The risk of uterine rupture is not increased with single- compared with double-layer closure: a Swedish cohort study

Trial of labor after cesarean, vaginal birth after cesarean, and the risk of uterine rupture: an expert review

The decision to pursue a trial of labor after cesarean delivery is complex and depends on patient preference, the likelihood of successful vaginal birth after cesarean delivery, assessment of the risks vs benefits of trial of labor after cesarean delivery, and available resources to support safe trial of labor after cesarean delivery at the planned birthing center. The most feared complication of trial of labor after cesarean delivery is uterine rupture, which can have catastrophic consequences, including substantial maternal and perinatal morbidity and mortality. Although the absolute risk of uterine rupture is low, several clinical, historical, obstetrical, and intrapartum factors have been associated with increased risk. It is therefore critical for clinicians managing patients during trial of labor after cesarean delivery to be aware of these risk factors to appropriately select candidates for trial of labor after cesarean delivery and maximize the safety and benefits while minimizing the risks. Caution is advised when considering labor augmentation and induction in patients with a previous cesarean delivery. With established hospital safety protocols that dictate close maternal and fetal monitoring, avoidance of prostaglandins, and careful titration of oxytocin infusion when induction agents are needed, spontaneous and induced trial of labor after cesarean delivery are safe and should be offered to most patients with 1 previous low transverse, low vertical, or unknown uterine incision after appropriate evaluation, counseling, planning, and shared decision-making. Future research should focus on clarifying true risk factors and identifying the optimal approach to intrapartum and induction management, tools for antenatal prediction, and strategies for prevention of uterine rupture during trial of labor after cesarean delivery. A better understanding will facilitate patient counseling, support efforts to improve trial of labor after cesarean delivery and vaginal birth after cesarean delivery rates, and reduce the morbidity and mortality associated with uterine rupture during trial of labor after cesarean delivery.

Term breech presentation-Intended cesarean section versus intended vaginal delivery-A systematic review and meta-analysis

INTRODUCTION

Three per cent of all infants are born in breech presentation, still the preferred way to deliver them remains controversial. The objective of this systematic review was to assess the safety for the mother and child depending on intended mode of delivery when the baby is in breech position at term.

MATERIAL AND METHODS

The population (P) was pregnant women with a child in breech presentation, from gestational week 34⁺⁰ . The intervention (I) was the intention to deliver by cesarean section, the comparison (C) was the intention to deliver vaginally. Outcomes (O) were perinatal mortality, perinatal morbidity, maternal mortality, maternal morbidity, conversion of delivery mode, and the mother's experience. Systematic literature searches were performed. We included randomized trials, cohort studies with more than 500 women/group and case series for more than 15 000 women published between 1990 and October 2021, written in English or the Nordic languages. The certainty of evidence was assessed using the GRADE approach and data were pooled in meta-analyses. PROSPERO registration number: CRD42020209546.

RESULTS

Thirty-two articles were included (with 530 604 women). The certainty of evidence was moderate or low because the study designs were mostly retrospective cohort studies. The only randomized trial showed reduced risk of perinatal mortality for planned cesarean section, risk ratio (RR) 0.27 (95% confidence interval [CI] 0.08-0.97, 2078 women, low certainty of evidence), stillbirths excluded. A meta-analysis of cohort studies resulted in a similar estimate, RR 0.36 (95% CI 0.25-0.51, 21 studies, 388 714 women, low certainty of evidence). We also found reduced risk for outcomes representing perinatal morbidity 0-28 days: 5-min Apgar score less than 7 in one randomized controlled trial: RR 0.27 (95% CI 0.12-0.58, 2033 women, moderate certainty of evidence), and in a meta-analysis: RR 0.1 (95% CI 0.14-0.26, 18 studies, 217 024 women, moderate certainty of evidence); APGAR score less than 4 at 5 min: RR 0.39 (95% CI 0.19-0.81, five studies, 44 498 women, low certainty of evidence); and pH less than 7.0: RR 0.23 (95% CI 0.12-0.43, four studies, 13 440 women, low certainty of evidence). Outcomes for the mother were similar in the groups except for reduced risk for experience of urinary incontinence in the group of planned cesarean section: RR 0.62 (95% CI 0.41-0.93, one study, 1940 women, low certainty of evidence). The conversion rate from planned vaginal delivery to emergency cesarean section ranged from 16% to 51% (median 41.8%, 10 studies, 50 763 women, moderate certainty of evidence).

CONCLUSIONS

Intended cesarean section may reduce the risk of perinatal mortality and perinatal as well as some maternal morbidity compared with intended vaginal delivery. It is uncertain whether there is any difference in maternal mortality. The conversion rate from intended vaginal delivery to emergency cesarean section is high.

Risk factors and outcomes associated with type of uterine rupture

PURPOSE

To identify risk factors associated with the occurrence of complete uterine rupture (CUR) in comparison to partial uterine rupture (PUR) to further investigate to what extent a standardized definition is needed and what clinical implications can be drawn.

METHODS

Between 2005 and 2017 cases with CUR and PUR at Charité University Berlin, Germany were retrospectively identified. Demographic, obstetric and outcome variables were analyzed regarding the type of rupture. Binary multivariate regression analysis was conducted to identify risk factors associated with CUR. In addition, the intended route of delivery (trial of labor after cesarean delivery (TOLAC) and elective repeat cesarean delivery (ERCD)), divided according to the type of rupture, was compared.

RESULTS

92 cases with uterine rupture were identified out of a total of 64.063 births (0.14%). Puerperal complications were more frequent in CUR (67.9 versus 41.1%, p = 0.021). Multiparity ≥ 3 was more frequent in CUR (31 versus 10.7%, p = 0.020). Factors increasing the risk for CUR were parity ≥ 3 (OR = 3.8, p = 0.025), previous vaginal birth (OR = 4.4, p = 0.011), TOLAC (OR = 6.5, p < 0.001) and the use of oxytocin (OR = 2.9, p = 0.036). After multivariate analysis, the only independent risk factor associated with CUR was TOLAC (OR = 7.4, p = 0.017).

CONCLUSION

TOLAC is the only independent risk factor for CUR. After optimized antenatal counselling TOLAC and ERCD had comparable short-term maternal and fetal outcomes in a high resource setting. A high number of previous vaginal births does not eliminate the risk of uterine rupture. A clear distinction between CUR and PUR is essential to ensure comparability among studies.

Single- Versus Double-Layer Uterine Closure After Cesarean Section Delivery: A Systematic Review and Meta-Analysis

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.

Time matters-a Swedish cohort study of labor duration and risk of uterine rupture

INTRODUCTION

Uterine rupture is an obstetric emergency associated with maternal and neonatal morbidity. The main risk factor is a prior cesarean section, with rupture occurring in subsequent labor. The aim of this study was to assess the risk of uterine rupture by labor duration and labor management.

MATERIAL AND METHODS

This is a Swedish register-based cohort study of women who underwent labor in 2013-2018 after a primary cesarean section (n = 20 046). Duration of labor was the main exposure, calculated from onset of regular labor contractions and birth; both timepoints were retrieved from electronic medical records for 12 583 labors, 63% of the study population. Uterine rupture was calculated as events per 1000 births at different timepoints during labor. Risk estimates for uterine rupture by labor duration, induction of labor, use of oxytocin and epidural analgesia were calculated using Poisson regression, adjusted for maternal and birth characteristics. Estimates were presented as adjusted rate ratios (ARR) with 95% confidence intervals (CI).

RESULTS

The prevalence of uterine rupture was 1.4% (282/20 046 deliveries). Labor duration was 9.88 hours (95% CI 8.93-10.83) for women with uterine rupture, 8.20 hours (95% CI 8.10-8.31) for women with vaginal delivery, and 10.71 hours (95% CI 10.46-10.97) for women with cesarean section without uterine rupture. Few women (1.0/1000) experienced uterine rupture during the first 3 hours of labor. Uterine rupture occurred in 15.6/1000 births with labor duration over 12 hours. The highest risk for uterine rupture per hour compared with vaginal delivery was observed at 6 hours (ARR 1.20, 95% CI 1.11-1.30). Induction of labor was associated with uterine rupture (ARR 1.54, 95% CI 1.19-1.99), with a particular high risk seen in those induced with prostaglandins and no risk observed with cervical catheter (ARR 1.19, 95% CI 0.83-1.71). Labor augmentation with oxytocin (ARR 1.60, 95% CI 1.25-2.05) and epidural analgesia (ARR 1.63, 95% CI 1.27-2.10) were also associated with uterine rupture.

CONCLUSIONS

Labor duration is an independent factor for uterine rupture among women attempting vaginal delivery after cesarean section. Medical induction and augmentation of labor increase the risk, regardless of maternal and birth characteristics.

Delivery after fetal death in women with earlier cesarean section. A review

The clinical management of intrauterine fetal demise (IUFD) in women with a previous cesarean delivery presents a dilemma for the obstetrician. With the current reluctance of obstetricians to perform vaginal birth after cesarean (VBAC) and the paucity of data to counsel women regarding maternal risks, management options are limited by physician's clinical experience and biases. In the setting of fetal demise, maternal safety becomes the primary concern. Medicolegal pressures may prevent physicians from attempting a trial of labor in this situation. In this review we will a focus on frequency of birth with IUFD after cesarean section (CS), we discuss the options (VBAC vs CS), different complications, methods for induction of vaginal birth as well as risk factors of vaginal birth and cesarean delivery.

Resection of deep-infiltrating endometriosis could be a risk factor for uterine rupture: a case series with review of the literature

Objective

To highlight the possible correlation between deep-infiltrating endometriosis (DIE) resection and subsequent uterine rupture.

Design

Case series and review of the literature.

Setting

Endometriosis referral hospitals.

Patient(s)

Seven young women who underwent laparoscopic resection of DIE, six of whom had uterine rupture before or during labor; the seventh patient had a posterior wall defect that placed her at increased risk of future uterine rupture.

Intervention(s)

Diagnosis of uterine rupture before or during labor in patients with a history of prior resection of DIE, leading to delivery by emergency delivery section or emergency laparotomy for exploration and repair.

Main Outcome Measure(s)

Immediate neonate and maternal salvaging caesarean delivery or laparotomy followed by surgical correction of the rupture.

Result(s)

As of 2019, no publications in the literature had considered uterine rupture among the obstetric complications of endometriosis. The reporting of such findings is crucial because of the increase in surgical management of endometriosis. We report seven cases of uterine rupture in pregnancy in women who had undergone resection of DIE. In six patients, surgeons found uterine rupture at the level of the previous resected endometriosis and diagnosed a posterior wall defect at the same level in one patient.

Conclusion(s)

Our case series sheds light on the potential increased risk of uterine rupture during pregnancy among women who have had a prior resection of DIE. In future, if these patients are considered high-risk pregnancy cases, their care should be managed by high-risk obstetric specialists.

Ultrasound cesarean scar assessment one year postpartum in relation to one- or two-layer uterine suture closure

INTRODUCTION

This study compared healing of the scars after cesarean section during the first postpartum year using a single- or double-layer suturing technique. Scarring was assessed by a transvaginal ultrasound. We explored the appearance and localization of uterine scars with regard to the obstetric history. Our aim was to compare the position of the scar or defect, if present, its dimensions, and any residual myometrium with respect to the suturing technique during the cesarean section.

MATERIAL AND METHODS

Women with uncomplicated singleton pregnancies indicated for elective or acute cesarean section were randomly allocated to the uterine closure technique group. During the first postpartum year, their lower uterine segment was examined with a transvaginal ultrasound in three consecutive visits at 6 weeks, 6 months and 12 months.

RESULTS

324 women attended the 12-month visit; of these, 149 underwent single-layer closure of the uterine incision and 175 double-layer technique. A higher proportion of the defects is seen in the single-layer closure technique of suturing. Defects in the single-layer group were wider (0.002) and the residual myometrial thickness in the single-layer group were thinner (0.019). Women who underwent cesarean section at the stage of full cervical dilation had scars that were closer to the external cervical os (0.000). The position of the uterus varies greatly between controls (0.000). The combination of uterine position and scar defect presence changed significantly between controls (0.001), and was significantly dependent on the suturing method (0.003). Defects with or without contact with the uterine cavity changed statistically between controls (0.017). Both types of defects were more common in the single-layer closure technique group.

CONCLUSIONS

The findings of this study demonstrate that double-layer technique with the first continuous nonlocking suture followed by a second continuous nonlocking suture is associated with better suture healing and greater residual myometrial thickness. No difference was observed between single- and double-layer closure for the presence of maternal infectious morbidity, wound infection or blood transfusion.

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

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.

Obstetric emergencies as antecedents to neonatal hypoxic ischemic encephalopathy, does parity matter?

INTRODUCTION

Our aim was to investigate the risk of moderate to severe hypoxic ischemic encephalopathy (HIE) by obstetric emergencies, with focus on the distribution of obstetric emergencies by parity, taking the history of a previous cesarean into account.

MATERIAL AND METHODS

Population-based cohort study of 692 428 live births at ≥ 36 weeks of gestation in Sweden, 2009-2015. Data were retrieved by linking the Swedish Medical Birth Register with the Swedish Neonatal Quality Register. Therapeutic hypothermia served as surrogate for moderate to severe HIE. Logistic regression analysis was used to estimate associations between HIE and placental abruption, eclampsia, cord prolapse, uterine rupture, and shoulder dystocia, presented as adjusted odds ratios (aORs) with 95% CI.

RESULTS

An obstetric emergency occurred in 133/464 (29%) of all HIE cases, more commonly in the parous (overall 37%; 48% with and 31% without a previous cesarean) than in the nulliparous (21%). Among nulliparas, shoulder dystocia was the most common obstetric emergency with the strongest association with HIE (aOR 48.2; 95% CI 28.2-82.6). In parous women without a previous cesarean, shoulder dystocia was most common, but placental abruption had the strongest association with HIE. Among parous women with a previous cesarean, uterine rupture was the most prevalent obstetric emergency with the strongest association with HIE (aOR 45.6; 95% CI 24.5-84.6).

CONCLUSIONS

Obstetric emergencies are common among cases of moderate to severe HIE. The strong association with shoulder dystocia in nullipara, and with uterine rupture in women with previous cesarean deliveries, implies an opportunity for reducing the incidence of HIE.

Induction of labor after one previous Cesarean section in women with an unfavorable cervix: A retrospective cohort study

Objective

Uterine rupture is a well-known but unusual complication in vaginal deliveries with a Cesarean section in the history. The risk of uterine rupture is at least two-fold when labor is induced. In Sweden, women are allowed to deliver vaginally after one previous Cesarean section, regardless if labor starts spontaneously or is induced. The aim of the study is to compare the proportion of uterine ruptures between the three methods (balloon catheter, Minprostin® and Cytotec®) for induction of labor in women with an unfavorable cervix and one previous Cesarean section.

Material and methods

Retrospective cohort study of all women with one previous Cesarean section and induction of labor with an unfavorable cervix at the four largest clinics in Stockholm during 2012–2015. Inclusion criteria: Women with a previous Cesarean section and induction of labor with a viable fetus, cephalic presentation, singleton, at ≥34 w, (n = 910).

Results

3.0% (27/910) of the women with induction of labor had a uterine rupture, 91% of them had no previous vaginal delivery. The proportion of uterine ruptures was 2.0% (6/295) with orally administrated Cytotec®, 2.1% (7/335) with balloon catheter and 5.0% (14/ 281) when Minprostin® was used.

Conclusions

No difference in the proportion of uterine ruptures was shown when orally administrated Cytotec® and balloon catheter were compared (p = 0.64). Orally administrated Cytotec® and balloon catheter give a high success rate of vaginal deliveries (almost 70%) despite an unfavorable cervix.

Operative technique at caesarean delivery and risk of complete uterine rupture in a subsequent trial of labour at term. A registry case-control study

Objective

To estimate the relation of single-layer closure at previous caesarean delivery, and other pre-labour and intra-partum risk factors for complete uterine rupture in trial of vaginal birth after a caesarean (TOLAC) at term.

Study design

Population-based case-control study. We identified all women (n = 39 742) recorded in the Danish Medical Birth Registry (DMBR) during a 12-year period (1997–2008) with a singleton pregnancy at term and TOLAC. Among these, all women with a complete uterine rupture were identified (cases). Information from the registry was validated against medical records. Controls were selected in the DMBR as the following two births with TOLAC at term and no uterine rupture. Detailed information from cases and controls was collected from manual review of medical records. Main outcome measure was complete uterine rupture during TOLAC at term.

Results

Upon validation, 175 cases and 272 controls met the above criteria. After adjustment for possible confounding factors there was no association between single layer closure and uterine rupture (aOR 1.38, CI: 0.88–2.17). Significant risk factors were: Induction with an unfavourable cervix (aOR 2.10 CI: 1.19–3.71), epidural (aOR 2.17 CI 1.31–3.57), augmentation by oxytocin for more than one hour (aOR 2.03 CI: 1.20–3.44), and birth weight ≥ 4000g (aOR 2.65 CI 1.05–6.64). Previous vaginal delivery (aOR 0.41 CI: 0.25–0.68) and inter-delivery interval of more than 24 months (aOR 0.38 CI: 0.18–0.78) reduced the risk of uterine rupture.

Conclusion

Single-layer uterine closure did not remain significantly associated to uterine rupture during TOLAC at term after adjustment for confounding factors. Induction of labour with an unfavourable cervix, birth weight ≥ 4000g and indicators of prolonged labour were all major risk factors for uterine rupture.

Risk of Cesarean scar defect following single- vs double-layer uterine closure: systematic review and meta-analysis of randomized controlled trials

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.

Single versus double-layer uterine closure at cesarean: impact on lower uterine segment thickness at next pregnancy

BACKGROUND

Uterine rupture is a potential life-threatening complication during a trial of labor after cesarean delivery. Single-layer closure of the uterus at cesarean delivery has been associated with an increased risk of uterine rupture compared with double-layer closure. Lower uterine segment thickness measurement by ultrasound has been used to evaluate the quality of the uterine scar after cesarean delivery and is associated with the risk of uterine rupture.

OBJECTIVE

To estimate the impact of previous uterine closure on lower uterine segment thickness.

STUDY DESIGN

Women with a previous single low-transverse cesarean delivery were recruited at 34-38 weeks' gestation. Transabdominal and transvaginal ultrasound evaluation of the lower uterine segment thickness was performed by a sonographer blinded to clinical data. Previous operative reports were reviewed to obtain the type of previous uterine closure. Third-trimester lower uterine segment thickness at the next pregnancy was compared according to the number of layers sutured and according to the type of thread for uterine closure, using weighted mean differences and multivariate logistic regression analyses.

RESULTS

Of 1613 women recruited, with operative reports available, 495 (31%) had a single-layer and 1118 (69%) had a double-layer closure. The mean third-trimester lower uterine segment thickness was 3.3 ± 1.3 mm and the proportion with lower uterine segment thickness <2.0 mm was 10.5%. Double-layer closure of the uterus was associated with a thicker lower uterine segment than single-layer closure (weighted mean difference: 0.11 mm; 95% confidence interval [CI], 0.02 to 0.21 mm). In multivariate logistic regression analyses, a double-layer closure also was associated with a reduced risk of lower uterine segment thickness <2.0 mm (odd ratio [OR], 0.68; 95% CI, 0.51 to 0.90). Compared with synthetic thread, the use of catgut for uterine closure had no significant impact on third-trimester lower uterine segment thickness (WMD: -0.10 mm; 95% CI, -0.22 to 0.02 mm) or on the risk of lower uterine segment thickness <2.0 mm (OR, 0.95; 95% CI, 0.67 to 1.33). Finally, double-layer closure was associated with a reduced risk of uterine scar defect (RR, 0.32; 95% CI, 0.17 to 0.61) at birth.

CONCLUSION

Compared with single-layer closure, a double-layer closure of the uterus at previous cesarean delivery is associated with a thicker third-trimester lower uterine segment and a reduced risk of lower uterine segment thickness <2.0 mm in the next pregnancy. The type of thread for uterine closure has no significant impact on lower uterine segment thickness.

Maternal complications in settings where two-thirds of extremely preterm births are delivered by cesarean section

OBJECTIVE

To investigate the maternal complications associated with cesarean section (CS) in the extremely preterm period according to the gestational week (GW) and to indication of delivery.

STUDY DESIGN

This is a retrospective case-referent study with a review of medical records of women who delivered at 22-27 weeks of gestation (n=647) at two level III units in Sweden. For abdominal delivery, gestational length was stratified into 22-24 (n=105) and 25-27 (n=301) weeks. For comparison, data on women who underwent a CS at term were identified in a register-based database.

RESULTS

The rate of CS in extremely preterm births was 62.8%. There was no difference in the complication rates, but types of incisions other than the low transverse incision were required more often at 22-24 (18.1%) weeks than at 25-27 GWs (9.6%) (P=0.02). Major maternal complications occurred in 6.6% compared with 2.1% in the extremely preterm and term CS, respectively (P<0.01). A maternal indication of extremely preterm CS increased the risk of complications.

CONCLUSIONS

Almost two-thirds of the births at 22-27 GWs had an abdominal delivery. No increase in short-term morbidity was observed at 22-24 weeks compared to 25-27 weeks. CS performed extremely preterm had more major complications recorded than cesarean at term. The complications are driven by the underlying maternal condition.

[About a case of uterine per-partum rupture, 37months after resection of a rectovaginal endometriosis nodule]

Endometriosis is a common condition in women, whose main repercussions are painful symptoms. In addition, it was shown that endometriosis was a major cause of infertility and various obstetric complications could be related to this pathology. Uterine rupture is a rare but serious complication whose incidence tends to decrease with the screening of women at risk, however, its fetal, maternal morbidity and mortality causes remains important. We were confronted with a case of posterior uterine rupture in a patient of 36 years, primipare term exceeded in immediate postpartum period. The patient's primary antecedent of uterine surgery torus was responsible for infertility endometriosis. The outcome was favorable for the mother, after a surgical treatment by laparotomy, and for the child. In the literature, two cases have been reported of uterine rupture after endometriosis surgery, which is why we found it interesting to report this rare case. Given the increase in surgical management of this disease, it seems relevant to ask whether, in the future, we should be more vigilant in monitoring pregnancy for these women.

Impact of adding a second layer to a single unlocked closure of a Cesarean uterine incision: randomized controlled trial

OBJECTIVE

To investigate short- and long-term effects on residual myometrial thickness (RMT) of adding a second layer to a single unlocked closure of a Cesarean uterine incision.

METHODS

This was a randomized double-blind controlled trial. Healthy nulliparous women scheduled for first-time elective Cesarean delivery were operated on using a modified version of the Misgav Ladach surgical technique. The women were examined by transabdominal ultrasound before discharge from the maternity ward and by transvaginal saline contrast sonohysterography at a minimum of 5 months postpartum.

RESULTS

Seventy-six nulliparae met the criteria and agreed to participate in the study. Thirty-five women were assigned to the single-layer technique and 38 to the double-layer unlocked closure technique. Groups were comparable regarding gestational age at delivery, duration of surgery and perioperative blood loss. There was no difference in RMT between the two groups, both at time of discharge (mean ± SD, 20.2 ± 8.0 mm vs 21.0 ± 9.7 mm) and after 5 months postpartum (mean, 5.7 ± 2.9 mm vs 5.7 ± 2.2 mm). RMT was approximately half that of the normal myometrium at both examinations.

CONCLUSION

The results of this study suggest that double-layer closure of a Cesarean uterine incision does not increase RMT compared with single-layer closure when an unlocked technique is used.