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Cesarean deliveries are associated with uterine scar defects that significantly impact women's health and future pregnancy outcomes. The methods used for hysterotomy closure following cesarean delivery have undergone significant evolution. Commonly used techniques, which are relatively rapid and maintain hemostasis, include the endometrium in a single-layer or "bulk" closure. Such endometrium-inclusive cesarean closure has been linked to an increased risk of scar defects and long-term complications. However, the available data show no difference in outcomes related to cesarean closure technique, leading to widespread adoption of single-layer closure. The debate over the best method for uterine closure as well as the etiology of scar defects remains unresolved. We present the endometrium-free closure technique, an approach that requires in-depth knowledge of uterine anatomy, including the ability to distinguish the 3 layers of the uterine wall, and employs reapproximation of these layers. A 30-year retrospective study of consecutive cesarean deliveries using this closure method reports a reduction in abnormal implantation in subsequent pregnancies. Key findings from sonohysterographic studies demonstrate a clinically significant reduction in the development and size of scar defects when the endometrium is excluded from the closure, in women with one or multiple cesarean deliveries. While formal changes in surgical guidelines may require further randomized trials, we believe that this technique has the potential to reduce adverse events and provide long-term benefits for women's reproductive health.

OBJECTIVE:To examine the prevalence and severity of postcesarean residual niche, evaluated using saline infusion sonohysterography, in an expanded cohort of women with one prior cesarean delivery and to assess the effect of uterine closure technique on the risk of placenta accreta spectrum (PAS) disorders. METHODS:This secondary analysis includes 70 patients who underwent saline infusion sonohysterography after one prior cesarean delivery. Patients were grouped according to hysterotomy closure technique: two-layer endometrium-free closure (technique A), and two- or one-layer routine closures (technique B). Niche dimensions and residual myometrial thickness were measured. The primary outcome was clinically significant niche (depth larger than 2 mm), a risk factor for PAS. Groups were compared using χ2, unpaired t test, Kruskal-Wallis, and logistic regression with significance at P<.05. RESULTS:There were 33 patients in the technique A group and 37 patients in the technique B group. Technique A was associated with smaller niche dimensions (P=.018 for width, .005 for depth, and .002 for length), and exhibited thicker residual myometrial thickness (8.5 mm vs 5.5 mm, P=.041) and a lower incidence of clinically significant niches. The odds of having a clinically significant niche were 27 times higher in the technique B group (adjusted odds ratio 27.1, 95% CI, 4.35-168.81, P<.001). CONCLUSION/CONCLUSIONS:Uterine closure techniques are associated with the development and size of postcesarean residual niches, which are critical risk factors for PAS disorders. Use of an endometrium-free closure technique during primary cesarean delivery is associated with a reduced risk of future niche formation and PAS complications.

Obstetric hemorrhage is a leading cause of maternal morbidity and mortality. An important etiology of obstetric hemorrhage is placenta accreta spectrum. In the last 2 decades, there has been increased clinical experience of the devastating effect of undiagnosed, as well as late diagnosed, cases of cesarean scar pregnancy. There is a growing body of evidence suggesting that cesarean scar pregnancy is an early precursor of second- and third-trimester placenta accreta spectrum. As such, cesarean scar pregnancy should be diagnosed in the early first trimester. This early diagnosis could be achieved by introducing regimented sonographic screening in pregnancies of patients with previous cesarean delivery. This opinion article evaluates the scientific and clinical basis of whether cesarean scar pregnancy, with special focus on its early first-trimester discovery, complies with the accepted requirements of a screening test. Each of the 10 classical screening criteria of Wilson and Jungner were systematically applied to evaluate if the criteria were met by cesarean scar pregnancy, to analyze if it is possible and realistic to carry out screening in a population-wide fashion.

OBJECTIVES/OBJECTIVE:To use saline infusion sonohysterography (SIS) to evaluate the effect of uterine closure technique on niche formation after multiple cesarean deliveries (CDs). METHODS:Patients with at least one prior CD were evaluated for niche via SIS. Subgroups of any number repeat CD (>1 prior), lower-order CD (<4 prior), and higher-order CD (≥4 prior) were analyzed, stratifying by hysterotomy closure technique at last cesarean preceding imaging; techniques included Technique A (endometrium-free double-layer closure) and Technique B (single- or double-layer routine endo-myometrial closure). Niche defects were quantified (depth, length, width, and residual myometrial thickness). The primary outcome was clinically significant niche, defined as depth >2 mm. Statistical analysis was performed using chi-square, ANOVA, t-test, Kruskal-Wallis, and multiple logistic regression, with p-values of <0.05 were statistically significant. RESULTS:A total of 172 post-cesarean SIS studies were reviewed: 105 after repeat CDs, 131 after lower-order CDs, and 41 after higher-order CDs. Technique A was associated with a shorter interval to imaging and more double-layer closures. Technique B was associated with more clinically significant niches across all subgroups, and these niches were significantly longer and deeper when present. Multiple logistic regression demonstrated a 5.6, 8.1, and 11-fold increased adjusted odds of clinically significant niche following Technique B closure in the repeat CD (p<0.01), lower-order CD (p<0.001), and higher-order CD (p=0.04) groups, respectively. CONCLUSIONS:While multiple CDs are known to increase risk for niche defects and their sequelae, hysterotomy closure technique may help to reduce niche development and severity.

The incidence of Cesarean scar pregnancies (CSPs) is rising globally. Ultrasound criteria for the diagnosis of CSPs have been described by the International Society of Ultrasound in obstetrics and gynecology and appear to be well used in various centers around the world. There is no guidance on best practices for expectant management of CSP, and there is considerable variation in how this is offered globally. Many studies have reported significant maternal morbidity in cases of CSP with fetal cardiac activity managed expectantly, largely relating to hemorrhage and cesarean hysterectomy from placenta accreta spectrum. However, high live birth rates are also reported. Literature describing the diagnosis and expectant management of CSP in low-resource settings is lacking. Expectant management in selected cases where no fetal cardiac activity is present is a reasonable option and can be associated with good maternal outcomes. Standardization in reporting different types of CSPs and correlating these with pregnancy outcomes will be an important next step in developing guidance for expectant management of this high-risk pregnancy with a high burden of complications.