Effect of single- and double-layer cesarean section closure on residual myometrial thickness and isthmocele - a systematic review and meta-analysis

Greg J Marchand, Ahmed Masoud, Alexa King, Stacy Ruther, Giovanna Brazil, Hollie Ulibarri, Julia Parise, Amanda Arroyo, Catherine Coriell, Sydnee Goetz, Ashley Christensen, Katelyn Sainz, Greg J Marchand, Ahmed Masoud, Alexa King, Stacy Ruther, Giovanna Brazil, Hollie Ulibarri, Julia Parise, Amanda Arroyo, Catherine Coriell, Sydnee Goetz, Ashley Christensen, Katelyn Sainz

Abstract

Objective: To determine the incidence of isthmocele, its effect on residual myometrial thickness (RMT), and other complications of Cesarean delivery (CD) in relation to single- and double-layer CD closure. We searched PubMed, SCOPUS, Web of Science, ClinicalTrials.gov, MEDLINE and Cochrane Library for relevant clinical trials assessing the use of single- and double-layer uterine closure in patients undergoing cesarean sections from inception through to March 2021.

Materials and methods: Our population was women undergoing cesarean section with uterine closure by any double-layer method, compared with those undergoing uterine closure through a single-layer method. RMT (in mm) was measured at 6 weeks, niche/isthmocele existence at 6 weeks, RMT (in mm) at 6-24 months and niche/isthmocele existence at 6-24 months. In order to present the highest quality evidence, we only included clinical trials in our analysis. To perform this review, we reported dichotomous outcomes using percent and total, while continuous outcomes were reported using mean ± standard deviations, and relative 95% confidence intervals using the inverse variance method.

Results: We found that the RMT in the double-layer closure group was significantly higher at six weeks [mean difference (MD)=-0.43 (-0.77, -0.09)], (p=0.01) and at 6-24 months of follow-up [MD=-1.27 (-2.28, -0.25)], (p=0.01). The incidence of isthmocele in the two groups, as well as the other investigated outcomes were similar across the different groups.

Conclusion: High-quality evidence shows that double-layer closure results in a higher RMT compared with a single-layer closure, despite no significant difference in isthmocele formation.

Keywords: Cesarean section closure; cesarean scar defects; double-layer closure; isthmocele cesarean section; single-layer closure.

Conflict of interest statement

Conflict of Interest: No conflict of interest was declared by the authors.

Figures

Figure 1
Figure 1
Analysis of the outcome of patients needing additional suturing
Figure 2
Figure 2
Analysis of the outcome of the number of additional suture throws required. 2B. Analysis of the outcome of the number of additional suture throws required, but after excluding one study to solve heterogeneity
Figure 3
Figure 3
Analysis of the outcome of total blood loss
Figure 4
Figure 4
Analysis of the outcome of change of hemoglobin level
Figure 5
Figure 5
Analysis of the outcome of postoperative hematocrit
Supplementary Figure S1
Supplementary Figure S1
The PRISMA flow diagram of our literature search
Supplementary Figure S2A
Supplementary Figure S2A
Graphical representation of the risk of bias assessment
Supplementary Figure S2B
Supplementary Figure S2B
Results of our assessment of bias of the included studies
Supplementary Figure S3
Supplementary Figure S3
The incidence of maternal infectious morbidity
Supplementary Figure S4
Supplementary Figure S4
The incidence of postpartum fever
Supplementary Figure S5
Supplementary Figure S5
Analysis of the number of patients needing blood transfusions
Supplementary Figure S6
Supplementary Figure S6
The incidence of endometriosis
Supplementary Figure S7A
Supplementary Figure S7A
Analysis of residual myometrium thickness (mm) at 6 weeks
Supplementary Figure S7B
Supplementary Figure S7B
Analysis of residual myometrium thickness (mm) at 6 weeks outcome
Supplementary Figure S8
Supplementary Figure S8
Analysis of niche/isthmocele prevalence at 6 weeks
Supplementary Figure S9
Supplementary Figure S9
Analysis of residual myometrium thickness (mm) at 6-24 months
Supplementary Figure S10A
Supplementary Figure S10A
Analysis of niche prevalence at 6-24 months
Supplementary Figure S10B
Supplementary Figure S10B
Analysis of niche prevalence at 6-24 months

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