Double layer closure of uterus during previous cesarean section results in thicker third-trimester lower uterine segment and decreases rate of uterine rupture by 3 to 5fold during trial of labor after cesarean (TOLAC) and vaginal birth after cesarean reports results of multicenter prospective cohort study published in July issue of Journal obstetrics and gynecology.
In U.S.A,
about 1.3 million babies are delivered by Cesarean every year, which roughly
equals to every 1 in every 3 children born in US (33%). Decrease in vaginal
births after cesarean and TOLAC has significantly contributed to the rising
C-section rates. Significant maternal and neonatal mortality and morbidity
because of uterine rupture has increased the rate of elective repeat C-section
(ERC).
Lower
uterine segment thickness (LUST) as measured by ultrasound is routinely used in
clinical practice to estimate the risk of uterine rupture during TOLAC. A value of <2.0 mm measured between 35 and
38 weeks is significantly associated with greater incidence of uterine rupture
or scar dehiscence compared with a measurement >2.0 mm.
The
researchers performed a secondary analysis of study conducted at 4 hospitals
over a period of 5 years. Out of 1856 women originally recruited, records about
uterine closure in previous C-section were available for 1613 patients.
Each of the
study participant received transvaginal and transabdominal sonography for
measuring LUST between 34 weeks to 38 weeks and 6 days of pregnancy. Each measurement was confirmed at least 3
times.
Thirty-one percent
(495) of patients had undergone a single layer closure, whereas 69% (1118) had
undergone a double layer closure at the time of previous C-section.
After
adjustment of confounding factors, it was observed that patients with double
layer uterine closure had 32% less odds of third-trimester LUST <2.0 mm in
the next pregnancy (P<.01).
Type of
catgut (Chromic vs synthetic) did not have any effect on thickness of lower
uterine segment in next pregnancy. Other factors that resulted in LUST < 2
mm were interdelivery interval <18 months; a body mass index >30 kg/m2;
and an elective or planned cesarean delivery.
If previous cesarean
was performed in labor than it resulted in thicker lower uterine segment as
compared to cesarean performed electively. So, double layer closure becomes all
the more important in elective cesarean sections.
Patients
were followed up till delivery and it was seen that patients with double layer
closure were slightly more likely to undergo TOLAC or vaginal birth. Double
layer closure was also significantly less likely to be associated with uterine
scar defect and dehiscence.
The authors
concluded that, “the current study supports the use of double-layer suture of
the uterus at cesarean, especially when it is performed before labor, to
optimize uterine scar healing. This technique could lead to a reduction of
uterine scar defects during a TOLAC.”
Full text can be accessed here.
Source: Single
versus double-layer uterine closure at cesarean: impact on lower uterine
segment thickness at next pregnancy
Vachon-Marceau,
Chantale et al.
American
Journal of Obstetrics & Gynecology , Volume 217 , Issue 1 , 65.e1 - 65.e5
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