Evaluation of the effect of surgical single or double layer closure of uterus during cesarean birth on the development of isthmocele

INTRODUCTION: Similar to developed and developing countries there is an increase in cesarean birth rate in our country. In the records %6-%36(%21 average) of births were reported to be delivered via ceaserean. Along with the increase in ceaserean birth rate there is also an increase in uterin rupture, placental invasion anomalies and other known complications with the following pregnancies. Other than these lately there was an apparent increase in incidences of uterine scar defects named isthmocele which can be evaluated as a pathologic recovery/insufficient recovery on the uterine incision line. Considering the connections that isthmocele has with gynecological problems, obstetric complications and potential subfertility it is important to search the causes of post ceaserean isthmocele and if possible develop preventive strategies. OBJECTIVE: In our study we aimed to evaluated the causes of uterine scar decefts and the effects of uterin closure technique on the isthmocele development. MATERIAL AND METHOD: In our study we included 86 patients who were admitted to the Department of Obstetrics and Gynecology, Ege University Hospital between December 2016 and December 2017 and required urgent or elective cesarean section. Patients with previous pregnancies, uterine surgical history, preeclampsia, eclampsia, HELLP, GDM/DM pregnant patients who use insulin, multiple pregnancies, preterm pregnancies before 37th week and placental invasion anomalies (plasenta previa, plasenta akreata, plasenta inkreata, plasenta perkreata) were not included in the study. We randomised the 86 patients within the criterias into three groups. With the permutation method patients were distributed two by two into the groups. In all three groups cesarean surgical protocol Modified Misgav Ladach technique was performed. Uterus defects were repaired with single-layer unlocked suturation in group 1, single-layer locked suturation in group 2, and double-layer suturation in group 3. After the operation patients were called back for postop follow up in 6th week and 6th month and the presence of cesarean scars and defects (isthmocele) were evaluated by transvaginal USG. Out of the 86 patients 1 of them was removed due to new pregnancy and 39 of them were removed because they did not attend the follow up. Remanining 46 patients were compared to each other in terms of istmosel development according to the three groups of uterin closure they were grouped into in the begining. RESULTS: There were no substantial differences of age, BMI, pregnancy week, smoking or other diseases (diabetes, hypertension) between the three groups. Double-layer group had 3 times more isthmocele compared to single-layer locked group but it was not statistically significant. Single-layer unlocked group had 12 times more isthmocele than the single-layer locked group and it was statistically significant. There were no complaints from any patient due to isthmocele. Although the cases with cervical dilatation and effacement had increased isthmocele development in all three groups but it was not statistically significant. There was no correlation between PI values of left and right uterine arteries and isthmocele area. CONCLUSION: Our study showed that single-layer locked suturation reduced the istmosel development rate and was statistically significant. Although during the cesarean section uterus repair with this technique appears to be advantageous over the others, it cannot be determined exactly which technique is the most appropriate, most likely due to many factors involved other than the suturing technique. Further studies including larger sample size with elimination of the other factors would greatly help to determine the most appropriate technique. Our aim is to be a leading study for the future studies. Keywords: Cesarean birth; uterus closure method; isthmocele.