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Preventing Isthmocele After Cesarean Section (PICS): A Pilot Randomized Controlled Trial

Published:August 12, 2022DOI:https://doi.org/10.1016/j.jogc.2022.08.003
      Cesarean delivery accounts for approximately 30% of deliveries in Canada. A cesarean scar defect (CSD), or isthmocele, is a myometrial defect ≥2 mm in depth at the cesarean scar site that can lead to major obstetrical and gynaecological complications.
      • Tulandi T.
      • Cohen A.
      Emerging manifestations of cesarean scar defect in reproductive-aged women.
      Although CSD treatments exist, interest has shifted to prevention, with suture technique being the most modifiable risk factor. Some studies have suggested a double-layer closure decreases CSD formation and increases residual myometrial thickness,
      • Roberge S.
      • Demers S.
      • Girard M.
      • et al.
      Impact of uterine closure on residual myometrial thickness after cesarean: a randomized controlled trial.
      but systematic reviews have suggested no difference between a single versus double-layer closure.
      • Roberge S.
      • Demers S.
      • Berghella V.
      • et al.
      Impact of single- vs double-layer closure on adverse outcomes and uterine scar defect: a systematic review and metaanalysis.
      However, a locked suture may result in a larger CSD with a higher risk of uterine rupture, without hemostatic benefit.
      • Roberge S.
      • Demers S.
      • Berghella V.
      • et al.
      Impact of single- vs double-layer closure on adverse outcomes and uterine scar defect: a systematic review and metaanalysis.
      We therefore hypothesized that an unlocked double-layer closure may prevent CSD formation. As such, our objective was to assess the feasibility of a pilot randomized controlled trial (RCT) comparing locked versus unlocked first layer cesarean scar closure.
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      References

        • Tulandi T.
        • Cohen A.
        Emerging manifestations of cesarean scar defect in reproductive-aged women.
        J Minim Invasive Gynecol. 2016; 23: 893-902
        • Roberge S.
        • Demers S.
        • Girard M.
        • et al.
        Impact of uterine closure on residual myometrial thickness after cesarean: a randomized controlled trial.
        Am J Obstet Gynecol. 2016; 214: 507.e1-507.e6
        • Roberge S.
        • Demers S.
        • Berghella V.
        • et al.
        Impact of single- vs double-layer closure on adverse outcomes and uterine scar defect: a systematic review and metaanalysis.
        Am J Obstet Gynecol. 2014; 211: 453-460