Double or Single Layer Closure for Best Cesarean-Section Outcomes?
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
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
Ultrasound findings post cesarean section
Intra-operative and short-term post-operative findings
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
Double-layer unlocked sutures were preferable to single-layer locked sutures regarding RMT, healing ratio and dysmenorrhea
Does Adding a 2nd Layer to Uterine Closure of a Cesarean Section Alter Outcomes?
There are randomized studies evaluating the addition of the second layer, but generally following locked suture technique
Bennich et al. (Ultrasound Obstet Gynecol, 2016) investigated the impact of adding a second layer to a single unlocked closure of a cesarean uterine incision on residual myometrial thickness (RMT) as a proxy for uterine rupture risk
Single or Double-Layer Closure at C-Section and Resulting Uterine Thickness
This study by Vachon-Marceau et al. (AJOG, 2017) aimed to determine if there is a difference in lower uterine segment thickness depending on single or double-layer C-section uterine closure.
Prospective Cohort Study
There is an increased risk of uterine rupture during a trial of labor following C-section. Uterine thickness on ultrasound has been studied as a proxy for scar quality and risk of rupture in future pregnancies. In this study, 1,613 women underwent transabdominal and transvaginal ultrasounds in their third trimester to assess lower uterine segment thickness and scar defects resulting from previous C-section. The sonographers were blinded to clinical information. 495 (31%) women had previously underwent a single-layer and 1,118 (69%) had a double-layer closure. Women who had a double-layer closure had thicker lower uterine segments than women with single-layer closure with a difference of 0.11 mm (95% CI, 0.02-0.21 mm). Using multivariate logistic regression to account for variables, double-layer closure was less likely to result in a thin lower uterine segment thickness of < 2.0 mm (odds ratio 0.68; 95% CI, 0.51-0.90). Double-layer closure was also associated with a decreased risk of uterine scar defect with a relative risk of 0.32 (95% CI, 0.17 – 0.61) at birth. Type of thread (catgut vs. synthetic) used for closure had no impact on lower uterine thickness. The authors conclude that double-layer closure resulted in reduced risk of uterine segment thickness <0.2 mm and visible uterine scar defect on ultrasound in the third trimester.
Do Different Surgical C-Section Techniques Affect Outcomes?
This study by the Coronis Collaborative Group (Lancet, 2016) aimed to determine if there were differences in maternal morbidity depending on which of five surgical techniques for caesarean section a woman received.
Randomized Control Trial
13,153 women were followed up with for a mean duration of 3.8 years after receiving a C-section through one of five surgical techniques. The five pairs of alternative surgical techniques surveyed were blunt vs. sharp abdominal entry; exteriorization of the uterus vs. intra-abdominal repair; single vs. double layer closure of the uterus; closure vs. non-closure of the peritoneum; and chromic catgut vs. polyglactin-910 sutures.
The study found no evidence to prefer one surgical technique over another based on the following outcomes
Blunt vs sharp abdominal entry
Abdominal hernias: no difference (adjusted relative risk 0·66; 95% CI 0·39–1·11)
Exteriorization vs abdominal repair
Infertility: no difference (adjusted relative risk 0·91, 0·71–1·18)
Ectopic pregnancy: no difference (adjusted relative risk 0·50, 0·15–1·66)
Single vs double uterine closure
Maternal death: no difference (adjusted relative risk 0·78, 0·46–1·32)
Composite of pregnancy complications (adjusted relative risk 1·20, 0·75–1·90)
Peritoneal closure vs non-closure
Pelvic adhesions (related complications such as infertility): no difference (adjusted relative risk 0·80, 0·61–1·06)
Chromic catgut vs polyglactin-910 sutures
Adverse pregnancy outcomes in a subsequent pregnancy, such as uterine rupture: no difference (adjusted relative risk 3·05, 0·32–29·29).
Overall, severe adverse outcomes were uncommon in these settings
Determination of technique will take in to account other factors including time and cost
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