CD outcomes similar between single- vs double-layer uterine closure

CD outcomes similar between single- vs double-layer uterine closure | Image Credit: © nenetus - © nenetus - stock.adobe.com.

Double-layer uterine closure is not superior vs single-layer closure in outcomes following a first cesarean delivery (CD), according to a recent study published in the American Journal of Obstetrics & Gynecology.¹

The rate of CD has risen over time, leading to more women experiencing long-term health outcomes. This includes a niche, presenting in 56% to 84% of patients with a previous CD.² Adverse gynecologic outcomes of a niche include dysmenorrhea, chronic pelvic pain, abnormal uterine bleeding, and fertility problems.¹

While the National Institute for Health and Care Excellence recommends a single-layer or double-layer uterine closure after a CD, there is currently no specific guideline from the American College of Obstetricians and Gynecologists. Additionally, data comparing single-layer vs double-layer uterine closure primarily assessed short-term outcomes.

To evaluate long-term outcomes of single-layer vs double-layer uterine closure in patients undergoing their first CD, investigators conducted the 2Close trial with a 3-year follow-up. Participants were recruited from maternity units across 32 university hospitals in the Netherlands.

Women aged 18 years or older undergoing their first CD and proficient in Dutch or English were included in the analysis. Those with inadequate possibility for counseling, previous major uterine surgery, known causes of menstrual disorders, current placenta accreta spectrum (PAS), or 3 or more current fetuses were excluded.

Participants were randomized 1:1 to receive either single-layer or double-layer uterine closure. CD was performed based on standardized procedure in both groups, and closure was performed using nonlocking continuous multifilament sutures at the incision in the single-layer group and in 2 layers in the double-layer group.

The live birth rate was reported as the primary long-term outcome in line with core infertility outcomes. Secondary outcomes included pregnancy rate, need for infertility treatment, obstetrical and gynecologic complications, and mode of delivery. These outcomes were determined based on questionnaires sent to participants from May 2019 to August 2021.

Similar baseline characteristics were reported between women in the single-layer group vs the double-layer group. Of respondents, 8.8% reported breastfeeding, 9.7% pregnancy, 30.9% hormonal contraception use, and 7.6% no menstrual cycles in the past 3 years.

A desire to conceive was reported by 50.4% of women in the single-layer group and 47.8% in the double-layer group. Conception occurred in 84.5% and 86.7% respectively, indicating no significant differences with a relative risk (RR) of 0.92. Similar miscarriage and ectopic pregnancy rates were also observed between groups.

In the single-layer group, a live birth rate of 67.7% was reported, with 5.9% having premature delivery before 37 weeks. These rates were 70.8% and 7.5%, respectively, in the double-layer group. Repeated CD was the delivery mode most often used, at 62.3% in the single-layer group and 60.8% in the double-layer group.

Uterine rupture rates did not significantly differ between groups, and a 5-minute Apgar score below 7 was reported in only 1 neonate in the double-layer group. Additionally, blood loss over 1000 mL was reported in 2 women in both the single-layer and double-layer group with uterine rupture. A PAS disorder during pregnancy was diagnosed in 2 women in the single-layer group.

These results indicated similar long-term outcomes from double-layer uterine closure vs single-layer closure after a first CD. Investigators concluded there is no preferrable closure technique and recommended additional research provide “a more comprehensive power analysis for obstetrical outcomes.”

References

1. Carry Verberkt C, Stegwee SI, Van der Voet LF, et al. Single-layer vs double-layer uterine closure during cesarean delivery: 3-year follow-up of a randomized controlled trial (2Close study). Am J Obstet Gynecol. 2024;231:346.e1-11. doi:10.1016/j.ajog.2023.12.032
2. Klein Meuleman SJM, Min N, Hehenkamp WJK, Post Uiterweer ED, Huirne JAF, de Leeuw RA. The definition, diagnosis, and symptoms of the uterine niche - A systematic review. Best Pract Res Clin Obstet Gynaecol. 2023;90:102390. doi:10.1016/j.bpobgyn.2023.102390