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Stegwee SI, Jordans IPM, van der Voet LF, Bongers MY, de Groot CJM, Lambalk CB, de Leeuw RA, Hehenkamp WJK, van de Ven PM, Bosmans JE, Pajkrt E, Bakkum EA, Radder CM, Hemelaar M, van Baal WM, Visser H, van Laar JOEH, van Vliet HAAM, Rijnders RJP, Sueters M, Janssen CAH, Hermes W, Feitsma AH, Kapiteijn K, Scheepers HCJ, Langenveld J, de Boer K, Coppus SFPJ, Schippers DH, Oei ALM, Kaplan M, Papatsonis DNM, de Vleeschouwer LHM, van Beek E, Bekker MN, Huisjes AJM, Meijer WJ, Deurloo KL, Boormans EMA, van Eijndhoven HWF, Huirne JAF. Single- versus double-layer closure of the caesarean (uterine) scar in the prevention of gynaecological symptoms in relation to niche development - the 2Close study: a multicentre randomised controlled trial. BMC Pregnancy Childbirth 2019; 19:85. [PMID: 30832681 PMCID: PMC6399840 DOI: 10.1186/s12884-019-2221-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 02/12/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Double-layer compared to single-layer closure of the uterus after a caesarean section (CS) leads to a thicker myometrial layer at the site of the CS scar, also called residual myometrium thickness (RMT). It possibly decreases the development of a niche, which is an interruption of the myometrium at the site of the uterine scar. Thin RMT and a niche are associated with gynaecological symptoms, obstetric complications in a subsequent pregnancy and delivery and possibly with subfertility. METHODS Women undergoing a first CS regardless of the gestational age will be asked to participate in this multicentre, double blinded randomised controlled trial (RCT). They will be randomised to single-layer closure or double-layer closure of the uterine incision. Single-layer closure (control group) is performed with a continuous running, unlocked suture, with or without endometrial saving technique. Double-layer closure (intervention group) is performed with the first layer in a continuous unlocked suture including the endometrial layer and the second layer is also continuous unlocked and imbricates the first. The primary outcome is the reported number of days with postmenstrual spotting during one menstrual cycle nine months after CS. Secondary outcomes include surgical data, ultrasound evaluation at three months, menstrual pattern, dysmenorrhea, quality of life, and sexual function at nine months. Structured transvaginal ultrasound (TVUS) evaluation is performed to assess the uterine scar and if necessary saline infusion sonohysterography (SIS) or gel instillation sonohysterography (GIS) will be added to the examination. Women and ultrasound examiners will be blinded for allocation. Reproductive outcomes at three years follow-up including fertility, mode of delivery and complications in subsequent deliveries will be studied as well. Analyses will be performed by intention to treat. 2290 women have to be randomised to show a reduction of 15% in the mean number of spotting days. Additionally, a cost-effectiveness analysis will be performed from a societal perspective. DISCUSSION This RCT will provide insight in the outcomes of single- compared to double-layer closure technique after CS, including postmenstrual spotting and subfertility in relation to niche development measured by ultrasound. TRIAL REGISTRATION Dutch Trial Register ( NTR5480 ). Registered 29 October 2015.
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Affiliation(s)
- S. I. Stegwee
- Department of Obstetrics and Gynaecology, Research institutes ‘Amsterdam Cardiovascular Sciences’ and ‘Amsterdam Reproduction and Development’, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
| | - I. P. M. Jordans
- Department of Obstetrics and Gynaecology, Research institutes ‘Amsterdam Cardiovascular Sciences’ and ‘Amsterdam Reproduction and Development’, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
| | - L. F. van der Voet
- Department of Obstetrics and Gynaecology, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE Deventer, the Netherlands
| | - M. Y. Bongers
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, De Run 4600, 5504 DB Veldhoven, the Netherlands
- Department of Obstetrics and Gynaecology, Research school ‘GROW’, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
| | - C. J. M. de Groot
- Department of Obstetrics and Gynaecology, Research institutes ‘Amsterdam Cardiovascular Sciences’ and ‘Amsterdam Reproduction and Development’, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
| | - C. B. Lambalk
- Department of Obstetrics and Gynaecology, Research institutes ‘Amsterdam Cardiovascular Sciences’ and ‘Amsterdam Reproduction and Development’, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
| | - R. A. de Leeuw
- Department of Obstetrics and Gynaecology, Research institutes ‘Amsterdam Cardiovascular Sciences’ and ‘Amsterdam Reproduction and Development’, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
| | - W. J. K. Hehenkamp
- Department of Obstetrics and Gynaecology, Research institutes ‘Amsterdam Cardiovascular Sciences’ and ‘Amsterdam Reproduction and Development’, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
| | - P. M. van de Ven
- Department of Epidemiology and Biostatistics, Vrije Universiteit Amsterdam, De Boelelaan 1105, 1081 HV Amsterdam, the Netherlands
| | - J. E. Bosmans
- Department of Health sciences, Faculty of Science, Research institute ‘Amsterdam Public Health’, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, the Netherlands
| | - E. Pajkrt
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - E. A. Bakkum
- Department of Obstetrics and Gynaecology, OLVG-oost, Oosterpark 9, 1091 AC Amsterdam, the Netherlands
| | - C. M. Radder
- Department of Obstetrics and Gynaecology, OLVG-west, Jan Tooropstraat 164, 1061 AE Amsterdam, the Netherlands
| | - M. Hemelaar
- Department of Obstetrics and Gynaecology, Westfriesgasthuis, Maelsonstraat 3, 1624 NP Hoorn, the Netherlands
| | - W. M. van Baal
- Department of Obstetrics and Gynaecology, Flevo hospital, Hospitaalweg 1, 1315 RA Almere, the Netherlands
| | - H. Visser
- Department of Obstetrics and Gynaecology, Tergooi hospital, Rijksstraatweg 1, 1261 AN Blaricum, the Netherlands
| | - J. O. E. H. van Laar
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, De Run 4600, 5504 DB Veldhoven, the Netherlands
| | - H. A. A. M. van Vliet
- Department of Obstetrics and Gynaecology, Catharina hospital, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands
| | - R. J. P. Rijnders
- Department of Obstetrics and Gynaecology, Jeroen Bosch hospital, Henri Dunantstraat 1, 5223 GZ ‘s-Hertogenbosch, the Netherlands
| | - M. Sueters
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - C. A. H. Janssen
- Department of Obstetrics and Gynaecology, Groene Hart hospital, Bleulandweg 10, 2803 HH Gouda, the Netherlands
| | - W. Hermes
- Department of Obstetrics and Gynaecology, Haaglanden Medical Centre – Westeinde hospital, Lijnbaan 32, 2512 VA Den Haag, the Netherlands
| | - A. H. Feitsma
- Department of Obstetrics and Gynaecology, Haga hospital, Els-Borst-Eilersplein 275, 2545 AA Den Haag, the Netherlands
| | - K. Kapiteijn
- Department of Obstetrics and Gynaecology, Reinier de Graaf hospital, Reinier de Graafweg 5, 2625 AD Delft, the Netherlands
| | - H. C. J. Scheepers
- Department of Obstetrics and Gynaecology, Research school ‘GROW’, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
| | - J. Langenveld
- Department of Obstetrics and Gynaecology, Zuyderland Medical Centre, Henri Dunantstraat 5, 6419 PC Heerlen, the Netherlands
| | - K. de Boer
- Department of Obstetrics and Gynaecology, Rijnstate hospital, Wagnerlaan 55, 6815 AD Arnhem, the Netherlands
| | - S. F. P. J. Coppus
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, the Netherlands
| | - D. H. Schippers
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, the Netherlands
| | - A. L. M. Oei
- Department of Obstetrics and Gynaecology, Bernhoven hospital, Nistelrodeseweg 10, 5406 PT Uden, the Netherlands
| | - M. Kaplan
- Department of Obstetrics and Gynaecology, Röpcke-Zweers hospital, Jan Weitkamplaan 4a, 7772 SE Hardenberg, the Netherlands
| | - D. N. M. Papatsonis
- Department of Obstetrics and Gynaecology, Amphia hospital, Langendijk 75, 4819 EV Breda, the Netherlands
| | - L. H. M. de Vleeschouwer
- Department of Obstetrics and Gynaecology, Sint Franciscus hospital, Kleiweg 500, 3045 PM Rotterdam, the Netherlands
| | - E. van Beek
- Department of Obstetrics and Gynaecology, Sint Antonius hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands
| | - M. N. Bekker
- Department of Obstetrics and Gynaecology, Birth Centre Wilhelmina Children hospital/University Medical Centre Utrecht, Lundlaan 6, 3584 EA Utrecht, the Netherlands
| | - A. J. M. Huisjes
- Department of Obstetrics and Gynaecology, Gelre hospital – location Apeldoorn, Albert Schweitzerlaan 31, 7334 DZ Apeldoorn, the Netherlands
| | - W. J. Meijer
- Department of Obstetrics and Gynaecology, Gelre hospital – location Zutphen, Den Elterweg 77, 7207 AE Zutphen, the Netherlands
| | - K. L. Deurloo
- Department of Obstetrics and Gynaecology, Diakonessenhuis, Bosboomstraat 1, 3582 KE Utrecht, the Netherlands
| | - E. M. A. Boormans
- Department of Obstetrics and Gynaecology, Meander Medical Centre, Maatweg 3, 3813 TZ Amersfoort, the Netherlands
| | - H. W. F. van Eijndhoven
- Department of Obstetrics and Gynaecology, Isala clinics, Dokter van Heesweg 2, 8025 AB Zwolle, the Netherlands
| | - J. A. F. Huirne
- Department of Obstetrics and Gynaecology, Research institutes ‘Amsterdam Cardiovascular Sciences’ and ‘Amsterdam Reproduction and Development’, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands
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Abstract
BACKGROUND Side effects of oral contraceptive pills (OCs) discourage adherence to and continuation of OC regimens. Strategies to decrease adverse effects led to the introduction of the triphasic OC in the 1980s. Whether triphasic OCs have higher accidental pregnancy rates than monophasic pills is unknown. Nor is it known if triphasic pills give better cycle control and fewer side effects than the monophasic pills. OBJECTIVES To compare triphasic OCs with monophasic OCs in terms of efficacy, cycle control, and discontinuation due to side effects. SEARCH STRATEGY We searched the computerized databases of MEDLINE, EMBASE, POPLINE, LILACS and CENTRAL. Additionally, we searched the reference lists of relevant articles and book chapters. We also contacted researchers and pharmaceutical companies in Europe and the U.S. to identify other trials not found in our search. SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing any triphasic OC with any monophasic pill used to prevent pregnancy. Interventions had to include at least three treatment cycles. DATA COLLECTION AND ANALYSIS We assessed the studies found in the literature searches for possible inclusion and for their methodological quality. We contacted the authors of all included studies and of possibly randomized trials for supplemental information about the methods and outcomes studied. We entered the data into RevMan 4.2 and calculated odds ratios for the outcome measures of efficacy, breakthrough bleeding, spotting, withdrawal bleeding and discontinuation. MAIN RESULTS Of 21 trials included, 18 examined contraceptive effectiveness: the triphasic and monophasic preparations did not differ significantly. Several trials reported favorable bleeding patterns, i.e. less spotting, breakthrough bleeding or amenorrhea, in triphasic versus monophasic OC users. However, meta-analysis was generally not possible due to differences in measuring and reporting the cycle disturbance data as well as differences in progestogen type and hormone dosages. No significant differences were found in the numbers of women who discontinued due to medical reasons, cycle disturbances, intermenstrual bleeding or adverse events. AUTHORS' CONCLUSIONS The available evidence is insufficient to determine whether triphasic OCs differ from monophasic OCs in effectiveness, bleeding patterns or discontinuation rates. Therefore, we recommend monophasic pills as a first choice for women starting OC use. Large, high-quality RCTs that compare triphasic and monophasic OCs with identical progestogens are needed to determine whether triphasic pills differ from monophasic OCs. Future studies should follow the WHO recommendations on recording menstrual bleeding patterns and the CONSORT reporting guidelines.
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Affiliation(s)
- H A A M van Vliet
- Leiden University Medical Center, Dep.of Obstetrics, Gynaecology and Reproductive Medecine, Albinusdreef 2, Leiden, Netherlands NL 2300 RC.
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