mean of 31.20% in case group and 46.47% in control group; P-value of .000). CONCLUSION Our study showed a strong association between the presence of adenomyosis and larger clinically more significant CSDs. To establish a causative relationship, we suggest a prospective cohort study to follow up the patients and compare the evolution of CSD in patients with and without adenomyosis.
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Affiliation(s)
- Fatemeh Shakki Katouli
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Science, Tehran, Iran
- Department of Radiology, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Jayran Zebardast
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Science, Tehran, Iran
- Department of Cognitive Linguistics, Institute for Cognitive Science Studies (ICSS), Tehran, Iran
| | - Zahra Tavoli
- Department of Obstetrics and Gynecology, Ziaeeian Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Bayani
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Science, Tehran, Iran
- Department of Radiology, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fahimeh Azizinik
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Science, Tehran, Iran
- Department of Radiology, Yas and Amir-Alam Hospitals, Tehran University of Medical Sciences, Tehran, Iran
| | - Moein Moradpour
- Department of Radiology, Taleghani Hospital, Shahid Beheshti Medical University, Tehran, Iran
| | - Reza Mardani
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Science, Tehran, Iran
- Department of Radiology, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Najme Meimani
- Research Center of Biomedical Technology and Robotics (RCBTR), Advanced Medical and Technologies and Equipment Institute (AMTEI), Tehran University of Medical Sciences, Tehran, Iran
| | - Somayeh Fathi
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Science, Tehran, Iran
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2
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Wilson RD. Fostering Excellence in Obstetrical Surgery. J Healthc Leadersh 2023; 15:355-373. [PMID: 38046534 PMCID: PMC10691271 DOI: 10.2147/jhl.s404498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/13/2023] [Indexed: 12/05/2023] Open
Abstract
Introduction This obstetric surgery review is directed toward the common obstetrical surgeries (caesarean delivery, VBAC/TOLAC, operative vaginal delivery, placenta accreta spectrum) with evidence for quality and safety to allow for obstetrical outcome excellence. Materials and Methods This focused scoping review has used a structured process for article identification and inclusion for each of the focused surgeries. Results The review results provide an obstetrical surgery (OS) overview for caesarean delivery, vaginal birth after caesarean delivery and/or trial of labor after caesarean delivery, operative vaginal delivery, placenta accreta spectrum; considerations for quality and safety variance due to non-clinical human factors; quality improvement (QI) tools; OS QI implementation cohorts; implementation considering certain barriers and solutions. Conclusion Administrative health care systems and obstetrical surgery care providers cannot afford, not to consider and implement, certain evidenced-based "bottom-up/top-down" processes for quality and safety, as the patients will demand the quality and the safety, but the lawyers should not have to enforce it.
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Affiliation(s)
- R Douglas Wilson
- Department of Obstetrics and Gynecology, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
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3
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Backer S, Khanna D, Sadr S, Khatibi A. Intra-operative Guidelines for the Prevention of Uterine Niche Formation in Cesarean Sections: A Review. Cureus 2023; 15:e44521. [PMID: 37790067 PMCID: PMC10544643 DOI: 10.7759/cureus.44521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
Formation of a uterine niche following a C-section can predispose the patient to future obstetric complications such as dehiscence, uterine rupture, ectopic pregnancy, and placenta accreta. The significant morbidity and mortality of these complications along with increasing C-section rates emphasizes the importance of prevention. However, there are no clear guidelines on intra-operative protocol to prevent postpartum niche formation. Besides surgical technique, the novel use of platelet-rich plasma (PRP) and mesenchymal stem cell (MSC) injections has demonstrated promising potential and may have applications in hysterotomy closures. The objective is to examine current research on optimal C-section procedures to prevent uterine niche formation and subsequent obstetric complications. A systematic review was conducted using PubMed and Google Scholar. Initial searches yielded 827 results. Inclusion criteria were human, animal, and in-vitro studies, peer-reviewed sources, and outcomes pertinent to the uterine niche. Exclusion criteria applied to articles with outcomes unrelated to myometrium and interventions outside of the intra-operative and immediate pre-/post-operative period. Based on the criteria, 41 articles were cited. Pathophysiology of uterine niche formation was associated with incisions through cervical tissue, adhesion formation, and poor approximation. Significant risk factors were low uterine incisions, advanced cervical dilatation, low station, non-closure of the peritoneum, and creation of a bladder flap. There was no consensus on uterine closure as it likely depends on surgical proficiency with the given technique, but a double-layered non-locking suture appears reliable to reduce niche severity. Recent trials indicate that intra-operative PRP/MSC injections may decrease niche incidence and severity, but more research is needed. If prevention or minimization of uterine niche is desired, the optimal C-section protocol should avoid low uterine incisions, choose uterine closure technique based on the surgeon's proficiency (double-layered non-locking is reliable), and close the peritoneum, and myometrial injection of PRP/MSC may be a useful adjunct intervention pending further clinical evidence.
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Affiliation(s)
- Sean Backer
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Tampa, USA
| | - Deepesh Khanna
- Foundational Sciences, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
| | - Sonia Sadr
- Foundational Sciences, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Ali Khatibi
- Obstetrics and Gynaecology, Sahlgrenska University Hospital, Gothenburg, SWE
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4
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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.
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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.
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5
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Klein Meuleman SJM, Min N, Hehenkamp WJK, Post Uiterweer ED, Huirne JAF, de Leeuw RA. The definition, diagnosis, and symptoms of the uterine niche - A systematic review. Best Pract Res Clin Obstet Gynaecol 2023; 90:102390. [PMID: 37506497 DOI: 10.1016/j.bpobgyn.2023.102390] [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: 04/19/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023]
Abstract
Of all neonates, 21% are delivered by cesarean section (CS). A long-term maternal complication of an SC is a uterine niche. The aim of this review is to provide an overview of the current literature on imaging techniques and niche-related symptomatology. We performed systematic searches on imaging and niche symptoms. For both searches, 87 new studies were included. Niche evaluation by transvaginal sonography (TVS) or contrast sonohysterography (SHG) proved superior over hysteroscopy or magnetic resonance imaging. Studies that used SHG in a random population identified a niche prevalence of 42%-84%. Niche prevalence differed based on niche definition, symptomatology, and imaging technique. Most studies reported an association with gynecological symptoms, poor reproductive outcomes, obstetrical complications, and reduced quality of life. In conclusion, non-invasive TVS and SHG are the superior imaging modalities to diagnose a niche. Niches are prevalent and strongly associated with gynecological symptoms and poor reproductive outcomes.
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Affiliation(s)
- S J M Klein Meuleman
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - N Min
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - W J K Hehenkamp
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands.
| | - E D Post Uiterweer
- Amsterdam University Medical Center, Location Amsterdam Medical Center, Uterine Repair Center, Department of Obstetrics & Gynaecology, Meibergdreef 9, Amsterdam, the Netherlands.
| | - J A F Huirne
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - R A de Leeuw
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
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Saccone G, De Angelis MC, Zizolfi B, Gragnano E, Musone M, Zullo F, Bifulco G, Sardo ADS. Monofilament vs multifilament suture for uterine closure at the time of cesarean delivery: a randomized clinical trial. Am J Obstet Gynecol MFM 2022; 4:100592. [DOI: 10.1016/j.ajogmf.2022.100592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/01/2022] [Indexed: 11/29/2022]
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7
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de Luget CD, Becchis E, Fernandez H, Donnez O, Quarello E. Can uterine niche be prevented? J Gynecol Obstet Hum Reprod 2021; 51:102299. [PMID: 34958983 DOI: 10.1016/j.jogoh.2021.102299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 12/12/2021] [Accepted: 12/20/2021] [Indexed: 12/31/2022]
Abstract
Uterine niche is a potential significant consequence of Caesarean section and is diagnosed by ultrasound. The timing of Caesarean section (during pre, early or advanced labour), location of the incision (distance from the internal os), techniques for opening and closing the uterine cavity, and bladder flap have been frequently mentioned in the literature, however, these factors continue to be a source of disagreement with respect to whether they increase the risk of uterine niche or protect against this complication. In this review, we outline and discuss the possible risk factors that may be responsible for this entity. The main factor upon which obstetricians can act is the rate of first Caesarean section, which can and should be reduced. Moreover, a rather high incision at a distance from the internal os, and a sparing use of bladder detachment should be always kept in mind as well.
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Affiliation(s)
- Claire Delage de Luget
- Service de Gynécologie-Obstétrique-AMP, Hôpital Saint Joseph, 26 Bd de Louvain, 13285 Marseille Cedex, France
| | - Elise Becchis
- Service de Gynécologie-Obstétrique-AMP, Hôpital Saint Joseph, 26 Bd de Louvain, 13285 Marseille Cedex, France
| | - Hervé Fernandez
- Service de gynécologie et obstétrique, Hôpital de Bicêtre, AP-HP, Le Kremlin Bicêtre, France, Université Paris-Saclay
| | - Olivier Donnez
- Institut du sein et de Chirurgie gynécologique d'Avignon (ICA), Polyclinique Urbain V (Groupe Elsan), Avignon, France
| | - Edwin Quarello
- Service de Gynécologie-Obstétrique-AMP, Hôpital Saint Joseph, 26 Bd de Louvain, 13285 Marseille Cedex, France.; Centre Image2, 6 rue Rocca, 13008 Marseille, France..
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8
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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.
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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
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9
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Post-caesarean Niche (Isthmocele) in Uterine Scar: An Update. J Obstet Gynaecol India 2021; 70:440-446. [PMID: 33417629 DOI: 10.1007/s13224-020-01370-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/01/2020] [Indexed: 10/23/2022] Open
Abstract
Uterine niche is one of the emerging complications of caesarean section. With rising caesarean rates, the caesarean-related iatrogenic complications are also on the rise. These include placenta accreta, scar ectopic pregnancy and uterine niche which is a newer entity being described in the recent literature. Uterine niche, also described as uterine isthmocele, caesarean scar defect and diverticulum, is an iatrogenic defect in the myometrium at the site of previous caesarean scar due to defective tissue healing. Patients may have varied symptoms including abnormal uterine bleeding, post-menstrual spotting and infertility, though many women may be asymptomatic and diagnosed incidentally. Diagnosis is made radiologically by transvaginal sonography, saline instillation sonohysterography or magnetic resonance imaging. Occurrence of niche may be prevented by using correct surgical technique during caesarean. Patients may be managed medically; however, subfertility and persistent symptoms may require surgical correction either by hysteroscopic resection or transabdominal or transvaginal repair. This mini-review comprehensively covers the potential risk factors, clinical presentation, diagnosis and management of this increasingly encountered condition due to rising caesarean rates.
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Yılmaz Baran Ş, Kalaycı H, Doğan Durdağ G, Yetkinel S, Alemdaroğlu S, Çok T, Bulgan Kılıçdağ E. Single- or double-layer uterine closure techniques following cesarean: A randomized trial. Acta Obstet Gynecol Scand 2020; 100:531-537. [PMID: 33029804 DOI: 10.1111/aogs.14018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Cesarean deliveries are commonly performed throughout the world. Although the uterine closure technique following this procedure may influence how the uterine scar heals, there is insufficient evidence for choosing the appropriate technique and so preventing long-term negative consequences. This prospective, randomized study examined the effects of single- and double-layer uterine closure techniques on uterine scar healing following cesarean delivery. MATERIAL AND METHODS This study assessed a total of 282 women aged 18-45 years who were in gestational weeks 24-41 of singleton pregnancies. None had previously undergone uterine surgeries. These participants completed their first cesarean deliveries at the time of study and were randomized into the following two treatment groups: single-layer closure with locking and double-layer closure with locking in the first layer, but not in the second layer (NCT03629028). However, the decidua was not included for treatment in either group. Participants were evaluated at 6-9 months after cesarean section by saline infusion sonohysterography to assess cesarean delivery scar defects. These procedures were conducted by experienced sonographers who were not aware of the uterine closure technique. RESULTS Of the 225 final participants, 109 received the single-layer closure technique, whereas 116 received the double-layer technique. The niche rates were 37% (n = 40) for the single-layer group and 45.7% (n = 53) for the double-layer group (P = .22, relative risk 1.4, 95% CI = 0.8-4.4). CONCLUSIONS The single- and double-layer closure techniques did not produce different impacts on uterine scar niche development.
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Affiliation(s)
- Şafak Yılmaz Baran
- Department of Obstetrics and Gynecology, Başkent University Faculty of Medicine, Adana, Turkey
| | - Hakan Kalaycı
- Department of Obstetrics and Gynecology, Başkent University Faculty of Medicine, Adana, Turkey
| | - Gülşen Doğan Durdağ
- Department of Obstetrics and Gynecology, Başkent University Faculty of Medicine, Adana, Turkey
| | - Selçuk Yetkinel
- Department of Obstetrics and Gynecology, Başkent University Faculty of Medicine, Adana, Turkey
| | - Songül Alemdaroğlu
- Department of Obstetrics and Gynecology, Başkent University Faculty of Medicine, Adana, Turkey
| | - Tayfun Çok
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and IVF Unit, Başkent University Faculty of Medicine, Adana, Turkey
| | - Esra Bulgan Kılıçdağ
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and IVF Unit, Başkent University Faculty of Medicine, Adana, Turkey
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11
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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.
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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
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