To the Editor,
We read with great interest the article by Hudić et al. who compared the rates of complete and incomplete uterine rupture in women who had single versus double-layer closure of their hysterotomy during a previous cesarean [Citation1]. However, to completely appreciate the results of their study, the authors should clarify some important points.
While they found no difference in the rate of complete uterine rupture between the two groups (1/303 vs 3/145, p = 0.1), they reported a potentially very high rate of incomplete uterine rupture, also known as ‘asymptomatic dehiscence’, in women with double-layer closure. However, uterine scar dehiscence is usually diagnosed at the time of repeat cesarean, and its prevalence could be related to the rate of cesarean. Therefore, we believe that the number of repeat cesareans should be given for both groups and used as the denominator to compare the rate of incomplete uterine rupture.
Our second point concerns the technique employed in both groups. Hudić et al. observed a much lower rate of complete uterine rupture (0.3%) in women with single-layer closure than Gyamfi et al. and Bujold et al. (8.6% and 3.0%, respectively) [Citation2,Citation3]. We suggest that one explanation could be the use, in this center, of non-locked continuous sutures in Misgav-Ladach cesareans compared to locked sutures commonly employed for single-layer closure in North America. We found that both techniques have been described for Misgav-Ladach cesareans [Citation4,Citation5]. On the other hand, we believe that more data on the double-layer closure technique in their center and a minimum of details about potential confounding factors related to uterine rupture are necessary to evaluate the external validity of their findings. The very high rate of complete uterine rupture with fetal death (2.1%) in the double-layer group is definitely unexpected in a cohort of women with a single previous cesarean and spontaneous labor. The authors should assess the rate and role of potential confounders, such as short interdelivery interval, fetal macrosomia, oxytocin use, recurrent cesarean, and dystocia during labor, in cases of complete and incomplete uterine rupture in both groups, and provide this information to your readers.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References
- Hudić I, Fatusić Z, Kamerić L, Misić M, Serak I, Latifagić A. Vaginal delivery after Misgav-Ladach cesarean section – is the risk of uterine rupture acceptable? J Matern Fetal Neonatal Med 2010;23:1156–1159.
- Gyamfi C, Juhasz G, Gyamfi P, Blumenfeld Y, Stone JL. Single- versus double-layer uterine incision closure and uterine rupture. J Matern Fetal Neonatal Med 2006;19:639–643.
- Bujold E, Bujold C, Hamilton EF, Harel F, Gauthier RJ. The impact of a single-layer or double-layer closure on uterine rupture. Am J Obstet Gynecol 2002;186:1326–1330.
- Federici D, Lacelli B, Muggiasca L, et al. Cesarean section using the Misgav Ladach method. Int J Gynaecol Obstet 1997;57:273–279.
- Holmgren G, Sjoholm L, Stark M. The Misgav Ladach method for cesarean section: method description. Acta Obstet Gynecol Scand 1999;78:615–621.