title: Risk of Cesarean scar defect following single- vs double-layer uterine closure: systematic review and meta-analysis of randomized controlled trials.
abstract: OBJECTIVE
  There is a growing body of evidence that suggests that the surgical technique for uterine closure following Cesarean delivery influences the healing of the Cesarean scar, but there is still no consensus on the optimal technique. The aim of this systematic review and meta-analysis was to compare the effect of single- vs double-layer uterine closure on the risk of uterine scar defect.
  
  
  METHODS
  MEDLINE, Scopus, ClinicalTrials.gov, PROSPERO, EMBASE and the Cochrane Central Register of Controlled Trials were searched from inception of each database until May 2016. All randomized controlled trials (RCTs) evaluating the effect of single- vs double-layer uterine closure following low transverse Cesarean section on the risk of uterine scar defect were included. The primary outcome was the incidence of uterine scar defects detected on ultrasound. Secondary outcomes were residual myometrial thickness evaluated by ultrasound and the incidence of uterine dehiscence and/or rupture in subsequent pregnancy. Summary measures were reported as relative risk (RR) or mean difference (MD), with 95% CIs. Quality of the evidence was assessed using the GRADE approach.
  
  
  RESULTS
  Nine RCTs (3969 participants) were included in the meta-analysis. The overall risk of bias of the included trials was low. Statistical heterogeneity within the studies was low, with no inconsistency in the primary and secondary outcomes. Women who received single-layer uterine closure had a similar incidence of uterine scar defects as did women who received double-layer closure (25% vs 43%; RR, 0.77 (95% CI, 0.36-1.64); five trials; 350 participants; low quality of evidence). Compared with double-layer uterine closure, women who received single-layer closure had a significantly thinner residual myometrium on ultrasound (MD, -2.19 mm (95% CI, -2.80 to -1.57 mm); four trials; 374 participants; low quality of evidence). No difference was found in the incidence of uterine dehiscence (0.4% vs 0.2%; RR, 1.34 (95% CI, 0.24-4.82); three trials; 3421 participants; low quality of evidence) or uterine rupture (0.1% vs 0.1%; RR, 0.52 (95% CI, 0.05-5.53); one trial; 3234 participants; low quality of evidence) in a subsequent pregnancy.
  
  
  CONCLUSIONS
  Single- and double-layer closure of the uterine incision following Cesarean delivery are associated with a similar incidence of Cesarean scar defects, as well as uterine dehiscence and rupture in a subsequent pregnancy. However, the quality level of summary estimates, as assessed by GRADE, was low, indicating that the true effect may be, or is even likely to be, substantially different from the estimate of the effect. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
authors.affiliation: Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy.
authors.forename: A
authors.initials: A
authors.lastname: Di Spiezio Sardo
authors.affiliation: Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy.
authors.forename: G
authors.identifier: http://orcid.org/0000-0003-0078-2113
authors.initials: G
authors.lastname: Saccone
authors.affiliation: Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA.
authors.forename: R
authors.initials: R
authors.lastname: McCurdy
authors.affiliation: Department of Obstetrics and Gynecology, Faculty of Medicine, Laval University, Québec, Canada.
authors.forename: E
authors.initials: E
authors.lastname: Bujold
authors.affiliation: Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Bifulco
authors.affiliation: Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA.
authors.forename: V
authors.identifier: http://orcid.org/0000-0003-2854-0239
authors.initials: V
authors.lastname: Berghella
mesh_terms: D002585:Cesarean Section / Q000009:adverse effects* / Q000379:methods; D002921:Cicatrix / Q000150:complications*; D005260:Female; D006801:Humans; D009215:Myometrium / Q000473:pathology; D011183:Postoperative Complications / Q000209:etiology*; D011247:Pregnancy; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors; D013529:Surgical Wound Dehiscence / Q000209:etiology*; D013536:Suture Techniques / Q000009:adverse effects*; D014597:Uterine Rupture / Q000209:etiology*; D014599:Uterus / Q000601:surgery
keywords: isthmocele; minimally invasive therapy; niche; scar defects; scar pregnancy; ultrasound