Ultrasonographic and hysteroscopic outcomes of uterine scar healing after cesarean section: Comparison of two types of single-layer suture

A common problem between gynecology, obstetrics, and reproductive medicine: Cesarean section scar defect

Approximately 60% of patients undergoing Cesarean sections may develop Cesarean Scar Defect (CSD), presenting a significant clinical challenge amidst the increasing Cesarean section rates. This condition, marked by a notch in the anterior uterine wall, has evolved as a notable topic in gynecological research. The multifactorial origins of CSD can be broadly classified into labor-related factors, patients' physical conditions, and surgical quality. However, conflicting influences of certain factors across studies make it challenging to determine effective preventive strategies. Additionally, CSD manifests with diverse symptoms, such as abnormal uterine bleeding, dysmenorrhea, chronic pelvic pain, dyspareunia, secondary infertility, and Cesarean scar pregnancy. Some symptoms are often attributed to other diagnoses, leading to delayed treatment. The quandary of when and how to manage CSD also adds to the complexity. Despite the development of various therapies, clear indications and optimal methods for specific conditions remain elusive. This longstanding challenge has troubled clinicians in both identifying and addressing this iatrogenic disease. Recent studies have yielded some compelling consensuses on various aspects of CSD. This review aims to consolidate the current literature on every facet of CSD. We hope to raise awareness among clinicians about this clinical problem, encouraging more relevant research to unveil the complete picture of CSD.

Effects of endometrial versus non-endometrial suturing on isthmocele development; a randomized controlled trial

OBJECTIVE

Incomplete healing after cesarean section (CS) can result in isthmocele formation. When suturing the uterus, fully folding the wound lips may embed the endometrial layer into the myometrium, leading to isthmocele development. Hence, this study aimed to compare the effects of endometrial and non-endometrial suturing on isthmocele development.

MATERIAL AND METHODS

This randomized controlled trial included 274 patients. Women who underwent primary CS were randomly allocated to one of the two study groups: endometrial suturing and non-endometrial suturing. The primary outcome was isthmocele rate at postpartum 6 months. Secondary outcomes were the volume of the isthmocele, thickness of the residual myometrium, menstrual irregularities (intermenstrual spotting), and the relationship between the isthmocele and uterine position.

RESULTS

A total of 159 patients (81 in the endometrial suturing group and 78 in the non-endometrial suturing group) were analyzed. The incidence of isthmocele was significantly lower in the non-endometrial suturing group than in the endometrial suturing group (12 [15.4%] vs. 24 [29.6%] patients; p = 0.032). Menstrual irregularities, such as intermenstrual spotting, were significantly higher in the endometrial suturing group than in the non-endometrial group (p = 0.019).

CONCLUSION

Uterine closure with non-endometrial suturing was associated with significantly lower isthmocele development and less intermenstrual spotting compared to that with endometrial suturing.

The Novel Parallel Closure Technique Compared to Single-Layer Closure of the Uterus After Primary Cesarean Section Decreases the Incidence of Isthmocele Formation and Increases Residual Myometrial Thickness

Background Isthmocele or a scar defect is a relatively common consequence of cesarean section resulting in menstrual disturbances and infertility and may compromise the myometrial integrity of the uterus in women contemplating subsequent vaginal birth. Several preventive measures have been suggested, including the modification of surgical techniques used for the closure of the uterine incision. The current study aimed to compare the incidence of isthmocele and assess residual myometrial thickness in women who underwent single versus parallel layered closure to approximate the endo-myometrial layer during cesarean section. Methodology This retrospective study evaluated data of women undergoing their first cesarean section under elective conditions (n = 497) where the uterine incision was closed using a single (n = 295) or a parallel layer (n = 202) technique. Patients were evaluated twice, at 3-6 months and 18 months postpartum, with a transvaginal ultrasound noting the presence or absence of an isthmocele and measurement of the residual myometrial thickness. Results Regardless of the closure technique, 64 (12.9%) women had an ultrasound-diagnosed isthmocele. Significantly fewer patients in the parallel-layer closure group presented with an isthmocele both at 3-6 (13.6 vs. 6.9%; p = 0.019) and 18 months (16.3 vs. 7.8%; p = 0.009) postpartum. Residual myometrium was significantly thicker in the parallel-layer closure group (8.0 vs. 13.2 mm at 3-6 months postpartum; p = 0.000 and 7.2 vs. 12.3 mm at 18 months postpartum; p = 0.004). For all patients, a retroverted position of the uterus at 3-6 months follow-up examination significantly increased the frequency of isthmocele (36/395 (9.1%) with an anteverted uterus and 18/102 (17.6%) with a retroverted uterus; p = 0.002). In patients with a single-layer closure, a retroverted uterus at the 3-6-month follow-up was associated with an isthmocele in 29.5% (18/61) of patients, while no isthmocele was recorded when the uterus was retroverted in the parallel-layer closure group (0/41) (p = 0.001). At 18 months postpartum, of the 64 patients with an isthmocele, 26 (40.6%) presented with abnormal uterine bleeding mainly in the form of postmenstrual spotting. Of the 26 patients with abnormal bleeding, 23 were in the single-layer and three were in the parallel-layer closure group. Conclusions The parallel-layer closure when compared to a single-layer closure of the uterine incision in patients undergoing primary cesarean section decreased the incidence of isthmocele formation and increased residual myometrial thickness. More patients in the single-layer closure group had menstrual cycle disturbances at 18 months postpartum.

FIGO good practice recommendations on surgical techniques to improve safety and reduce complications during cesarean delivery

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.

Aetiology, risk factors and preventive strategies for niche development: A review

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.

A Trimming Technique: A Case Report of a Novel Surgical Approach for Cesarean Scar Dehiscence During Cesarean Section

Cesarean section can lead to residual myometrial thickness thinning and cesarean scar syndrome. We report a novel trimming technique for residual myometrial thickness recovery in women with cesarean scar syndrome. Case 1: A 33-year-old woman who developed cesarean scar syndrome (CSS) and abnormal uterine bleeding post-cesarean scar became pregnant following hysteroscopic treatment. The myometrium at previous scar was dehiscent; therefore, a transverse incision was made above the scar. Post-operative uterine recovery failed owing to lochia retention, and developed cesarean scar syndrome again. Case 2: A 29-year-old woman who developed cesarean scar syndrome post-cesarean section became pregnant spontaneously. The myometrium at the previous scar was dehiscent like case 1. Scar repair was performed using a trimming technique during cesarean section; there were no subsequent complications and she conceived again spontaneously. Performing this novel surgical procedure during cesarean section may contribute to residual myometrial thickness recovery in women with cesarean scar syndrome.

Laparoscopic myomectomy - The importance of surgical techniques

Laparoscopy is a routine procedure for benign gynecological tumors. Although the laparoscopic approach for myomas is a common procedure, it can be challenging. To improve outcomes, research regarding port access, suture type, morcellation, and complication management remains ongoing. Myomectomy is the main surgical option for patients seeking uterus-sparing procedures to maintain future fertility. The laparoscopic technique is the most important in these cases, given that possible complications can impact fertility and pregnancy outcomes. Herein, we reviewed and collated the available data regarding different suture techniques, including advantages, difficulties, and possible long-term impacts.

Prevalence, definition, and etiology of cesarean scar defect and treatment of cesarean scar disorder: A narrative review

Background

Cesarean scar defects (CSD) are caused by cesarean sections and cause various symptoms. Although there has been no previous consensus on the name of this condition for a long time, it has been named cesarean scar disorder (CSDi).

Methods

This review summarizes the definition, prevalence, and etiology of CSD, as well as the pathophysiology and treatment of CSDi. We focused on surgical therapy and examined the effects and procedures of laparoscopy, hysteroscopy, and transvaginal surgery.

Main findings

The definition of CSD was proposed as an anechoic lesion with a depth of at least 2 mm because of the varied prevalence, owing to the lack of consensus. CSD incidence depends on the number of times, procedure, and situation of cesarean sections. Histopathological findings in CSD are fibrosis and adenomyosis, and chronic inflammation in the uterine and pelvic cavities decreases fertility in women with CSDi. Although the surgical procedures are not standardized, laparoscopic, hysteroscopic, and transvaginal surgeries are effective.

Conclusion

The cause and pathology of CSDi are becoming clear. However, there is variability in the prevalence and treatment strategies. Therefore, it is necessary to conduct further studies using the same definitions.

Fantastic niches and where to find them: the current diagnosis and management of uterine niche

Background

Caesarean section (CS) scar niche is a well recognised complication of caesarean delivery and is defined as an indentation at the site of the CS scar with a depth of at least 2mm.

Objectives

To review systematically the medical literature regarding the current diagnosis and management of uterine niche

Materials and methods

We carried out a systematic review using MeSH terms ‘niche’ OR ‘sacculation’ OR ‘caesarean scar defect’ OR ‘caesarean section scar’ OR ‘uterine defect’ OR ‘isthmocele.’ Articles included were peer-reviewed and in English language.

Main outcome measures

Prevalence, symptoms, diagnosis, pathophysiology and management of uterine niche.

Results

CS scar niche is common and, in a subgroup, produces a range of symptoms including post-menstrual bleeding, dyspareunia and subfertility. It may be linked to use of locked sutures during CS closure. Niche repair can be achieved laparoscopically or hysteroscopically and appears to improve symptoms, although solid conclusions regarding fertility outcomes cannot be drawn.

Conclusions

CS scar niche is associated with a range of symptoms. Repair may aid subfertile patients and those with post-menstrual spotting. The presence of a niche is probably irrelevant in the absence of symptoms.

What is new?

LNG-IUS and surgical repair appear to improve symptoms in those with a niche.

Online survey on uterotomy closure techniques in caesarean section

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.

Single- or double-layer uterine closure techniques following cesarean: A randomized trial

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.

A comparison of the effects of Two suture materials on isthmocele formation: A cohort study

OBJECTIVE

Cesarean scar defects (CSD) are a problem that may lead to complications and excessive cost. The optimal way to suture the uterus is a matter of debate. The aim of this study was to evaluate the effect of two suture materials on cesarean scar niches.

STUDY DESIGN

This was a cohort study that allocated women into two groups: uterotomy closure with vicryl or catgut sutures. Transvaginal ultrasound (TVUS) was performed six months after the cesarean section (CS) to assess the scar.

RESULTS

Totally, 250 patients enrolled in this study. After six months, 20 (18.2 %) patients in the catgut suture group and 13 (9.3 %) patients in the vicryl group had isthmocele according to their sonography reports. The prevalence of isthmocele was higher in the catgut group (p = 0.03). The residual myometrial thickness was greater in the vicryl group (4.98 cm ± 2.18) compared to the catgut suture group (3.70 cm ± 1.50; p = 0.001). The prevalence of postoperative gynecological sequelae such as postmenstrual spotting and pain were similar between the two groups.

CONCLUSION

Vicryl sutures were associated with a lower risk of CSD formation in comparison with catgut sutures.

An Optimal Uterine Closure Technique for Better Scar Healing and Avoiding Isthmocele in Cesarean Section: A Randomized Controlled Study

Objective: The aim of this study is to compare the effects of two different uterine closure techniques, used during cesarean section (CS) operations on isthmocele formation. Material and Methods: This prospective, randomized, controlled study was performed on 138 patients in a university hospital between the dates December 2016 and August 2017. Uterine closures were performed using the double-layer, far-far-near-near (FFNN) unlocked technique, in the study group (n = 70) and using a single-layer continuous locked (SLL) technique in the control group (n = 68). The presence of isthmocele, residual myometrial thickness (RMT), postmenstrual spotting, dysmenorrhea, chronic pelvic pain and uterus position were evaluated in postoperative sixth month. Results: Isthmocele formation was less frequent and RMT was greater in the study group when compared to the control group (p < 0.001 and p < 0.001, respectively). Duration of operation, amount of blood loss and additional hemostatic suture requirement were not significantly different between the two groups (p = 0.221, p = 0.520 and p = 0.930, respectively). Postmenstrual spotting was less common in FFNN group, while the rates of chronic pelvic pain and dysmenorrhea were not significantly different between the groups (p = 0.002, p = 0.205 and p = 0.490, respectively). Conclusion: The findings of the present study demonstrate that uterine closure using the FFNN technique is beneficial in terms of providing protection from isthmocele formation and ensuring sufficient RMT. This method has the potential to become the optimal uterine closure technique, but the findings of the present study should be supported by large-scale studies in the future.

Outcomes after Hysteroscopic Treatment of Symptomatic Isthmoceles in Patients with Abnormal Uterine Bleeding and Pelvic Pain: A Prospective Case Series

Background

Isthmoceles are described as complications associated with caesarean section (CS). Only symptomatic isthmoceles should be treated. The main symptoms are abnormal uterine bleeding (AUB) in the absence of any other causes, pelvic pain and secondary infertility. There are several techniques described for the correction of isthmoceles. Isthmoplasty can be performed by hysteroscopy, laparoscopy or vaginal surgery. The aim of this study was to assess the effectiveness of hysteroscopic surgical treatment of isthmoceles in women with associated symptoms such as pelvic pain and AUB.

Materials and Methods

A prospective case series study was performed; this study included all women with AUB, pelvic pain and ultrasonographic (US) diagnosis of isthmocele, who had undergone hysteroscopic correction between June 2014 and December 2017 in our Hospital.

Results

Thirty eight women underwent surgical hysteroscopy for correction of symptomatic isthmoceles. All patients presented AUB, 42.1% experienced pelvic pain and 28.9% had secondary infertility. US evaluation of isthmoceles was performed using 2D ultrasound. The residual myometrial thickness (RMT) above the isthmocele was measured in women who expected future pregnancy; if it was <2.5 mm the patient was not included in the study because the cor- rection was performed laparoscopically. Follow-up was performed one and two months after the surgery. In all cases, pelvic pain was resolved one month after the surgery. AUB disappeared within the first month in 87.5% of patients and in the second month in 96.8% of subjects; however, one patient needed further surgery to alleviate her symptoms. Secondary infertility was assessed one year after surgical isthmoplasty. Seven women completed the first year of fol- low up, and three of them (42.8%) reported pregnancy after treatment between six and eight months after the surgery.

Conclusion

Hysteroscopic correction of symptomatic isthmoceles may constitute a safe and effective technique for patients who present AUB and pelvic pain.

Isthmocele: From Risk Factors to Management

OBJECTIVE

 The aim of the present study was to perform a comprehensive review of the literature to provide a complete and clear picture of isthmocele-a hypoechoic area within the myometrium at the site of the uterine scar of a previous cesarean section-by exploring in depth every aspect of this condition.

METHODS

 A comprehensive review of the literature was performed to identify the most relevant studies about this topic.

RESULTS

 Every aspect of isthmocele has been studied and described: pathophysiology, clinical symptoms, classification, and diagnosis. Its treatment, both medical and surgical, has also been reported according to the actual literature data.

CONCLUSION

 Cesarean section is the most common surgical procedure performed worldwide, and one of the consequences of this technique is isthmocele. A single and systematic classification of isthmocele is needed to improve its diagnosis and management. Further studies should be performed to better understand its pathogenesis.

Uterine caesarean closure techniques affect ultrasound findings and maternal outcomes: a systematic review and meta-analysis

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.

Laparoscopic isthmocele treatment - single center experience

INTRODUCTION

A cesarean section is the most frequently performed surgery in modern obstetrics. In case of an incorrect wound healing process there is a risk of a persistent uterine wall defect. Nowadays, due to the high frequency of cesarean sections, obstetricians have to deal with the threat of uterine rupture due to pathological wound healing. It has been proven that isthmocele can cause abnormal uterine bleeding (AUB), pelvic pain (PP), and secondary infertility (SI), and can be a place of improper pregnancy placement.

AIM

This article presents our experience with isthmocele treatment. We describe our diagnostic process scheme, method of corrective surgery and main therapeutic outcomes.

MATERIAL AND METHODS

In this manuscript we present a single center's experience in isthmocele therapy. We have operated on 16 patients who suffered from abnormal uterine bleeding, pain disorders or secondary infertility possibly due to a cesarean scar defect.

RESULTS

The results obtained in our center are promising. In 9 of 11 (81.8%) women with abnormal bleeding we obtained complete resolution of symptoms. We had slightly worse results in the case of pelvic pain. In 4 (66.6%) of 6 patients the pain resolved completely. We have obtained 7 pregnancies in 11 (63.6%) patients operated on due to secondary infertility.

CONCLUSIONS

In our opinion, laparoscopic treatment seems to be currently one of the most effective methods in isthmocele therapy. Further investigation is necessary to determine the indications for surgery, suitable treatment strategies and appropriate care.

Suturing method as a factor for uterine vascularity after laparoscopic myomectomy

OBJECTIVE

To evaluate the vascularity of the myometrium after laparoscopic myomectomy sutured by two different methods using contrast-enhanced Magnetic Resonance Imaging.

STUDY DESIGN

Twenty-eight women who had symptomatic leiomyomas and underwent laparoscopic myomectomy between June 2013 and July 2014 were included in the present study. In the first half period, continuous sutures were used in 12 patients, and in the latter half period, single interrupted sutures were used in 16 patients. Contrast-enhanced Magnetic Resonance Imaging was used 3 or 6 months after surgery to evaluate vascularity after laparoscopic myomectomy. We defined avascularity index as the percentage of avascular area after surgery to cross sectional area of myoma before surgery. The Wilcoxon rank-sum test was applied to compare avascularity indeces in the two study groups.

RESULTS

At 3 months after surgery, avascularity index in continuous sutures group was significantly higher than that in single interrupted sutures group (median 5.0 vs.1.2, p<0.001), suggesting a poorer vascular recovery of the myometrium sutured continuously.

CONCLUSION

Simple interrupted suturing might be superior to continuous suturing in terms of vascularity evaluated using contrast enhanced Magnetic Resonance Imaging.

Comparison of the primary cesarean hysterotomy scars after single- and double-layer interrupted closure

INTRODUCTION

It is unclear whether hysterotomy closure techniques can affect niche development. Therefore, this study aimed to analyze the effect of single-layer and double-layer interrupted closures of hysterotomy incisions during primary cesarean section on the formation of uterine niches.

MATERIAL AND METHODS

A prospective cohort study of women undergoing primary cesarean section was performed between June 2011 and July 2014. Saline contrast sonohysterography was used to measure the niche depth and residual myometrium. The ratio of the niche depth to the sum of the niche depth and residual myometrium thickness (niche ratio) was calculated.

RESULTS

Niches were identified in 14/58 (24.1%) women with single-layer sutures and 55/209 (26.3%) women with double-layer sutures (p = 0.74). Single-layer closure was associated with more than a five-fold increase in the odds of a niche ratio ≥0.4 (odds ratio 5.59; 95% CI 1.71-18.28).

CONCLUSION

Single-layer closure may be associated with an increased risk of larger niches (niche ratio ≥0.4), although it may not increase the overall frequency of niche formation.

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.

Why do niches develop in Caesarean uterine scars? Hypotheses on the aetiology of niche development

Caesarean section (CS) results in the occurrence of the phenomenon 'niche'. A 'niche' describes the presence of a hypoechoic area within the myometrium of the lower uterine segment, reflecting a discontinuation of the myometrium at the site of a previous CS. Using gel or saline instillation sonohysterography, a niche is identified in the scar in more than half of the women who had had a CS, most with the uterus closed in one single layer, without closure of the peritoneum. An incompletely healed scar is a long-term complication of the CS and is associated with more gynaecological symptoms than is commonly acknowledged. Approximately 30% of women with a niche report spotting at 6-12 months after their CS. Other reported symptoms in women with a niche are dysmenorrhoea, chronic pelvic pain and dyspareunia. Given the association between a niche and gynaecological symptoms, obstetric complications and potentially with subfertility, it is important to elucidate the aetiology of niche development after CS in order to develop preventive strategies. Based on current published data and our observations during sonographic, hysteroscopic and laparoscopic evaluations of niches we postulate some hypotheses on niche development. Possible factors that could play a role in niche development include a very low incision through cervical tissue, inadequate suturing technique during closure of the uterine scar, surgical interventions that increase adhesion formation or patient-related factors that impair wound healing or increase inflammation or adhesion formation.

Macroscopic, histochemical, and immunohistochemical comparison of hysterorrhaphy using catgut and chitosan suture wires

The objective of the current article was to compare the quality of the healing process after hysterorrhaphy with catgut and chitosan suture wires via macroscopic, histochemical, and immunohistochemical evaluations. Seven ewes were submitted to a video-assisted laparotomy. A hysterectomy was performed with subsequent catgut and chitosan hysterorrhaphy in both horns. Then, macroscopic evaluation and biopsies of the hysterorrhaphy and control areas were carried out after 30 days. Although postoperative adhesion was observed in five animals of the catgut group, no adhesions were detected in the chitosan one. Additionally, there was a significant difference in increasing collagen type III and connective tissue for the chitosan group when compared to the control and catgut groups. A larger amount of blood vessels was also observed in the control group in comparison with the catgut and chitosan groups. Collagen type I and vascular endothelial growth factor-A (VEGF-A) were significantly different among groups. Thus, chitosan promoted a preventive effect on postoperative adhesion formation in the hysterorrhaphy areas, with increasing collagen type III deposition during tissue mending, which granted an enhanced healing process.

Clinical diagnosis and therapy of uterine scar defects after caesarean section in non-pregnant women

PURPOSE

Caesarean delivery (c-section) scar dehiscences may cause bleeding abnormalities, e.g. postmenstrual spotting, dysmenorrhea and abdominal pain, secondary sterility and at worst peripartum uterine rupture. The purpose of this study was firstly to identify the correlation of women's complaints after c-section with scar-related clinical symptoms. Secondly, the effects of corrective surgery on preoperatively existing complaints were analysed and assessed in the patient population of our clinic.

METHODS

We present data of a retrospective study of 13 premenopausal, non-pregnant women with symptomatic c-section scars. In 9 out of 13 patients, a microsurgical uterus reconstruction was performed by mini-laparotomy. The postoperative changes of scar-associated symptoms were assessed by a questionnaire as earliest as 4 months after surgery (N = 5).

RESULTS

The c-section scar was visualised by transvaginal sonography in 12 out of 13 women by a typical U- or V-shaped hypoechoic or anechoic fluid accumulation in the region of former uterotomy and in all 13 patients by hysteroscopy. Bleeding disorders were often accompanied by dysmenorrhea/abdominal pain (38.5%, N = 5) and secondary sterility (46.2%, N = 6). Blood residues in the scar pouch and bleeding disorders/postmenstrual spotting were found in 30.8% of patients (N = 4) and combined with secondary sterility in 38.5% of patients (N = 5). Reconstructive surgeries resulted in discontinuation of bleeding disorders in all women and a pregnancy in three out of five patients (60%) with secondary sterility.

CONCLUSION

Clinical symptoms, e.g. "bleeding disorders" like postmenstrual spotting, "pain/dysmenorrhea" and "secondary sterility" could be specific indicators for the diagnosis of uterine dehiscence after c-section. Scar dehiscences can be diagnosed by obtaining the patients medical history and asking for typical symptoms followed by vaginal sonography and diagnostic hysteroscopy. If a c-section scar defect is confirmed, microsurgical uterus reconstruction can stop postmenstrual spotting, reduce abdominal pain/dysmenorrhea and improve fertility.

Impact of single- vs double-layer closure on adverse outcomes and uterine scar defect: a systematic review and metaanalysis

A systematic review and metaanalysis were performed through electronic database searches to estimate the effect of uterine closure at cesarean on the risk of adverse maternal outcome and on uterine scar evaluated by ultrasound. Randomized controlled trials, which compared single vs double layers and locking vs unlocking sutures for uterine closure of low transverse cesarean, were included. Outcomes were short-term complications (endometritis, wound infection, maternal infectious morbidity, blood transfusion, duration of surgical procedure, length of hospital stay, mean blood loss), uterine rupture or dehiscence at next pregnancy, and uterine scar evaluation by ultrasound. Twenty of 1278 citations were included in the analysis. We found that all types of closure were comparable for short-term maternal outcomes, except for single-layer closure, which had shorter operative time (-6.1 minutes; 95% confidence interval [CI], -8.7 to -3.4; P < .001) than double-layer closure. Single layer (-2.6 mm; 95% CI, -3.1 to -2.1; P < .001) and locked first layer (mean difference, -2.5 mm; 95% CI, -3.2 to -1.8; P < .001) were associated with lower residual myometrial thickness. Two studies reported no significant difference between single- vs double-layer closure for uterine dehiscence (relative risk, 1.86; 95% CI, 0.44-7.90; P = .40) or uterine rupture (no case). In conclusion, current evidence based on randomized trials does not support a specific type of uterine closure for optimal maternal outcomes and is insufficient to conclude about the risk of uterine rupture. Single-layer closure and locked first layer are possibly coupled with thinner residual myometrium thickness.

Surgical techniques for uterine incision and uterine closure at the time of caesarean section

BACKGROUND

Caesarean section is a common operation. Techniques vary depending on both the clinical situation and the preferences of the operator.

OBJECTIVES

To compare the effects of 1) different types of uterine incision, 2) methods of performing the uterine incision, 3) suture materials and technique of uterine closure (including single versus double layer closure of the uterine incision) on maternal health, infant health, and healthcare resource use.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 September 2013) and reference lists of all identified papers.

SELECTION CRITERIA

All published, unpublished, and ongoing randomised controlled trials comparing various types and closure of uterine incision during caesarean section.

DATA COLLECTION AND ANALYSIS

Two review authors evaluated trials for inclusion and methodological quality without consideration of their results according to the stated eligibility criteria and extracted data independently.

MAIN RESULTS

Our search strategy identified 60 studies for consideration, of which 27 randomised trials involving 17,808 women undergoing caesarean section were included in the review. Overall, the methodological quality of the trials was variable, with 12 of the 27 included trials adequately describing the randomisation sequence, with less than half describing adequately methods of allocation concealment, and only six trials indicating blinding of outcome assessors.Two trials compared auto-suture devices with traditional hysterotomy involving 300 women. No statistically significant difference in febrile morbidity between the stapler and conventional incision groups was apparent (risk ratio (RR) 0.92; 95% confidence interval (CI) 0.38 to 2.20).Five studies were included in the review that compared blunt versus sharp dissection when performing the uterine incision involving 2141 women. There were no statistically significant differences identified for the primary outcome febrile morbidity following blunt or sharp extension of the uterine incision (four studies; 1941 women; RR 0.86; 95% CI 0.70 to 1.05). Mean blood loss (two studies; 1145 women; average mean difference (MD) -55.00 mL; 95% CI -79.48 to -30.52), and the need for blood transfusion (two studies; 1345 women; RR 0.24; 95% CI 0.09 to 0.62) were significantly lower following blunt extension.A single trial compared transverse with cephalad-caudad blunt extension of the uterine incision, involving 811 women, and while mean blood loss was reported to be lower following transverse extension (one study; 811 women; MD 42.00 mL; 95% CI 1.31 to 82.69), the clinical significance of such a small volume difference is of uncertain clinical relevance. There were no other statistically significant differences identified for the limited outcomes reported.A single trial comparing chromic catgut with polygactin-910, involving 9544 women reported that catgut closure versus closure with polygactin was associated with a significant reduction in the need for blood transfusion (one study, 9544 women, RR 0.49, 95% CI 0.32 to 0.76) and a significant reduction in complications requiring re-laparotomy (one study, 9544 women, RR 0.58, 95% CI 0.37 to 0.89).Nineteen studies were identified comparing single layer with double layer closure of the uterus, with data contributed to the meta-analyses from 14 studies. There were no statistically significant differences identified for the primary outcome, febrile morbidity (nine studies; 13,890 women; RR 0.98; 95% CI 0.85 to 1.12). Although the meta-analysis suggested single layer closure was associated with a reduction in mean blood loss, heterogeneity is high and this limits the clinical applicability of the result. There were no differences identified in risk of blood transfusion (four studies; 13,571 women; average RR 0.86; 95% CI 0.63 to 1.17; Heterogeneity: Tau² = 0.15; I² = 49%), or other reported clinical outcomes.

AUTHORS' CONCLUSIONS

Caesarean section is a common procedure performed on women worldwide. There is increasing evidence that for many techniques, short-term maternal outcomes are equivalent. Until long-term health effects are known, surgeons should continue to use the techniques they prefer and currently use.

Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: systematic review

OBJECTIVE

To review systematically the medical literature reporting on the prevalence of a niche at the site of a Cesarean section (CS) scar using various diagnostic methods, on potential risk factors for the development of a niche and on niche-related gynecological symptoms in non-pregnant women.

METHODS

The PubMed and EMBASE databases were searched. All types of clinical study reporting on the prevalence, risk factors and/or symptoms of a niche in non-pregnant women with a history of CS were included, apart from case reports and case series.

RESULTS

Twenty-one papers were selected for inclusion in the review. A wide range in the prevalence of a niche was found. Using contrast-enhanced sonohysterography in a random population of women with a history of CS, the prevalence was found to vary between 56% and 84%. Nine studies reported on risk factors and each study evaluated different factors, which made it difficult to compare studies. Risk factors could be classified into four categories: those related to closure technique, to development of the lower uterine segment or location of the incision or to wound healing, and miscellaneous factors. Probable risk factors are single-layer myometrium closure, multiple CSs and uterine retroflexion. Six out of eight studies that evaluated niche-related symptoms described an association between the presence of a niche and postmenstrual spotting.

CONCLUSIONS

The reported prevalence of a niche in non-pregnant women varies depending on the method of detection, the criteria used to define a niche and the study population. Potential risk factors can be categorized into four main categories, which may be useful for future research and meta-analyses. The predominant symptom associated with a niche is postmenstrual spotting.

Laparoscopic correction of the uterine muscle loss in the scar after a Caesarean section delivery

Caesarean section is the most frequently conducted surgery in modern obstetrics. It involves a significant risk of complications; also disorders in the area of the scar after hysterotomy may lead to menstrual disorders, pain and secondary infertility. In light of the presented facts the significance of a good uterus muscle correction method is high. We present a case of a 28-year-old patient after Caesarean section with further reproductive plans. In the ultrasonographic examination the residual thickness of the uterine wall was approx. 2.5–3 mm. The patient was operated on using laparoscopy and the fibrotic scar tissue was removed. During the follow-up examination in transvaginal ultrasonography the uterine muscularis was continuous on the whole surface. Laparoscopic treatment ensures the appropriate visibility which makes the risk of damage to the adjacent organs lower, and the time of convalescence is short. It provides repetitive good results from the anatomical and functional points of view.