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#Grand Rounds

Does a Low Uterine Incision During Cesarean Lead to Increased Risk of Large Scar Defects?

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BACKGROUND AND PURPOSE:

  • Low uterine incisions may cause increased risk of subsequent large scar defects with potential for dehiscence and/or rupture
  • Vikhareva et al. (Ultrasound in Obstetrics and Gynecology, 2018) investigated risk of incision level and large uterine scar defects 6-9 months after delivery

METHODS:

  • Two-center, randomized, single-blind trial (RCT)
    • Assessment of the primary outcome was masked
  • Participants
    • Primary section
    • Emergent
    • Cervical dilation ≥ 5 cm
  • Large scar defect: Defined as remaining myometrial thickness ≤2.5 mm
  • Interventions
    • High incision: 2 cm above the plica vesicouterina
    • Low incision: 2 cm below the plica vesicouterina
  • Assessment of incisional scar
    • Saline contrast sonohysterography at 6-9 months post-surgery
  • Primary outcome
    • Presence of a large scar defect
  • Secondary outcomes
    • Perinatal outcome
    • Operative complications within 8 weeks of delivery
    • Long-term outcome in subsequent pregnancy

RESULTS:

  • 55 women high incision group | 59 women in low incision group
    • Median follow-up time 4 years 7 months
    • 49% of women had a subsequent pregnancy (56 women)
    • Double layer closure used in all participants
  • Primary Outcome: Incision defects were greater in the low incision group (P < 0.001)
    • High incision group: 7% (4 women)
    • Low incision group: 41% (24 women)
    • Odds ratio (OR): 8.7 (95% CI, 2.8–27.4)
  • Secondary outcomes: No differences in secondary outcomes

CONCLUSION:

  • Low cesarean hysterotomy level is associated with a higher risk of scar defects 6-9 months after delivery by a 6-fold higher rate
  • Authors note that enrollment was stopped early due to changes at the participating hospitals that made compliance with protocol difficult
    • However, despite power calculation based on 176 rather than 122 women, the findings were still statistically significant    

Learn More – Primary Sources:

Hysterotomy level at Cesarean section and occurrence of large scar defects: a randomized single‐blind trial

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Related ObG Topics:

Single or Double-Layer Closure at C-Section and Resulting Uterine Thickness
Diagnosis and Treatment of Cesarean Scar Pregnancies
Do Different Surgical C-Section Techniques Affect Outcomes?

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