The effect of uterine closure technique on cesarean scar niche development after multiple cesarean deliveries

OBJECTIVES

To use saline infusion sonohysterography (SIS) to evaluate the effect of uterine closure technique on niche formation after multiple cesarean deliveries (CDs).

METHODS

Patients with at least one prior CD were evaluated for niche via SIS. Subgroups of any number repeat CD (>1 prior), lower-order CD (<4 prior), and higher-order CD (≥4 prior) were analyzed, stratifying by hysterotomy closure technique at last cesarean preceding imaging; techniques included Technique A (endometrium-free double-layer closure) and Technique B (single- or double-layer routine endo-myometrial closure). Niche defects were quantified (depth, length, width, and residual myometrial thickness). The primary outcome was clinically significant niche, defined as depth >2 mm. Statistical analysis was performed using chi-square, ANOVA, t-test, Kruskal-Wallis, and multiple logistic regression, with p-values of <0.05 were statistically significant.

RESULTS

A total of 172 post-cesarean SIS studies were reviewed: 105 after repeat CDs, 131 after lower-order CDs, and 41 after higher-order CDs. Technique A was associated with a shorter interval to imaging and more double-layer closures. Technique B was associated with more clinically significant niches across all subgroups, and these niches were significantly longer and deeper when present. Multiple logistic regression demonstrated a 5.6, 8.1, and 11-fold increased adjusted odds of clinically significant niche following Technique B closure in the repeat CD (p<0.01), lower-order CD (p<0.001), and higher-order CD (p=0.04) groups, respectively.

CONCLUSIONS

While multiple CDs are known to increase risk for niche defects and their sequelae, hysterotomy closure technique may help to reduce niche development and severity.

Impact of selected risk factors on uterine healing after cesarean section in women with single-layer uterine closure: A prospective study using two- and three-dimensional transvaginal ultrasonography

BACKGROUND

Modern obstetrics must meet many challenges, including long-term complications resulting from the presence of a uterine niche after cesarean section.

OBJECTIVES

To assess the impact of selected risk factors on the uterine healing process after cesarean section. The uterus was closed with a single-layer continuous suture covering the entire thickness of the myometrium, excluding the decidua.

MATERIAL AND METHODS

A prospective, case-controlled study was carried out at 2nd Department of Gynecology and Obstetrics, Wroclaw Medical University, Poland. Women who delivered by cesarean section at our Department were invited to undergo an ultrasonographic assessment of the cesarean section scar from 6 to 9 weeks after the procedure. In all cases, the uterus was closed with a single-layer continuous suture. The ultrasound examination of the niche was performed according to the modified Delphi protocol. The volume of the niche was calculated and a 3D model was created. The obtained data were analyzed with clinical information from the maternal medical history and the course of the pregnancy.

RESULTS

A total of 204 patients participated in the study. Five patients had a residual myometrial thickness (RMT) <2.2 mm and 35 had a residual myometrial thickness to adjacent myometrial thickness ratio (RMT/AMT) ≤0.5. In 45% of women, pregnancy course was complicated by gestational diabetes mellitus (GDM), gestational hypertension and hypothyroidism. The cervical canal was colonized with pathogenic flora in 22% of women. No correlation between maternal and gestational age at delivery, presence of medical complications during pregnancy, colonization of the cervical canal, and presence of niche and its parameters were found.

CONCLUSIONS

Our study revealed that the selected risk factors, such as systemic diseases during pregnancy and in the maternal medical history, as well as the colonization of the cervical canal, have no impact on uterine scar healing in women undergoing single-layer uterine closure spanning the entire thickness of the myometrium, excluding the decidua.