Bibliographic record
Abstract
In a large cohort study including more than 7600 women with previous caesarean section, Hesselman et al. observed a similar rate of uterine rupture in women with a single-layer closure compared with women with a double-layer closure of the uterus at previous caesarean section (adjusted relative risk 1.13; 95% confidence interval [95%] 0.75–1.70). (Hesselman et al. BJOG 2014; doi: 10.1111/1471-0528.13015) This finding is in agreement with a recent meta-analysis showing no significant difference between the two types of closure (odds ratio [OR] 1.17; 95% CI 0.66–4.44). (Roberge et al. Int J Gynaecol Obstet 2011;115:5–10). There is therefore accumulating observations suggesting a minor role, if any, for the number of layers used for uterus closure on the risk of uterine rupture in the next pregnancy. However, other aspects of uterus closure have to be closely evaluated. The latter meta-analysis suggests that a locked single-layer closure could be related to uterine rupture (OR 4.96; 95% CI 2.58–9.52), which is in agreement with another meta-analysis of randomised trials showing that locking a single-layer can lead to a thinner residual myometrium thickness evaluated by ultrasound after caesarean (Roberge et al. Am J Obstet Gynecol 2014 in press). There are at least two potential explanations beyond such association: it is possible that the locked suture, by being more haemostatic, can cause a strangulation of the scar tissue and lead to weaker healing. It is also possible that the weakness of the scar is secondary to the fact that this technique is usually performed with inclusion of the inner part of the uterine wall (decidua/endome-trium) in the scar tissue (Figure 1). In several animal models, Poidevin demonstrated that suturing the complete thickness of the uterus, including the endometrium, was associated with inclusions of endometrial tissue in the scar, resulting in scar defects several weeks or months later (Poidevin. Cesarean section scars. Springfield [IL]: Charles C. Thomas Publisher; 1965). Beside the incomplete healing and the increased risk of uterine rupture, another multicentre case–control study reported that including the inner side of the uterine wall (decidua/endometrium) into the scar with a continuous suture, was associated with an increasing rate of placenta accreta in women with placenta praevia, independently of the number of layers used for uterus closure (Sumigama et al. BJOG 2014;121:866–74). Therefore, the cumulative evidence suggests that continuous suture with inclusion of the inner side of the uterine wall (decidua/endometrial layer) at the time of caesarean section is associated with impaired uterine scar evaluated by ultrasound, and with potential long-term consequences such as placenta accreta. Original works from our group (Bujold et al. Am J Obstet Gynecol 2002;186:1326–30; Bujold et al. Obstet Gynecol 2010;116:43–50) suggest a significant increase of uterine rupture with single-layer closure, perhaps related to the fact that the single-layer closure typically used in North America included the full uterine wall and its inner side into the scar. Future comparative studies, including observational and randomised trials, should focus not necessarily on the number of layers at the time of caesarean but on the inclusion or exclusion of the endometrium in the first layer. There are no conflicts of interest to disclose.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.002 | 0.014 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.003 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.005 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".