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Grand Rounds

Double or Single Layer Closure for Best Cesarean-Section Outcomes?

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BACKGROUND AND PURPOSE:

  • Niche on ultrasound describes a triangular anechoic area at the site of a previous cesarean section
    • Seen with saline or gel contrast hysterosonography
    • Residual myometrium thickness (RMT) at apex of niche is thin
  • Possible that RMT thickness related to closure technique
  • Stegwee et al. (BJOG, 2017) examined whether uterine closure technique after cesarean section has an impact on maternal and ultrasound outcomes

METHODS:

  • Systematic review and meta-analysis
  • Literature search of randomized controlled trials (RCTs) or prospective cohort studies that evaluated uterine closure techniques and reported on ultrasound findings, perioperative or long-term outcomes
  • The following techniques were included in the analyses
    • Single- versus double-layer closure
    • Locked versus unlocked suturing
    • Inclusion versus exclusion of the decidua
  • Outcomes
    • Ultrasound findings post cesarean section
    • Intra-operative and short-term post-operative findings
    • Gynecologic symptoms
    • Reproductive outcomes

RESULTS:

  • Meta analyses performed using twenty studies
  • Data was analyzed from 15,053 women
  • RMT decreased by 1.26 mm after single- vs double-layer closure (95% CI -1.93 to -0.58; P=0.0003)
    • More pronounced with locked sutures
  • Healing ratio (RMT/adjacent myometrium thickness) was decreased with single-layer closure (Weighted mean difference -7.74%, 95% CI -13.31 to -2.17)
    • More pronounced with locked sutures
  • Niche more common when the decidua was excluded (RR 1.71, 95% CI 1.11-2.62)
  • Dysmenorrhea occurred more often in the single-layer group (RR 1.23, 95% CI 1.01-1.48)
  • Incidence of uterine rupture was similar (RR 1.91, 95% CI 0.63-5.74) between groups

CONCLUSION:

  • Double-layer unlocked sutures were preferable to single-layer locked sutures regarding RMT, healing ratio and dysmenorrhea
  • Niche prevalence increased with excluded decidua

Learn More – Primary Sources:

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

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Related ObG Topics:

Can Evidence-Based Interventions Reduce C-section Complications?
Single or Double-Layer Closure at C-Section and Resulting Uterine Thickness
Does Adding a 2nd Layer to Uterine Closure of a Cesarean Section Alter Outcomes?

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