Uterine Scar Evaluation during the Postpartum: Pleading for Extradecidual Suturing during Cesarean Section

Abstract

Objective Our objective is to evaluate ultrasound differences in uterine scar between techniques using extramucosal suturing and full thickness suturing of the uterine incision.

Study Design A retrospective observational study included cases of primary cesarean section. At 6-week postpartum, we evaluated by endovaginal ultrasound two elements in the sagittal view: the thickness of the uterine scar and the surface of defect (niche). Hysterotomy sites closed using a running full-thickness technique including the uterine mucosa (group 1) were compared to hysterotomies operated by the same surgeon but with extramucosal suturing (group 2). The operator switched from the running suture technique to extramucosal in 2013.

Results The study included 241 patients (115 cases in group 1 that were compared to 126 cases in group 2). There were no significant differences in age or body mass index between the two groups. Cesarean scar and niche were detectable in the entire studied population. There was a significant difference in both uterine scar thickness (5.8 vs. 6.2 mm, p = 0.02) and the presence and size of the niche (49 vs. 40 mm², p = 0.001) in transvaginal ultrasound performed at 6-week postpartum.

Conclusion Extramucosal suturing of the uterine scar seems to be associated with a better outcome on the postpartum ultrasound evaluation.

Key Points

• The technique for suturing the hysterotomy can be the source of healing changes.

• An extramucosal suturing of the uterus seems to give a better aspect at the postpartum ultrasound.

• Decreasing the niche at cesarean scar may be beneficial for future pregnancies.

Keywords

cesarean section - suturing technique - scar - niche - ultrasound

Synopsis

Comparing the full-thickness suturing technique to extramucosal suturing of the uterine incision showed a better scar on postpartum ultrasound evaluation.

Publication History

Received: 09 October 2022

Accepted: 26 January 2023

Accepted Manuscript online:
31 January 2023

Article published online:
07 March 2023

• References

• 1 Yazicioglu F, Gökdogan A, Kelekci S, Aygün M, Savan K. Incomplete healing of the uterine incision after caesarean section: is it preventable?. Eur J Obstet Gynecol Reprod Biol 2006; 124 (01) 32-36
• 2 Al Naimi A, Wolnicki B, Mouzakiti N, Reinbach T, Louwen F, Bahlmann F. Anatomy of the sonographic post-cesarean uterus. Arch Gynecol Obstet 2021; 304 (06) 1485-1491
• 3 Regnard C, Nosbusch M, Fellemans C. et al. Cesarean section scar evaluation by saline contrast sonohysterography. Ultrasound Obstet Gynecol 2004; 23 (03) 289-292
• 4 Stegwee SI, Jordans I, van der Voet LF. et al. Uterine caesarean closure techniques affect ultrasound findings and maternal outcomes: a systematic review and meta-analysis. BJOG 2018; 125 (09) 1097-1108
• 5 Hayakawa H, Itakura A, Mitsui T. et al. Methods for myometrium closure and other factors impacting effects on cesarean section scars of the uterine segment detected by the ultrasonography. Acta Obstet Gynecol Scand 2006; 85 (04) 429-434
• 6 Armstrong V, Hansen WF, Van Voorhis BJ, Syrop CH. Detection of cesarean scars by transvaginal ultrasound. Obstet Gynecol 2003; 101 (01) 61-65
• 7 Vervoort AJ, Uittenbogaard LB, Hehenkamp WJ, Brölmann HA, Mol BW, Huirne JA. Why do niches develop in Caesarean uterine scars? Hypotheses on the aetiology of niche development. Hum Reprod 2015; 30 (12) 2695-2702
• 8 Pomorski M, Fuchs T, Rosner-Tenerowicz A, Zimmer M. Standardized ultrasonographic approach for the assessment of risk factors of incomplete healing of the cesarean section scar in the uterus. Eur J Obstet Gynecol Reprod Biol 2016; 205: 141-145
• 9 Osser OV, Jokubkiene L, Valentin L. High prevalence of defects in cesarean section scars at transvaginal ultrasound examination. Ultrasound Obstet Gynecol 2009; 34 (01) 90-97
• 10 Zimmer EZ, Bardin R, Tamir A, Bronshtein M. Sonographic imaging of cervical scars after Cesarean section. Ultrasound Obstet Gynecol 2004; 23 (06) 594-598
• 11 Bujold E. The optimal uterine closure technique during cesarean. N Am J Med Sci 2012; 4 (08) 362-363
• 12 Babu K, Magon N. Uterine closure in cesarean delivery: a new technique. N Am J Med Sci 2012; 4 (08) 358-361
• 13 Kok N, Wiersma IC, Opmeer BC, de Graaf IM, Mol BW, Pajkrt E. Sonographic measurement of lower uterine segment thickness to predict uterine rupture during a trial of labor in women with previous cesarean section: a meta-analysis. Ultrasound Obstet Gynecol 2013; 42 (02) 132-139
• 14 Roberge S, Boutin A, Chaillet N. et al. Systematic review of cesarean scar assessment in the nonpregnant state: imaging techniques and uterine scar defect. Am J Perinatol 2012; 29 (06) 465-471
• 15 Antoine C, Meyer JA, Silverstein JS, Alexander J, Oh C, Timor-Tritsch IE. The impact of uterine incision closure techniques on post-cesarean delivery niche formation and size: sonohysterographic examination of nonpregnant women. J Ultrasound Med 2022; 41 (07) 1763-177