Tek kat ve çift kat onarımın rezidüel miyometriyal kalınlık, istmosel oluşumu ve jinekolojik bozukluklar üzerine etkisi: Prospektif Randomize Kontrollü Bir Çalışma.

Year 2023, Volume: 13 Issue: 3, 444 - 450, 31.05.2023

Melis Arık , Deniz Simsek , Burcu Dinçgez , Emin Üstünyurt

https://doi.org/10.16899/jcm.1229480

Abstract

Abstract: Klinisyenler sezaryenin plasental yapışık sendromları, uterin skarlı gebelikler, uterin rüptür, anormal adet kanaması veya istmosel gibi uzun dönem komplikasyonlarını azaltmak için büyük çaba sarf etmektedirler. Sezaryen kesisinin kapatma tekniği konusunda bir tartışma mevcuttur. Bu çalışmanın amacı, rezidüel miyometriyal kalınlık, istmosel, adet bozuklukları, dismenore ve disparoni üzerindeki histerotomi insizyonunun tek katmanlı ve çift katmanlı kapatılmasının etkisini karşılaştırmaktı.
Materyal Method: Temmuz – Ekim 2021 tarihleri ​​arasında Bursa Yüksek İhtisas Eğitim Araştırma Hastanesi adlı üçüncü basamak bir merkezde prospektif bir randomize kohort çalışması yapılmıştır. Hastalar randomize olarak tek katlı kilitli devamlı onarım ve çift katmanlı kilitsiz devamlı onarım gruplarına ayrılmıştır. Hastalar istmosel oluşumunu, rezidüel miyometriyum kalınlığını değerlendirmek için transvajinal ultrason ile muayene edimiştir ve menstrüel özellikler, dismenore ve disparoni hakkında sorgulanmıştır. Hastalar ayrıca ilk sezaryen ve birden fazla sezaryen uygulanan gruplara ayrılmıştır.
Results:
Histerotomi insizyonu tek kat kilitli devamlı (TKKD) ve çift kat kilitsiz devamlı (ÇKKD) teknikle kapatılan kadın sayısı sırasıyla 68 ve 71'dir. Demografik değişkenler, obstetrik öykü, postoperatif komplikasyonlar, neonatal sonuçlar açısından istatistiksel olarak anlamlı fark bulunmamıştır. Bu grupların karşılaştırılmasında adet sonrası kanama, ağır adet kanaması, ilişki sonrası kanama, dismenore, disparoni açısından anlamlı fark olmadığı görülmüştür. İnsizyonel rezidüel miyometrial kalınlık p değeri 0,007 ile ÇKKD grubunda daha yüksekti. TKKD grubunda 6 hasta ve ÇKKD grubunda 5 hastada istmosel saptandı (p: 0,941).
Hastalar ayrıca ilk kez sezaryen (TKKD n: 33'e karşı ÇKKD, n:33) ve birden fazla sezaryen (TKKD n: 35'e karşı ÇKKD, n:38) olan kadınlar olarak kategorize edilmiştir. Bu alt gruplardaki hastaların karşılaştırılması da istmosel oluşumu, menstrüel bozukluklar veya rezidüel miyometrial kalınlık açısından anlamlı farklılık görülmemiştir.
Conclusions:
İstmosel insidansı veya menstrüel bozukluklar açısından, tek kat ile çift kat kapatma karşılaştırıldığında anlamlı bir fark meydana gelmemiştir. Ancak, histerotomi insizyonları çift kat kilitsiz devamlı teknikle kapatılan kadınlarda, özellikle tekrarlanan sezaryen uygulanan kadınlar, tek kat kapatma grubuna göre daha kalın bir rezidü miyometriyuma sahip bulunmuştur.

Keywords

Single layer, Double layer, Cesarean, Isthmocele, Residual Myometrial Thickness

Supporting Institution

Bursa Yüksek İhtisas Eğitim ve Araştırma Hastanesi

Project Number

2011-KAEK-25 2020/06-02

Effect of the single-layer and double-layer closure on residual myometrial thickness, isthmocele occurrence, and gynecological disorders: A Prospective Randomized Controlled Study

Abstract

Abstract:
Physicians are making great efforts to decrease the long-term complications of the cesarean section such as placental adherent syndromes, uterine scar pregnancies, uterine rupture, abnormal menstrual bleeding, or isthmocele. There is a controversy about the closure technique of the cesarean incision. The purpose of that study was to compare the impact of single layer versus double-layer closure of the hysterotomy incision on the residual myometrial thickness, isthmocele, menstrual disorders, dysmenorrhea, and dyspareunia.
Material and Method
A prospective randomized cohort study has been performed in a tertiary center named Bursa Yuksek İhtisas Training Research Hospital between July – October 2021. Patients were randomly assigned to each procedure (1:1) to the Single Layer Locked Continuous group and Double-layer Continuous un-locked group as uterine closure technique. Patients were examined via transvaginal ultrasound to evaluate the isthmocele occurrence, residual myometrium thickness, and inquired about menstrual properties, dysmenorrhea, and dyspareunia. Patients were also divided into groups via underwent first cesarean and more than one cesarean.
Results:
The numbers of the women whose hysterotomy incision was closed by single-layer locked continuous( SLLC) technique and double-layer un-locked continuous(DLUC) technique 68 and 71 respectively. There was no statistically significant difference in terms of demographic variables, obstetric history, post-operative complications, neonatal outcomes. The comparison of these groups revealed that there was no significant difference in terms of post-menstrual bleeding, heavy menstrual bleeding, post-coital bleeding, dysmenorrhea, dyspareunia. The incisional residual myometrial thickness was higher in the DLUC group with a p-value of 0,007. Six patients in SLLC and 5 patients in the DLUC group have detected isthmocele (p: 0,941).
Patients have also been categorized as women who undergone their first cesarean section (SLLC n: 33 versus DLUC, n:33) and more than one cesarean section (SLLC n: 35 versus DLUC, n:38). Comparing the patients in these subgroups also did not differ significantly in terms of isthmocele occurrence, menstrual disorders, or residual myometrial thickness.
Conclusion:
No significant difference had occurred in terms of isthmocele incidence, or menstrual disorders comparing the single layer versus double-layer closure. However, women whose hysterotomy insicions were closed with double-layer un-locked continuous technique have a thicker resudial myometrium than single layer closure group especially women who underwent repeated cesarean.

Keywords

Single layer, Double layer, Cesarean, Isthmocele, Residual Myometrial Thickness

Project Number

2011-KAEK-25 2020/06-02

References

• 1. Gabbe SG, Niebyl JR, Simpson JL, Landon MB, Galan HL, Jauniaux ER, et al. Obstetrics: normal and problem pregnancies e-book: Elsevier Health Sciences; 2016.
• 2. Sewell JE. Cesarean section–a brief history. A brochure to accompany an exhibition on the history of cesarean section at the National Library of Medicine. 1993;30.
• 3. Gilliam M, editor Cesarean delivery on request: reproductive consequences. Seminars in perinatology; 2006: Elsevier.
• 4. Hamilton BE, Osterman MJ, Driscoll AK, Rossen LM. Births: Provisional data for 2017. 2018.
• 5. Arulkumaran S. Best practice in labour and delivery: Cambridge University Press; 2016.
• 6. Grivell RM, Dodd JM. Short-and long-term outcomes after cesarean section. Expert Review of Obstetrics & Gynecology. 2011;6(2):205-15.
• 7. Mascarello KC, Horta BL, Silveira MF. Maternal complications and cesarean section without indication: systematic review and meta-analysis. Rev Saude Publica 2017;51.
• 8. Simsek D, Urun C, Altekin Y. Determinants of cesarean-related complications: high number of repeat cesarean, operation type or placental pathologies? J Matern Fetal Neonatal Med. 2020:1-7.
• 9. Clark EA, Silver RM. Long-term maternal morbidity associated with repeat cesarean delivery. Am J Obstet Gynecol. 2011;205(6):S2-S10.
• 10. Van der Voet L, Bij de Vaate A, Veersema S, Brölmann H, Huirne J. Long‐term complications of caesarean section. The niche in the scar: a prospective cohort study on niche prevalence and its relation to abnormal uterine bleeding. BJOG. 2014;121(2):236-44.
• 11. Bij de Vaate A. Br€ olmann HAM, van der Voet LF, van der Slikke JW, Veersema S, Huirne JAF. Ultrasound evaluation of the caeserean scar: relation between a niche and postmenstrual spotting. Ultrasound Obstet Gynecol. 2011;37:93-9.
• 12. Stegwee S, Jordans I, Van Der Voet L, Bongers M, De Groot C, Lambalk C, et al. Single-versus double-layer closure of the caesarean (uterine) scar in the prevention of gynaecological symptoms in relation to niche development–the 2Close study: a multicentre randomised controlled trial. BMC pregnancy and childbirth. 2019;19(1):1-11.
• 13. Antila-Långsjö RM, Mäenpää JU, Huhtala HS, Tomás EI, Staff SM. Cesarean scar defect: a prospective study on risk factors. Am J Obstet Gynecol. 2018;219(5):458. e1-. e8.
• 14. Palacios-Jaraquemada JM, D'Antonio F. Placenta Accreta Spectrum Disorder: Uterine Dehiscence, Not Placental Invasion. Obstetrics & Gynecology. 2020;136(3):631.
• 15. Shao Y, Pradhan M. Higher incision at upper part of lower segment caesarean section. JNMA J Nepal Med Assoc. 2014;52(194):764-70.
• 16. Dicle O, Küçükler C, Pirnar T, Erata Y, Posaci C. Magnetic resonance imaging evaluation of incision healing after cesarean sections. European radiology. 1997;7(1):31-4.
• 17. Dodd JM, Anderson ER, Gates S, Grivell RM. Surgical techniques for uterine incision and uterine closure at the time of caesarean section. Cochrane database of Systematic reviews. 2014(7).
• 18. Roberge S, Demers S, Berghella V, Chaillet N, Moore L, Bujold E. Impact of single-vs double-layer closure on adverse outcomes and uterine scar defect: a systematic review and metaanalysis. Ame J Obstet and Gyne. 2014;211(5):453-60.
• 19. Bamberg C, Hinkson L, Dudenhausen JW, Bujak V, Kalache KD, Henrich W. Longitudinal transvaginal ultrasound evaluation of cesarean scar niche incidence and depth in the first two years after single‐or double‐layer uterotomy closure: a randomized controlled trial. Acta Obstet Gynecol Scand. 2017;96(12):1484-9.
• 20. Bij de Vaate A, Van der Voet L, Naji O, Witmer M, Veersema S, Brölmann H, et al. Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following Cesarean section: systematic review. Ultrasound Obstet Gynecol. 2014;43(4):372-82.
• 21. Di Spiezio Sardo A, Saccone G, McCurdy R, Bujold E, Bifulco G, Berghella V. Risk of Cesarean scar defect following single‐vs double‐layer uterine closure: systematic review and meta‐analysis of randomized controlled trials. Ultrasound Obstet Gynecol. 2017;50(5):578-83.
• 22. Stegwee S, Jordans I, Van der Voet L, Van De Ven P, Ket J, Lambalk C, et al. Uterine caesarean closure techniques affect ultrasound findings and maternal outcomes: a systematic review and meta‐analysis. BJOG. 2018;125(9):1097-108.
• 23. Roberge S, Chaillet N, Boutin A, Moore L, Jastrow N, Brassard N, et al. Single-versus double-layer closure of the hysterotomy incision during cesarean delivery and risk of uterine rupture. Int J Gynecol Obstet. 2011;115(1):5-10.
• 24. Roberge S, Demers S, Girard M, Vikhareva O, Markey S, Chaillet N, et al. Impact of uterine closure on residual myometrial thickness after cesarean: a randomized controlled trial. Am J Obstet Gynecol. 2016;214(4):507. e1-. e6.
• 25. Gyamfi C, Juhasz G, Gyamfi P, Blumenfeld Y, Stone JL. Single-versus double-layer uterine incision closure and uterine rupture. J Matern Fetal Neonatal Med. 2006;19(10):639-43.
• 26. Stegwee SI, van der Voet LF, Ben AJ, de Leeuw RA, van de Ven PM, Duijnhoven RG, et al. Effect of single‐versus double‐layer uterine closure during caesarean section on postmenstrual spotting (2Close): multicentre, double‐blind, randomised controlled superiority trial. BJOG:.2021;128(5):866-78.
• 27. Vachon-Marceau C, Demers S, Bujold E, Roberge S, Gauthier RJ, Pasquier J-C, et al. Single versus double-layer uterine closure at cesarean: impact on lower uterine segment thickness at next pregnancy. Am J Obstet Gynecol. 2017;217(1):65. e1-. e5
• 28. Blumenfeld Y, Caughey A, El‐Sayed Y, Daniels K, Lyell D. Single‐versus double‐layer hysterotomy closure at primary caesarean delivery and bladder adhesions. BJOG. 2010;117(6):690-4.