A Prospective Randomized Clinical Trial of Single vs. Double Layer Closure of Hysterotomy at the Time of Cesarean Delivery: The Effect on Uterine Scar Thickness

Abstract

Purpose We undertook a randomized clinical trial to examine the outcome of a single vs. a double layer uterine closure using ultrasound to assess uterine scar thickness.

Materials and Methods Participating women were allocated to one of three uterotomy suture techniques: continuous single layer unlocked suturing, continuous locked single layer suturing, or double layer suturing. Transvaginal ultrasound of uterine scar thickness was performed 6 weeks and 6 – 24 months after Cesarean delivery. Sonographers were blinded to the closure technique.

Results An “intent-to-treat” and “as treated” ANOVA analysis included 435 patients (n = 149 single layer unlocked suturing, n = 157 single layer locked suturing, and n = 129 double layer suturing). 6 weeks postpartum, the median scar thickness did not differ among the three groups: 10.0 (8.5 – 12.3 mm) single layer unlocked vs. 10.1 (8.2 – 12.7 mm) single layer locked vs. 10.8 (8.1 – 12.8 mm) double layer; (p = 0.84). At the time of the second follow-up, the uterine scar was not significantly (p = 0.06) thicker if the uterus had been closed with a double layer closure 7.3 (5.7 – 9.1 mm), compared to single layer unlocked 6.4 (5.0 – 8.8 mm) or locked suturing techniques 6.8 (5.2 – 8.7 mm). Women who underwent primary or elective Cesarean delivery showed a significantly (p = 0.03, p = 0.02, “as treated”) increased median scar thickness after double layer closure vs. single layer unlocked suture.

Conclusion A double layer closure of the hysterotomy is associated with a thicker myometrium scar only in primary or elective Cesarean delivery patients.

Zusammenfassung

Ziel In der prospektiv randomisierten Studie wurde die Uterotomienarbe mittels transvaginalen Ultraschalls nach ein- oder zweischichtiger Verschlusstechnik bei der Sectio Cesarea beurteilt.

Material und Methoden Die Uterotomie wurde entweder einfach fortlaufend oder fortlaufend durchschlungen, überwendlich oder zweischichtig verschlossen. Die transvaginale Messung der Narbendicke erfolgte nach 6 Wochen und 6 – 24 Monate postpartum, wobei die Untersucher für die Nahtform verblindet waren.

Ergebnisse In die „Intention-to-treat“ und „As treated“ ANOVA Analyse wurden 435 Patientinnen eingeschlossen (n = 149 einfach fortlaufender Verschluss der Uterotomie, n = 157 fortlaufend durchschlungen überwendliche Naht, n = 129 doppelte Verschlusstechnik). Sechs Wochen postpartum war die mediane Narbendicke in allen drei Gruppen nicht signifikant unterschiedlich (p = 0,84); 10,0 (8,5 – 12,3 mm) einfach fortlaufende Naht vs. 10,1 (8,2 – 12,7 mm) fortlaufend durchschlungen überwendliche Naht vs 10,8 (8,1 – 12,8 mm) doppelte Naht. Beim zweiten Follow-up war die Uterotomienarbe nicht signifikant unterschiedlich (p = 0,06); nach einer doppelten Naht 7,3 (5,7 – 9,1 mm), im Vergleich zur einfach fortlaufenden Naht 6,4 (5,0 – 8,8 mm) oder fortlaufend durchschlungen überwendlichen Naht 6,8 (5,2 – 8,7 mm). Ausschließlich Schwangere, die ihren ersten oder elektiven Kaiserschnitt erhielten, zeigten eine signifikant (p = 0,03, p = 0,02, „As treated“) dickere Uterotomienarbe nach doppelter Naht im Vergleich zu Frauen nach einfach fortlaufender Naht.

Schlussfolgerung In unserem Studienkollektiv war die doppelte Naht im Vergleich zur einfach fortlaufenden Naht der Uterotomie nur bei Erstsectiones und elektiven Eingriffen mit einer signifikant dickeren Narbe assoziiert.

Key words

uterus - ultrasound - obstetrics - pregnancy - surgery

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