Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2025 Jun 1;145(6):674-682.
doi: 10.1097/AOG.0000000000005813. Epub 2025 Jan 9.

Endometrium-Free Closure Technique During Cesarean Delivery for Reducing the Risk of Niche Formation and Placenta Accreta Spectrum Disorders

Clarel Antoine  1 , Jessica A Meyer, Jenna Silverstein, Julia Buldo-Licciardi, Chen Lyu, Ilan E Timor-Tritsch
Affiliations

Endometrium-Free Closure Technique During Cesarean Delivery for Reducing the Risk of Niche Formation and Placenta Accreta Spectrum Disorders

Clarel Antoine et al. Obstet Gynecol. .

Abstract

Objective: To examine the prevalence and severity of postcesarean residual niche, evaluated using saline infusion sonohysterography, in an expanded cohort of women with one prior cesarean delivery and to assess the effect of uterine closure technique on the risk of placenta accreta spectrum (PAS) disorders.

Methods: This secondary analysis includes 70 patients who underwent saline infusion sonohysterography after one prior cesarean delivery. Patients were grouped according to hysterotomy closure technique: two-layer endometrium-free closure (technique A), and two- or one-layer routine closures (technique B). Niche dimensions and residual myometrial thickness were measured. The primary outcome was clinically significant niche (depth larger than 2 mm), a risk factor for PAS. Groups were compared using χ 2 , unpaired t test, Kruskal-Wallis, and logistic regression with significance at P <.05.

Results: There were 33 patients in the technique A group and 37 patients in the technique B group. Technique A was associated with smaller niche dimensions ( P =.018 for width, .005 for depth, and .002 for length), and exhibited thicker residual myometrial thickness (8.5 mm vs 5.5 mm, P =.041) and a lower incidence of clinically significant niches. The odds of having a clinically significant niche were 27 times higher in the technique B group (adjusted odds ratio 27.1, 95% CI, 4.35-168.81, P <.001).

Conclusion: Uterine closure techniques are associated with the development and size of postcesarean residual niches, which are critical risk factors for PAS disorders. Use of an endometrium-free closure technique during primary cesarean delivery is associated with a reduced risk of future niche formation and PAS complications.

PubMed Disclaimer

Conflict of interest statement

Financial Disclosure The authors did not report any potential conflicts of interest.

References

    1. Boerma T, Ronsmans C, Melesse DY, Barros AJD, Barros FC, Juan L, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet (London, England) 2018;392:1341–8. doi: 10.1016/S0140-6736(18)31928-7 - DOI
    1. Antoine C, Young BK. Cesarean section one hundred years 1920–2020: the Good, the Bad and the Ugly. J Perinatal Med 2020;49:5–16. doi: 10.1515/jpm-2020-0305 - DOI
    1. Jordans IPM, de Leeuw RA, Stegwee SI, Amso NN, Barri-Soldevila PN, van den Bosch T, et al. Sonographic examination of uterine niche in non-pregnant women: a modified Delphi procedure. Ultrasound Obstet Gynecol 2019;53:107–15. doi: 10.1002/uog.19049 - DOI
    1. Monteagudo A, Carreno C, Timor-Tritsch IE. Saline infusion sonohysterography in nonpregnant women with previous cesarean delivery: the “niche” in the scar. J Ultrasound Med 2001;20:1105–15. doi: 10.7863/jum.2001.20.10.1105 - DOI
    1. McGowan S, Goumalatsou C, Kent A. Fantastic niches and where to find them: the current diagnosis and management of uterine niche. Facts Views Vis ObGyn 2022;14:37–47. doi: 10.52054/FVVO.14.1.003 - DOI