Uterine closure techniques during cesarean delivery and placenta accreta spectrum incidence in subsequent pregnancies: A systematic review and meta-analysis.

OBJECTIVE: To evaluate multiple uterine closure techniques during cesarean delivery (CD) and placenta accreta spectrum (PAS) incidence in the following pregnancy. DESIGN: Systematic review with meta-analysis. DATA SOURCES: Medline, Cochrane Library, EMBASE, PubMed Central, Scopus, and ClinicalTrial.gov were electronically searched from their inception to September 2025. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included all studies with a control population that compared different uterine closure techniques during CD-namely (1) type of suture; (2) inclusion or not of the decidua; (3) continuous versus interrupted suture; (4) locking versus non-locking suture; (5) pursed-string or not; (6) single- versus double-layer suture-with PAS incidence at the following pregnancy. DATA SYNTHESIS: The primary outcome was PAS incidence at the following pregnancy. RESULTS: We could not find any controlled study with follow-up data for PAS at the subsequent pregnancy in terms of type of suture utilized, inclusion or not of the decidua, or pursed-string closure at index CD. Three trials, including 1787 pregnancies, were analyzed and judged as "high quality," showing a potential association between continuous versus interrupted suture and PAS, but no difference with respect to locking versus non-locking or single- versus double-layer closures. CONCLUSIONS: As of now, it is impossible to mandate a specific uterine closure technique during CD with the aim of reducing the incidence of PAS at the following pregnancy. Large randomized controlled trials are needed.