Letter to the Editor
org
Hysterotomy closure at cesarean, beyond the
number of layers; a response
We appreciate the authors’ comments on our publication of the
3-year follow-up of our study that compared single-layer and
double-layer closure during a first cesarean delivery (CD).1 Our
randomized controlled trial found that double-layer closure
was not superior in terms of reproductive outcomes.2 This is in
line with the publication of the 9-month results that also did
not show any difference in the prevalence of niches or the
thickness of the residual myometrium (RMT).
First, Dr Maheux-Lacroix and Bujold raised concerns
about including or excluding the endometrium in hysterot-
omy closure and its influence on scar healing. In the double-
layer closure group, the endometrium was consistently
included, whereas in the single-layer group, the decision to
include or exclude the endometrium was left to the surgeon,
potentially introducing confounding factors. In the single-
layer closure group, in 71.7% of women the endometrium
was included, whereas in 28.3% it was excluded. This reflects
the routine practice observed in the Netherlands. In a
nationwide survey conducted in 2015 that assessed the
method of closure among Dutch gynecologists, approxi-
mately half of the 528 included the endometrium, whereas
the other half excluded the endometrium in single-layer
closures. However, we observed a growing trend among
younger gynecologist in the Netherlands toward including the
endometrium when using single-layer closure. Apart from
this, more changes have occurred in the past years, for
example, transitioning from a Pfannenstiel incision to a
modified Misgav-Ladach procedure, abandonment of peri-
toneal closure, and a reduction in surgical exposure and skills
because of changes in working hours and increased speciali-
zation among gynecologists and residents performing CD.
The importance of surgical experience is underlined by our
study’s finding of more niches when suturing was performed
by residents instead of gynecologists. These potential con-
founders may also play a role in the literature that was
mentioned by Dr Maheux-Lacroix and Bujold. In our sys-
tematic review, 2 randomized controlled trials (RCTs) and 1
retrospective cohort study compared inclusion with exclusion
of the endometrial layer and reported more niches after the
exclusion of the endometrium.3 However, these studies were
not powered to study reproductive outcomes. Thus, we
remain uncertain about whether the inclusion or exclusion of
the endometrium impacts the development of a niche and
related problems. We agree with Dr Maheux-Lacroix and
Bujold that because of the conflicting results, a large RCT with
sufficient power is needed in which endometrium exclusion is
compared with endometrium inclusion during single-layer
closure.
Second, they raised concerns regarding the incidence of
cesarean scar pregnancies (CSP) and placenta accreta spec-
trum (PAS) disorders during the subsequent pregnancy after
ajog.
single-layer closure for which 3 and 2 cases were recorded,
respectively, when compared with no cases in the double-
layer group. This may lead to the impression that the
single-layer technique is not equivalent to the double-layer
technique. However, our study was powered to detect spot-
ting at the 9-month follow-up and not to detect rare
obstetrical outcomes. Both CSP and PAS are related to the
prevalence of niches. The thickness of the RMT was equal in
both groups, and the prevalence of niches was slightly higher
in the double-layer group. Because of the limited sample size,
we cannot draw any solid conclusions about the prevalence of
these rare events. Dr Maheux-Lacroix and Bujold are
confused about how we arrived at a relative risk of 0.99 (95%
confidence interval, 0.99e1.00) for CSP and PAS disorders.
The reported relative risks were obtained through statistical
analyses and taking into account subsequent pregnancies and
event rates using logistic regression methods. After reevalu-
ation using Firth-type logistic regression specifically tailored
for small sample sizes, the results similarly indicated insuffi-
cient evidence to draw firm conclusions.
The prevalence of uterine ruptures was 2.7% (4/149) in the
single-layer group and 2.1% (3/146) in the double-layer
group after trial of labor, and this was higher than ex-
pected. Comprehensive reporting and heightened scrutiny
might have played a role, but another factor might be that, in
general, in the Netherlands we have a relatively high rate of
women who undergo trial of labor without previous scar
examination. Two of the 7 uterine ruptures occurred outside
the trial of labor group; 1 was observed during a scheduled
CD and the other in an emergency setting with acute
abdominal pain, both in the double-layer group. No severe
maternal or neonatal morbidity occurred.
Regarding our conclusion, based on short-term ultrasound
assessment and the absence of a difference in the primary
outcome (postmenstrual spotting) at the 9-month follow-up,
along with no demonstrated superiority associated with
double-layer closure in the long-term follow-up, we maintain
that surgeons can choose whether to suture the hysterotomy
in 1 or 2 layers without specific guidance regarding the
endometrium until new evidence become available after
future RCTs. -
Carry Verberkt, MD
Department of Obstetrics and Gynaecology
Amsterdam University Medical Center
Vrije Universiteit Amsterdam
Amsterdam
The Netherlands
Amsterdam Reproduction and Development
Amsterdam
The Netherlands
JULY 2024 American Journal of Obstetrics & Gynecology e45
Letter to the Editor ajog.org

Sanne I. Stegwee, PhD

Department of Obstetrics and Gynaecology REFERENCES
Erasmus University Medical Center 1. Maheux-Lacroix S, Bujold E. Hysterotomy closure at cesarean:
University Medical Centre Rotterdam beyond the number of layers. Am J Obstet Gynecol 2024;231:
e44.
Rotterdam
2. Verberkt C, Stegwee SI, Van der Voet LF, et al. Single-layer vs double-
The Netherlands
layer uterine closure during cesarean delivery: 3-year follow-up of a
Judith A. F. Huirne, MD, PhD randomized controlled trial (2Close study). Am J Obstet Gynecol 2023.
Department of Obstetrics & Gynaecology [Epub ahead of print].
Amsterdam University Medical Center 3. Verberkt C, Lemmers M, de Vries R, Stegwee SI, de Leeuw RA,
University of Amsterdam Huirne JAF. Aetiology, risk factors and preventive strategies for niche
Meibergdreef 9 development: a review. Best Pract Res Clin Obstet Gynaecol 2023;90:
102363.
Amsterdam
The Netherlands
j.huirne@amsterdamumc.nl ª 2024 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.ajog.
The authors report no conflict of interest. 2024.02.312

e46 American Journal of Obstetrics & Gynecology JULY 2024