Endometrium-free uterine closure technique and abnormal placental implantation in subsequent pregnancies

Background: Abnormal placentation can result in massive hemorrhage, which is the leading cause of severe maternal morbidities and mortality in its management. Over the past 50 years, the incidence of placenta previa (PP), abnormal implantation of the placenta, and cesarean scar pregnancy have continued to rise. This coincides with the well-documented parallel rise in the rate of cesarean deliveries, the performance of multiple repeat cesarean deliveries and the adoption of newer uterine closure techniques. However, no studies have examined the role of uterine closure techniques in abnormal placentation in women with a history of a prior cesarean delivery.

Objective: To assess the practicality of one specific uterine closure technique at cesarean delivery and to evaluate the relationship between previous cesarean delivery and subsequent development of abnormal implantation of the placenta, as well as neonatal and other perioperative outcomes after receiving an endometrium-free uterine closure technique.

Methods: This retrospective observational study considered cesarean deliveries (n = 727) and subsequent vaginal births after cesarean delivery (n = 109) among total deliveries (n = 4496) performed in private practice at NYU Langone Health from 1985 to 2015. All cesarean deliveries were performed using the endometrium-free uterine closure technique. The primary outcome was the incidence of abnormal implantation of the placenta in subsequent pregnancies. The secondary outcomes were neonatal and maternal complications, specifically postoperative hemoglobin and hematocrit concentration losses. The association between independent variables and outcomes were evaluated using mixed-effect regression models.

Results: In contrast to published data, independent of the number of repeat cesarean deliveries, the presence of 26 (3.1%) PPs and of 366 (43.8%) anterior placentas, there were no patients with abnormal implantation of the placenta in a cesarean scar, neither prenatally nor at delivery. Maternal hemorrhage, postoperative and neonatal complications did not reach clinical significance. The statistical analysis revealed that, when compared with women who had fewer repeat cesarean deliveries using endometrium-free uterine closure technique, those with the most had a lesser risk of forming PP and less blood loss, as measured by both hematocrit and hemoglobin evaluation.

Conclusion: In this retrospective cohort study, the exclusion of the endometrium during the endometrium-free uterine closure technique was associated with fewer placental abnormalities in subsequent pregnancies and reduced life-threatening maternal morbidity for future cesarean deliveries.