Vol 93, No 7 (2022)
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Perfect cesarean section — the Holy Grail of obstetricians

Michal Pomorski1, Mariusz Zimmer1
Pubmed: 35942722
Ginekol Pol 2022;93(7):523-524.

Abstract

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EDITORIAL

Ginekologia Polska

2022, vol. 93, no. 6, 523–524

Copyright © 2022 PTGiP

ISSN 0017–0011, e-ISSN 2543–6767

DOI 10.5603/GP.2022.0073

Perfect cesarean section — the Holy Grail of obstetricians

Michal PomorskiMariusz Zimmer
2nd Department of Gynecology and Obstetrics, Wroclaw Medical University, Poland

Corresponding author:

Michal Pomorski

2nd Department of Gynecology and Obstetrics, Wroclaw Medical University, Poland

e-mail: pomorski.md@gmail.com

This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.

Caesarean section (CS), as the most frequently performed major surgical procedure worldwide (21.1% women give birth by CS almost 30 million CSs annually), has several advantages [1]. The obvious one is it’s a safe option for delivery when due to maternal or fetal indications the vaginal delivery is contraindicated. Moreover, there are long-term advantages like decreased rates of pelvic floor dysfunction (especially stress urinary incontinence and pelvic organ prolapse) when compared to women who deliver vaginally [2, 3].

Major progress has been achieved in the reduction of early CS complications, such as wound infection (i.e., antibiotic prophylaxis), postpartum haemorrhage (i.e., carbetocin infusion), pain control (i.e., transversus abdominis plane block) and thromboembolic complications (i.e., low molecular weight heparin, early mobilization) [4, 5].

However, there are no roses without thorns. Above all, there are ongoing concerns about increased maternal mortality related to CS [6]. Also, an urgent problem is maternal morbidity expressed in skyrocketing frequency of long-term CS complications. These complications are mostly related to the incomplete healing of the uterine CS scar. In pregnant women they include potentially life-threatening complications like cesarean scar dehiscence or rupture, CS scar pregnancy and its direct consequence placenta previa accreta [7]. In nonpregnant women the long-term CS complications include abnormal uterine bleeding, subfertility and pelvic pain syndrome [8–10]. Also, CS related intra-abdominal adhesions, mainly between the uterus and abdominal wall, negatively affect the safety of subsequent surgical procedures and increase the risk of incomplete healing of the uterine CS scar [11].

As the incompletely healed uterine CS scar seems to play crucial role in the etiology of long-term CS complications the current research should be focused on the improvement of surgical techniques that allow better healing of the uterine CS scar and decrease adhesion formation.

Making a long story short the cornerstone on the way to modern CS was change from vertical uterine incision to low transverse incision introduced by John Martin Munro Kerr in 1926, which was then combined with transverse “Pfannenstiel” abdominal entry [12]. The next step was the introduction of blunt dissection techniques for abdominal entry by Joel-Cohen and uterine entry the Misgav-Ladach method. These novel techniques allowed decreased blood loss, shortening of the operation time and recovery period [12]. However, after millions of CSs and dozens of studies the uterine closure technique that allows complete healing of the CS scar is still missing [13, 14]. There are also no general guidelines on CS technique from skin incision to skin closure. The American College of Obstetricians and Gynecologists advises autonomy of obstetricians in choosing their preferred CS technique, considering their safety regarding short-term complications [12]. However, the impact of this techniques on the above listed long-term CS complications is still under evaluation, with no final conclusions [12, 15].

One of the steps forward on the way to the „perfect” CS might be the “novel technique uterine suturing” (NTUS) described by Ugur Erkayiran and Tufan Arslanca in the current issue of Ginekologia Polska in a study entitled: “Comparative analysis of classical primary continuous and novel technique uterine suturing methods on uterine scar formation after caesarian section: a prospective clinical study” [16]. In this study the CS scar niche incidence did not differ between the group with NUTS closure and the group with classical primary continuous suturing, however the residual myometrial thickness (RMT) was significantly thicker in the NUTS group.

According to the current knowledge the RMT has crucial value in terms of risk for scar related complications in subsequent pregnancies. Randomized studies revealed that low RMT values measured in the non-pregnant uterus using transvaginal ultrasound (TVUS) predict the occurrence of CS scar dehiscence and rupture in the next pregnancy [17, 18].

Moreover, in women with cesarean scar pregnancy (CSP) the RMT value of2 mm measured at the first prenatal ultrasound predicts in all cases the development of placenta previa accreta when the pregnancy is continued [19].

In our opinion the key to success in improvement of CS technique is the evaluation of own results. In our centre the 2nd Department of Gynecology and Obstetrics, Medical University Wroclaw, Poland (Head: Prof. Mariusz Zimmer) in 2005 we introduced the first standardized ultrasonographic assessment of the CS scar in the non-pregnant uterus. The scar was assessed six weeks after CS. The results published in Ginekologia Polska in 2007 revealed that in 94.5% of women the scar niche was detected [20]. After analysis of the results a mandatory full thickness single layer uterine closure without the inclusion of decidua was implemented. Further studies on women after CS performed in our department revealed significant decrease in niche detection [18]. Among 204 women included in the latest publication from our center only five patients (2.4%) had a RMT < 2.2 mm [21].

The last word in the topic on the improvement of the CS technique is not said. We should be aware that even small progress in the most common major surgery worldwide may have positive impact on wellbeing of millions of women and thus on public health. The key to the success is the evaluation of own surgical results both in the settings of big clinical trials and in the micro scale by the surgeons themselves. The tool for CS scar assessment TVUS is widely available and uterine CS scar assessment techniques are easy to implement and use [22]. Dear Readers, we encourage all of you to assess the CS scars after the cesareans you have performed maybe your technique will turn out to be a milestone on the way to a perfect CS.

Conflict of interest

The authors have no conflicts of interest to declare.

References

  1. Betran AP, Ye J, Moller AB, et al. Trends and projections of caesarean section rates: global and regional estimates. BMJ Glob Health. 2021; 6(6), doi: 10.1136/bmjgh-2021-005671, indexed in Pubmed: 34130991.
  2. Handa VL, Blomquist JL, Knoepp LR, et al. Pelvic floor disorders 5-10 years after vaginal or cesarean childbirth. Obstet Gynecol. 2011; 118(4): 777784, doi: 10.1097/AOG.0b013e3182267f2f, indexed in Pubmed: 21897313.
  3. Sliwa J, Kryza-Ottou A, Grobelak J, et al. Anterior abdominal fixation - a new option in the surgical treatment of pelvic organ prolapse. Ginekol Pol. 2021; 92(7): 471474, doi: 10.5603/GP.a2021.0004, indexed in Pubmed: 33844247.
  4. Feduniw S, Warzecha D, Szymusik I, et al. Epidemiology, prevention and management of early postpartum hemorrhage - a systematic review. Ginekol Pol. 2020; 91(1): 3844, doi: 10.5603/GP.2020.0009, indexed in Pubmed: 32039467.
  5. Kupiec A, Zwierzchowski J, Kowal-Janicka J, et al. The analgesic efficiency of transversus abdominis plane (TAP) block after caesarean delivery. Ginekol Pol. 2018; 89(8): 421424, doi: 10.5603/GP.a2018.0072, indexed in Pubmed: 30215460.
  6. Molina G, Weiser T, Lipsitz S, et al. Relationship Between Cesarean Delivery Rate and Maternal and Neonatal Mortality. JAMA. 2015; 314(21): 2263, doi: 10.1001/jama.2015.15553.
  7. Timor-Tritsch IE, Monteagudo A, Calì G, et al. Cesarean Scar Pregnancy: Diagnosis and Pathogenesis. Obstet Gynecol Clin North Am. 2019; 46(4): 797811, doi: 10.1016/j.ogc.2019.07.009, indexed in Pubmed: 31677755.
  8. Pomorski M, Fuchs T, Rosner-Tenerowicz A, et al. Sonographic evaluation of surgical repair of uterine cesarean scar defects. J Clin Ultrasound. 2017; 45(8): 455460, doi: 10.1002/jcu.22449, indexed in Pubmed: 28186617.
  9. Pomorski M, Zimmer M. Complete separation of the uterine cesarean section scar - a new cause of secondary infertility? Fertil.Steril. 2014; 102(3): 283.
  10. van der Voet LF, Vervoort AJ, Veersema S, et al. Minimally invasive therapy for gynaecological symptoms related to a niche in the caesarean scar: a systematic review. BJOG. 2014; 121(2): 145156, doi: 10.1111/1471-0528.12537, indexed in Pubmed: 24373589.
  11. Vervoort AJ, Uittenbogaard LB, Hehenkamp WJK, et al. Why do niches develop in Caesarean uterine scars? Hypotheses on the aetiology of niche development. Hum Reprod. 2015; 30(12): 26952702, doi: 10.1093/humrep/dev240, indexed in Pubmed: 26409016.
  12. Antoine C, Young BK. Cesarean section one hundred years 1920-2020: the Good, the Bad and the Ugly. J Perinat Med. 2020; 49(1): 516, doi: 10.1515/jpm-2020-0305, indexed in Pubmed: 32887190.
  13. Di Spiezio Sardo A, Saccone G, McCurdy R, et al. 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): 578583, doi: 10.1002/uog.17401, indexed in Pubmed: 28070914.
  14. Laganà AS, Cromi A, Tozzi R, et al. Uterine Scar Healing After Cesarean Section: Managing an Old Surgery in an Evidence-Based Environment. J Invest Surg. 2019; 32(8): 770772, doi: 10.1080/08941939.2018.1465145, indexed in Pubmed: 29741973.
  15. Dodd JM, Anderson ER, Gates S. Surgical techniques involving the uterus at the time of caesarean section. Cochrane Database of Systematic Reviews. 2004, doi: 10.1002/14651858.cd004732.
  16. Erkayiran U, Arslanca T. Comparative analysis of classical primary continuous and novel technique uterine suturing methods on uterine scar formation after caesarian section: a prospective clinical study. Ginekol Pol. 2022 [Epub ahead of print], doi: 10.5603/GP.a2022.0022, indexed in Pubmed: 35419795.
  17. Osser OV, Valentin L. Clinical Importance of Appearance of Cesarean Hysterotomy Scar at Transvaginal Ultrasonography in Nonpregnant Women. Obstetrics & Gynecology. 2011; 117(3): 525532, doi: 10.1097/aog.0b013e318209abf0.
  18. Pomorski M, Fuchs T, Rosner-Tenerowicz A, et al. 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: 141145, doi: 10.1016/j.ejogrb.2016.08.032, indexed in Pubmed: 27591715.
  19. Agten AK, Cali G, Monteagudo A, et al. The clinical outcome of cesarean scar pregnancies implanted “on the scar” versus “in the niche”. American Journal of Obstetrics and Gynecology. 2017; 216(5): 510.e1510.e6, doi: 10.1016/j.ajog.2017.01.019.
  20. Zimmer M, Pomorski M, Fuchs T, et al. Ultrasonographic analysis of cesarean scars features in nonpregnant uterus. Ginekol Pol. 2007; 78(11): 842846.
  21. Budny-Winska J, Zimmer-Stelmach A, Pomorski M. Two- and three-dimensional transvaginal ultrasound in assessment of the impact of selected obstetric risk factors on cesarean scar niche formation: the case-controlled study. Ginekol Pol. 2021; 92(5): 378382, doi: 10.5603/GP.a2021.0024, indexed in Pubmed: 33757154.
  22. Budny-Winska J, Pomorski M. Uterine niche after cesarean section: a review of diagnostic methods. Ginekol Pol. 2021; 92(10): 726730, doi: 10.5603/GP.a2021.0195, indexed in Pubmed: 34747000.