Impact of Using Synthetic Absorbable Monofilament Versus Multifilament Suture Material for Uterine Closure on the Development of Uterine Isthmocele : A Rondamized Controlled Clinical Trial
Phase: NA
Conditions: Uterine Scar
Sponsor: Ain Shams Maternity Hospital

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PROTOCOL OF THESIS FOR PARTIAL FULFILMENT OF 
MD DEGREE IN OBSTETRICS & GYNAECOLOGY 
 
 
Title of the Protocol: Impact of using synthetic absorbable 
monofilament versus multifilament suture material for uterine 
closure on the development of uterine Isthmocele: A randomized 
controlled clinical trial 
 
Postgraduate Student: Mohammed Essam ElDin Mohammed 
Degree: M.B.B.Ch.,2017 3 MSc.,2021 
Faculty of Medicine - Ain Shams University 
 
 
DIRECTOR:  
Prof. Mohammed EL Kaddy 
Academic Position:  Professor of Obstetrics & Gynecology 
Department:  
Obstetrics & Gynecology 
 
Faculty of Medicine, Ain Shams University  
 
Co-DIRECTOR:  
Prof. Mohamed Hamed  
Academic Position:  Assistant Professor of Obstetrics & Gynecology 
Department:  
Obstetrics & Gynecology 
 
Faculty of Medicine, Ain Shams University 
 
Co-DIRECTOR:  
Dr. Yassmin Nashaat Talaat 
Academic Position:  Lecturer of Obstetrics & Gynecology 
Department:  
Obstetrics & Gynecology 
 
Faculty of Medicine, Ain Shams University 
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Faculty of Medicine 
Ain Shams University 
2023 
December 12,2023

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What is already known on this subject? AND 
What does this study add? 
ĞƐĂƌĞĂŶƐĞĐƚŝŽŶŝƐŽŶĞŽĨƚŚĞŵŽƐƚĐŽŵŵŽŶŽƉĞƌĂƚŝǀĞƉƌŽĐĞĚƵƌĞƐƉĞƌĨŽƌŵĞĚŝŶŵŽĚĞƌŶ
ŽďƐƚĞƚƌŝĐƐ(Mackeen et al., 2012)͕ƚŚĂƚďĞĐŽŵĞŝŶĐƌĞĂƐŝŶŐůǇĐŽŵŵŽŶŝŶďŽƚŚĚĞǀĞůŽƉĞĚĂŶĚ
ĚĞǀĞůŽƉŝŶŐ ĐŽƵŶƚƌŝĞƐ ĨŽƌ Ă ǀĂƌŝĞƚǇ ŽĨ ƌĞĂƐŽŶƐ ƚŽĚĂǇ (Vogel et al., 2015)͕ ƚŚƵƐ ĂŶǇ ƵƐĞĨƵů
ƌĞĨŝŶĞŵĞŶƚŝŶƚŚĞŽƉĞƌĂƚŝǀĞƚĞĐŚŶŝƋƵĞ͕ŚŽǁĞǀĞƌŵŝŶŝŵĂů͕ŝƐůŝŬĞůǇƚŽǇŝĞůĚƐƵďƐƚĂŶƚŝĂůďĞŶĞĨŝƚƐ͘
ůŽƐƵƌĞŽĨƚŚĞƵƚĞƌŝŶĞŝŶĐŝƐŝŽŶŝƐĂŬĞǇƐƚĞƉŝŶĐĂĞƐĂƌĞĂŶƐĞĐƚŝŽŶ͕ĂŶĚŝƚŝƐŝŵƉĞƌĂƚŝǀĞƚŚĂƚĂŶ
ŽƉƚŝŵĂůƐƵƌŐŝĐĂůƚĞĐŚŶŝƋƵĞďĞĞŵƉůŽǇĞĚĨŽƌĐůŽƐŝŶŐĂƵƚĞƌŝŶĞƐĐĂƌ͘dŚŝƐƚĞĐŚŶŝƋƵĞƐŚŽƵůĚďĞĂďůĞ
ƚŽǁŝƚŚƐƚĂŶĚƚŚĞƐƚƌĞƐƐŽĨƐƵďƐĞƋƵĞŶƚůĂďŽƌ͘ . (Yazicioglu, 2006). 
Cesarean section can effectively prevent maternal and perinatal mortality and morbidity. 
However, there are many short and long-term complications of Cesarean section. One of the most 
common complications is the isthmocele, which was first described by Morris in 1995, as a wedge-
shaped distortion at the uterine incision site. (Gubbini G et al.,2008). 
/ƐƚŚŵŽĐĞůĞ͕ ĂůƐŽ ŬŶŽǁŶ ĂƐ Ă ŶŝĐŚĞ͕ ĂŶ ŝƐƚŚŵŽĐĞůĞ͕ Žƌ ĞƐĂƌĞĂŶ ƐĐĂƌ ĚĞŚŝƐĐĞŶĐĞ͕ ŚĂƐ ďĞĞŶ
ŝŵƉůŝĐĂƚĞĚĂƐĂĨĂĐƚŽƌŝŶĐůŝŶŝĐĂůƉƌŽďůĞŵƐĂƐ ƵƚĞƌŝŶĞƌƵƉƚƵƌĞ͕ĂŶĚĐĞƐĂƌĞĂŶƐĐĂƌĞĐƚŽƉŝĐƉƌĞŐŶĂŶĐǇ. 
(Morris H et al.,1995). 
.  
In this study we aim at comparing using synthetic absorbable monofilament sutures in 
uterine closure during caesarean delivery with using synthetic absorbable multifilament sutures as 
regards the reduction in the rate of isthmocele. 
 
1.INTRODUCTION/ REVIEW 
Cesarean section is the most common type of obstetric surgery (Mistry k et al.,2013)  with 
substantial increases in the number of Cesarean section deliveries in middle- and high-income 
countries in recent years.(Betrán AP et al.,2014). The rates of caesarean section vary by region, 
accounting for 3.3% of deliveries in Africa, 33.7% in Latin America, 27.3% In Asia, and 40.5% in 
China, with a global average of 15.9% (WHO,2009). However, there are short and long-term 
complications of Cesarean section, including effects on other surgical procedures, as well as on 
subsequent Cesarean section operations. One of the most common complications is the isthmocele, 
which is noted more frequently with increasing Cesarean section operations. (Villar J et al.,2007). 
Isthmocele can develop after transverse incision of the lower uterine segment. This pouch-
like structure, first described by Morris in 1995, also called isthmocele, niche, or caesarean scar 
dehiscence, is located at the site of the old caesarean scar on the anterior uterine isthmus. (Baranov 
A et al.,2016). 
Sutures are an essential part of any major surgery, serving to hold opposing tissues together 
and accelerate the healing process, resulting in decreased scarring of the affected areas. 
Many authors have investigated possible risk factors related to isthmocele, particularly those 

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related to uterine closure, number of caesarean births, uterine position, and labour before caesarean 
delivery. (Tower AM1 et al., 2013). However, studies examining the role of the suture material 
in formation of isthmocele are limited.  
 Isthmocele has been implicated as an etiologic factor in clinical problems, such as rupture of 
the uterus during a subsequent pregnancy, ectopic pregnancy at the caesarean scar, caesarean scar 
endometriosis, secondary infertility, postmenstrual spotting and dysmenorrhea. . (ŝũĚĞsĂĂƚĞ:͕
ϮϬϭϭͿ͘
The development of isthmocele is associated with a deficiency of uterine scar healing. The 
prevention of isthmocele should be the first and most essential aim of overcoming isthmocele-
related complications. Therefore, numerous studies have recently focused on the development and 
prevention of isthmocele. (McCurdy R et al.,2017). 
To assess the healing of scar and the risk of uterine rupture and other complications, 
ultrasonography is used in the evaluation of uterine scar 6 weeks after delivery. It has generally been 
found that, the thicker the uterine scar, the lower the rate of complications. This may be due to that 
the thicker scar is stronger, and thus performs better than a thinner one. (Litzka, 2021). 
Closure of the uterine incision is a key step in caesarean delivery, correct approximation of 
the cut margins is of a critical value. (Vikhareva Osser , 2011).  Limited data are available to 
evaluate the role of the suture materials in uterine scar healing and the development of isthmocele. 
(Ba_bu÷ A et al.,2019).  
Monofilament suture (polyglycolide-co-caprolactone) material is made of a single strand, 
which is relatively more resistant to harboring microorganisms. It also exhibits less resistance to 
passage through tissue unlike multifilament suture which inflict more microtrauma as they pass 
through tissues. However, great care must be taken in handling and tying a monofilament suture, 
because crushing or crimping of the suture can weaken it and lead to undesirable and premature 
suture failure. Multifilament suture material (polyglactin) is composed of several filaments twisted 
or braided together. It generally has greater tensile strength and better pliability and flexibility than 
monofilament suture material, and it handles and ties well. Multifilament sutures also induce a more 
intense inflammatory response and contribute to larger knot volumes than monofilaments. However, 
because multifilament materials have increased capillarity, the increased absorption of fluid may 
facilitate the introduction of pathogens, which increases the risk for wound infection and dehiscence. 
(Islam A, et al.2011) 
An internationally recognized definition for isthmocele was only agreed upon in 2019 by the 
European task force, which defined a cesarean scar defect as an <indentation at the site in the cesarean 
section scar with a depth of at least 2)mm.= This definition was further subclassified as follows: simple 
niche, simple niche with one branch, and complex niche (with more than one branch). A branch was 
defined as the thinner part of the main niche that is directed toward the serosa and has a width smaller 
than the main niche. Residual myometrial thickness "RMT" is the distance between the tip of the hypo 
echoic triangle and the surface of anterior uterine wall measured by mm.) At the apex of the main niche, 
the RMT is often decreased. (Jordans IPM et al,2019). 
The present study aimed to evaluate how the use of Monocryl (monofilament synthetic 

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absorbable sutures) instead of Vicryl (multifilament synthetic absorbable sutures) in the continuous 
double-layer unlocked closure technique for low transverse uterine incisions impacts uterine scar 
healing after Cesarean section. 
 
2.AIM / OBJECTIVES 
To evaluate the impact of using synthetic absorbable monofilament sutures in uterine 
closure during caesarean delivery compared to using synthetic absorbable multifilament sutures on 
the development of Isthmocele. 
Research Question: 
Will uterine closure using synthetic absorbable monofilament sutures during caesarean 
delivery reduce the incidence of isthmocele compared to uterine closure using synthetic absorbable 
multifilament sutures? 
 
3.METHODOLOGY: 
Patients and Methods/ Subjects and Methods/ Material and Methods 
÷ Study Type: A Randomized Controlled Trial. 
÷ Study Setting: The study will be conducted at Ain Shams University Maternity Hospital (labour 
ward and the Ultrasound (Special Care unit for the fetus). 
÷ Study Period: 1 year. (from December 2023 to December 2024) 
÷ Sampling Method:  Convenience sample from El-Demrdash hospital population that attending 
the ER. 
÷ Study Population: The study will be conducted on (140) women divided into two equal groups. 
÷ Sample Justification:  Based on the results of Saccone et al. (2022), with the mean defect width 
in mm in monofilament group 2.9 ñ 0.6 and in multifilament group 3.4 ñ1 mm, alpha error 5% 
and power of study 80%, the required sample is 140 patients 70 in each group. The program for 
sample size calculation is STATA 10. 
Inclusion criteria: 
R Age: 20-45 years old 
R Singleton pregnancy.  
R Gestational age between 37 completed weeks to 42 weeks.  
R Patients undergoing elective primary caesarean section  
Exclusion criteria:  
R History of uterine surgery (e.g. hysterotomy, myomectomy, perforation, caesarean section). 
(to be able to differentiate between the recent CS scar and the old scar) 
R Abnormal placental invasion (placenta previa and accrete ) ( more liable to undergo Cesarean 
hysterectomy) 
R Uterine anomalies (e.g., septum, Mullerian anomalies or fibroids). (may be localized at the 
suture line and therefore affect the scar) 

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R Drugs intake that affects bleeding or tissue healing e.g., anti-coagulants, immunosuppressive 
drugs and chronic use of steroids (more than 14 days pre-operative) 
R Any medical Co-morbidity (diabetes mellitus, Hypertension and Thyroid abnormalities) 
(more liable to affect the healing) 
÷ Randomization: 
Randomization will be done using computer generated random sequence. Study population 
will be randomized into one of the two groups: 
R Group (I): 70 patients will undergo uterine closure using Monofilament suture material. (A) 
(1/0, Monocryl®). 
R Group (II): 70 patients will undergo uterine closure using Multifilament suture material. (B) 
(1/0, Vicryl®). 
÷ Allocation concealment: 
One hundred and forty opaque envelopes will be numbered serially and each envelope with 
the corresponding number which denotes the allocated group will be put according to randomization 
table. Then all envelopes will be closed and put in one box. When the first patient is included, the 
first envelope will be opened and the patient will be allocated according to the letter inside. 
÷ Blinding:  
Double blinding is difficult because the surgeon will perform the procedure. However, the 
measured outcomes are objective and unlikely to be biased by lack of blinding. Patient is blinded, 
sonography (measuring the outcome is blind to type of repair). Statistical analysis will be blinded to 
group allocation (single blinded) 
÷ Study procedures and interventions: 
The patients will be randomly divided into 2 groups using a computer-generated number based 
on the type of suture materials to be used for the continuous double-layer unlocked closure of the low 
transverse uterine incision during Cesarean section.  
Surgery will be done by the most senior resident. 
Baseline Evaluation 
All participants will be submitted to:  
R Complete history taking including personal history, history of present pregnancy, past history, 
menstrual history, obstetric history, medical history and family history. 
R General, abdominal, and pelvic examination.  
R Laboratory investigation: complete blood picture, coagulation profile, random blood sugar, 
liver enzymes and serum creatinine. 
R Ultrasound examination: Basic ultrasound examination will be done for all women to assess 
(fetal life, Biometry, amniotic fluid and placental location). 
Preoperative antibiotic prophylaxis: 
Two grams of cefazolin (under trade name of Zinol® manufactured by Pharco B International, 
New Borg El Arab, Egypt.) to be administered 15 3 60 minutes before incision. (Bratzler et al., 
2013, Witt et al, 2013). 

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Anesthesia: All anesthesia techniques can be considered. 
Operative steps: <All surgeries will be performed by the same surgeon rank=. 
R Antisepsis of urethral meatus and catheterization under aseptic conditions. 
R Vaginal toilet will be done to all patients with povidone iodine solution before the operation. 
R Scrubbing the abdomen will be done by using povidone iodine solution 10%. 
R All women will undergo Pfannenstiel-Kerr cesarean section. 
R Open of the anterior abdominal wall in layers by scalpel. 
R Lower segment uterine incision. 
R Deliver of the head by firm wrist flexion, then insertion of fingertips into the uterine incision 
and advance them around the fetal head to deliver the shoulder and the body 
R Deliver the placenta by controlled cord traction. 
R Oxytocin (5 IU by slow intravenous injection) will be used to encourage contraction of the 
uterus and to decrease blood loss. 
R After delivery of the fetus and placenta: 
Group (A):"Interventional group" 
Closure of the uterus in two layers in continuous unlocked sutures using synthetic absorbable 
monofilament suture (Monocryl 1). (EGYMONOCRYL® manufactured by Taisier-Med Obour, 
Egypt). 
Group (B):"Control Group" 
Closure of the uterus in two layers in continuous unlocked sutures using synthetic absorbable 
multifilament suture (Vicryl 1) (EGYSORB® manufactured by Taisier-Med Obour, Egypt). 
 
R Fascia will be closed as continuous running sutures using an absorbable suture (Vicryl 1) 
R Subcutaneous closure: The subcutaneous adipose layer should be closed when the layer is g 
2 cm by Vicryl 0. (Chelmow et al., 2004). 
R Skin closure: Reapproximation of the skin will be performed with subcuticular suture using 
2-0 polypropylene nonabsorbable suture (EGYPROLENE® manufactured by Taisier-Med 
Obour city, Cairo, Egypt.).  
Post-operative care: 
§ All patients will receive Non-Steroidal Anti-Inflammatory drugs immediately postoperative 
then one ampoule 12 hours postoperative, (Altman, 2015). and according to Ain Shams 
Maternity hospital protocol. 
R Vital signs (pulse, blood pressure, temperature) of the patients will be measured four times 
daily during hospitalization. 
R At 6 h postoperatively, urinary Foley catheters will be removed and oral intake with clear 
fluids will be started. (ACOG, 2008). 
R A venous blood sample for complete blood count examination will be withdrawn after 24 
hours postoperative. 
R Regular antipyretic will not be used so as not to mask possible postpartum pyrexia. 

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R Patients will be instructed for postoperative wound care e.g.: to always keep wound dressing 
dry and clean and in case it gets wet it is to be dressed in an aseptic non-touch technique. 
R Follow up for assessment after 1 week of delivery to check the wound, and after 6 months to 
undergo the Ultrasound. 
 
 
Outcomes: 
Primary outcome: the incidence of isthmocele by transvaginal ultrasound 6 months after 
delivery. 
isthmocele is defined as an anechoic defect communicating with the endometrial cavity at the 
anterior wall of the lower uterine segment.  
For each case the following isthmocele measurements will be obtained: 
1. The thinning extent, calculated by a ratio between (a) and (b). 
(a): thickness of the residual myometrium over the defect. 
(b): total intact myometrium. A severe deficiency occurs when more than 50% of myometrium 
is lost at the niche scar site. 
2. Width of isthmocele (c) 
3. Depth of isthmocele (d) 
Furthermore, we will record the shape of the defect (i.e., triangular, round, or oval). Moreover, 
the residual myometrial thickness will be measured. In case of isthmocele, RMT overlying the defect 
and the adjacent myometrial thickness fundal to the defect will be recorded. According to previous 
literature, the diagnosis of isthmocele was made in case of depth of the defect at least 2.00 mm in the 
longitudinal plan. (Naji O et al, 2012). 
 
 
Figure 1. 
Secondary outcomes: 
1. Amount of blood loss. 
ABL = weight kg * age sex factor (65ml/ kg)*initial HGB(g/dl)-final HGB(g/dl) 8 12-hours 
postoperative=. / intial HGB (g/dl)  (M. E. Brecher,2003) 
2. Need for extra hemostatic sutures. 
3. Need for blood transfusion. 

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4. Wound infection. 
5. Hospital stay after the delivery. 
6. Post-operative fever. 
(Defined as a temperature higher than 38 c on two consecutive postoperative days or higher 
than 39 c on any postoperative day). (Abdelmaseeh TA et al, 2022) 
7. Primary Postpartum hemorrhage. (Defined as CƵŵƵůĂƚŝǀĞďůŽŽĚůŽƐƐŐƌĞĂƚĞƌƚŚĂŶϭϬϬϬŵ>ǁŝƚŚ
ƐŝŐŶƐĂŶĚƐǇŵƉƚŽŵƐŽĨŚǇƉŽǀŽůĞŵŝĂǁŝƚŚŝŶϮϰŚŽƵƌƐŽĨƚŚĞĚĞůŝǀĞƌǇͿ͘(ASOG,2017). 
÷ Statistical analysis: 
           Based on the results of  Saccone et al 2022 ,  with the mean defect width in mm in 
mononfilament group 2.9 ñ 0.6 and in multifilament group 3.4 ñ1 mm, alpha error 5% and power of 
study 80%, the required sample is 140 patients 70 in each group . The program for sample size 
calculation is STATA 10. 
 
÷  Ethical Consideration: 
This study will be done after approval of the ethical committee of the department of obstetrics 
and gynecology, faculty of medicine, Ain Shams University. Informed consent will be taken from all 
participants before recruitment in the study, and after explaining the purpose and procedures of the 
study. The investigator will obtain the written, signed informed consent of each subject prior to 
performing any study specific procedures on the subject. The investigator will retain the original 
signed informed consent form. All laboratory specimens, evaluation forms, reports, and other records 
that leave the site will not include unique personal data to maintain subject confidentiality. The study 
will be based on the investigator self-funding. 
 
Protocol approval:  
Before the beginning of the study and in accordance with the local regulation followed, the 
protocol and all the corresponding documents will be declared for ethical and research approval by 
the council of OB/GYN Department, Ain Shams University according to the the ethical committee 
Patient right to withdraw 
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4.REFERENCES: 
1. Abouda H, Channoufi B, Bouyahia M, Braham M, Zhioua F, Bouchahda H 
and Mourali M. (2018): <Accuracy of pre-operative real time dynamic 
transvaginal ultrasound sliding sign in prediction of pelvic adhesions in women 
with previous abdominopelvic surgery. A prospective multicenter double 
blinded study=. Ultrasound Obstet Gynecol; 51:2533258. 
 
2. Yazicioglu F, Gokdogan A, Kelekci S, Aygün M, Savan K (2006): Incomplete healing 
of the uterine incision after caesarean section: Is it preventable? Eur J Obstet Gynecol 
Reprod Biol 2006; 124: 32336. 
 
3. Vikhareva Osser O, Valentin L. (2011): Clinical importance of appearance of cesarean 
hysterotomy scar at transvaginal ultrasonography in nonpregnant women. Obstet 
Gynecol, 117:525- 532. 
 
4. Altman R (2015): <Advances in NSAID development: evolution of diclofenac 
products using pharmaceutical technology=. Drugs; 75: 859-77.  
5. American College of Obstetricians and Gynecologists (ACOG) Practice 
Bulletin No. 199 (2018): <Use of Prophylactic Antibiotics in Labor and 
Delivery=. Obstetrics & Gynecology; 132(3): 1033119.  
6. Ayachi A, Bouchahda R, Derouich S, Mkaouer L and Kehila M. (2018): 
<Accuracy of preoperative real-time dynamic transvaginal ultrasound sliding 
sign in prediction of pelvic adhesions in women with previous abdominopelvic 
surgery: prospective, multicenter, double-blind study=. Ultrasound Obstet 
Gynecol.; 51(2):253-258. 
7. Baranov A, Gunnarsson G, Salvesen KA et al. Cesarean hysterotomy scar in 
non-pregnant women: reliability of transvaginal sonography with and without 
contrast enhancement. Ultrasound Obstet Gynecol 2016; 47: 4993505 
8. Jordans IPM, de Leeuw RA, Stegwee SI, et al. Sonographic examination of 
uterine niche in non-pregnant women: a modified Delphi procedure. Ultrasound Obstet 
Gynecol. 2019;53(1):107-115. 

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9. Ba_bu÷ A, Do÷an O, Ellibe_ Kaya A et al. Does suture material affect uterine 
scar healing after cesarean section? Results from a randomized controlled trial. 
J Invest Surg 2019; 32: 7633769. 
10. Betrán AP, Ye J, Moller A-B, Zhang J, Gülmezoglu AM, Torloni MR. The 
increasing trend in caesarean section rates: Global, regional and national estimates: 19903
2014. Zeeb H, ed. PLoS ON. 
11. Bij de Vaate AJ, Brölmann HA, van der Voet LF, van der Slikke JW, 
Veersema S, Huirne JA. Ultrasound evaluation of the Cesarean scar: relation 
between a niche and postmenstrual spotting. Ultrasound Obstet Gynecol 
2011;37(1):9339. 
12. Buderer NM. (1996): <Statistical methodology: Incorporating the prevalence of 
disease into the sample size calculation for sensitivity and specificity=. Acad 
Emerg Med.; 3(9):895-900. 
 
13. Di Spiezio Sardo A, Saccone G, McCurdy R et al. Risk of cesarean scar defect 
in single- versus double-layer uterine closure: a systematic review and meta-
analysis of randomized controlled trials. Ultrasound Obstet Gynecol 2017; 50: 
5783583 
 
14. El-Shawarby SA, Salim R, Lavery S and Saridogan E (2009): <Uterine 
adherence to anterior abdominal wall after caesarean section=. BJOG 2011; 118: 
113331135.  
 
15. Ethicon 
Inc. 
Wound 
Closure 
Manual. 
2005. 
Available 
at: 
http://www.uphs.upenn.edu/surgery/Education/facilities/measey/Wound_Closu
re_Manual.pdf. (accessed December 12, 2014). 
 
16. Fabres C, Arriagada P, Fernández C, Mackenna A, Zegers F, Fernández E. 
Surgical treatment and follow-up of women with intermenstrual bleeding due to 
cesarean section scar defect. J Minim Invasive Gynecol 2005;12(1):2538. 
 
17. Islam A, Ehsan A. Comparison of suture material and technique of closure of 
subcutaneous fat and skin in caesarean section. N Am J Med Sci. 2011 
Feb;3(2):85-8. doi: 10.4297/najms.2011.385. PMID: 22540072; PMCID: 
PMC3336893. 
 
 

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

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ͳͳ
18. Greenberg JA, Clark RM. Advances in suture material for obstetric and 
gynecologic surgery. Rev Obstet Gynecol. 2009;2:1463158. PMID:19826572. 
 
19. Gubbini G, Casadio P, Marra E.Resectoscopic correction of the <isthmocele= 
in women with postmenstrual abnormal uterine bleeding and secondary 
infertility. 
J 
Minim 
Invasive 
Gynecol. 
2008;15:1723175. 
doi:10.1016/j.jmig.2007.10.004. 
 
 
20. Health Statistics Yearbook,2015. Republic of Turkey Ministry of Health. 
Nomenclature of Territorial Units for Statistics and Provinces 
 
21. Martin JA, Hamilton BE, Osterman MJ, Driscoll AK and Mathews TJ 
(2017): <Births: Final data for 2015=. Natl Vital Stat Rep; 66. 
 
22. Mistry K, Fingar KR, Elixhauser A. Variation in the Rate of Cesarean Section 
Across U.S. Hospitals, 2013: Statistical Brief #211. Healthcare Cost and 
Utilization Project (HCUP) Statistical Briefs. Rockville. 
  
23. Morales KJ, Gordon MC and Bates GW (2007): <Postcesarean delivery 
adhesions associated with delayed delivery of infant=. Am J Obstet Gynecol; 
196: 461.e13461.e6.  
 
24. Morris H. Surgical pathology of the lower uterine segment caesarean section 
scar: is the scar a source of clinical symptoms? Int J Gynecol Pathol. 
1995;14:16320. doi:10.1097/00004347-199501000-00004. 
 
25. Nominato NS, Prates LF, Lauar I, Morais J, Maia L, Geber S. Caesarean 
section greatly increases risk of scar endometriosis. Eur J Obstet Gynecol 
Reprod Biol 2010;152(1): 8335. 
 
26. Piessens S, Edwards A. Sonographic evaluation for endometriosis in 
routine pelvic ultrasound. J Minim Invasive Gynecol 2020;27: 26536 
27. Royal College of Obstetricians and Gynecologists (RCOG) (2016): 
<Prevention and management of postpartum haemorrhage=. (Green-top 
Guideline; No. 52). 
28. Rozenberg P, Goffinet F, Philippe HJ, Nisand I. Thickness of the lower 
uterine segment: its influence in the management of patients with previous 
cesarean sections. Eur J Obstet Gynecol Reprod Biol 1999;87(1):39345. 



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






DdŚĞƐŝƐƉƌŽƚŽĐŽůͬD&ͬ/^ZKͬ&ĂĐƵůƚǇKĨDĞĚŝĐŝŶĞͬ^h
ͳʹ
29. Naji O, Abdallah Y, Bij De Vaate AJ, et al.Standardized approach for imaging 
and measuringcesarean section scars using ultrasonography.Ultrasound Obstet 
Gynecol2012;39:25239. 
30. Stegwee SI, Jordans I, van der Voet LF et al. Uterine caesarean closure 
techniques affect ultrasound findings and maternal outcomes: a systematic 
review and meta-analysis. BJOG 2018; 125: 109731108. 
31. Sheth SS, Shah NM and Varaiya D (2008): <A sonographic and clinical sign 
to detect specific adhesions following cesarean section=. J Gynecol Surg 2008; 
24: 27336.  
32. Abdelmaseeh TA, Azmat CE, Oliver TI. Postoperative Fever In: StatPearls. 
Treasure 
Island 
(FL): 
StatPearls 
Publishing; 
2023 
Jan-. Available 
from: 
https://www.ncbi.nlm.nih.gov/books/NBK482299/ 
 
33. Tower AM1, Frishman GN. Cesarean scar defects: an underrecognized cause 
of abnormal uterine bleeding and other gynecologic complications. J Minim 
Invasive Gynecol. 2013;20(5):5623572. doi:10.1016/j.jmig.2013.03.008. 
 
34. Tulandi T, Agdi M, Zarei A, Miner L and Sikirica V (2009): <Adhesion 
development and morbidity after repeat cesarean delivery=. Am J Obstet 
Gynecol; 201: 56. 1. 
 
 
35. Villar J, Carroli G, Zavaleta N, et al. Maternal and neonatal individual risks 
and benefits associated with caesarean delivery: multicenter, prospective study. 
BMJ. 2007;335(7628):1025. doi:10.1136/bmj.39363.706956.55. 
PMID:17977819. 
 
36. Wang W, Long W, Yu Q. Complication of cesarean section: pregnancy on the 
cicatrix of a previous cesarean section. Chin Med J (Engl) 2002;115(2):24236 
 
37. World Health Organization. World Health Statistics 2009 
[www.who.int/whosis/whostat/2009/en/index.html]. Last accessed 11 May 
2010. 
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Patients Enrolment Data (Form 3) 
Case Record Form 
 
Title  
Description 
Name  
 
Case Number  
 
Phone 
 
Group  
 
 Date of enrollment  
 
Address  
 
Age  
 
Well informed consent  
 
Elective section 
 
Weight  
 
Parity  
 
 Gestational age  
 
Placenta accreta spectrum during that 
pregnancy  
 
Any uterine anomalies  
 
Chorioamnionitis in that pregnancy  
 
 Medical history  
 
Surgical history 
 
Pre-operative haemoglobin level  
 
 Post-operative haemoglobin level  
 
Total blood loss 
 
Number of received blood components 
 
Procedure time 
 

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ICU admission 
 
Hospital stay 
 
Post-operative fever 
 
Wound infection 
 
Trans vaginal US after 6 months  
ø Isthmocele? 
 Yes or NO 
if Yes ø Isthmocele measurements will be 
obtained. 
 
Bladder injury in that Cesarean section  
 
Post-partum hemorrhage  
 
 
 
 
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