http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, 2014; 27(13): 1312–1315 ! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2013.856876
ORIGINAL ARTICLE
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/06/15 For personal use only.
Predictive value of striae gravidarum severity for intraperitoneal adhesions or uterine scar healing in patients with previous caesarean delivery Ayse Nur Cakir Gungor1, Sevilay Oguz2, Servet Hacivelioglu1, Selda Isik2, Ahmet Uysal1, Meryem Gencer1, and Emine Cosar1 1
Department of Obstetrics and Gynecology and 2Department of Dermatology, Faculty of Medicine, Canakkale Onsekiz Mart University, Canakkale, Turkey Abstract
Keywords
Objective: Previous abdominal operations might cause severe intraperitoneal adhesions (IPA), which can complicate caesarean section (CS) procedures. When selecting the mode and timing of delivery, obstetricians are also curious about uterine scar healing if the previous operation was a CS. Uterine scar thickness is an indicator of uterine scar healing. We aimed to evaluate the possible predictive value of striae gravidarum (SG) on IPA formation and uterine scar thickness (UST). Methods: Fifty-five women with a previous CS history were evaluated for SG Davey Score. They were investigated for IPAs and lower segment uterine scar thickness during the current CS operation. Results: Out of the patients with no SG (n ¼ 11), mild SG (n ¼ 10) and severe SG (n ¼ 34), 1 (9.1%), 3 (30%) and 17 (50%) had IPA, respectively (p ¼ 0.044). The mean uterine scar thicknesses in the no SG, mild SG and severe SG groups were 3.82 4.04, 5.20 4.13 and 5.18 3.52, respectively (p ¼ 0.561). Conclusions: To the best of our knowledge, this was the first study to investigate the relationship between SG and IPA and uterine scar thickness. The SG status of a patient with a previous delivery and abdominal operation history might help predict IPA status before planning a new operation.
Caesarean scar, intraabdominal adhesions, stretch marks
Introduction A history of previous abdominal surgeries is a risk factor for a new abdominal operation. One or more previous caesarean section (CS) surgeries might complicate any type of abdominal operation, particularly laparoscopic procedures and CSs [1] and also might cause infertility [2]. Several methods have been used to predict adhesions after abdominal operations. High-resolution ultrasonography (US) [3], magnetic resonance imaging (MRI) [4] and scar healing properties [5,6] were the methods that were evaluated in the English literature for this study. Another adverse effect of a CS operation that might complicate any subsequent deliveries is uterine scar formation. Prediction of uterine scar healing is substantial, especially for selecting the mode of delivery; one of the most important but infrequent complications of vaginal birth after
Address for correspondence: Ayse Nur Cakir Gungor, Department of Obstetrics and Gynecology, Faculty of Medicine, Canakkale Onsekiz Mart University, Canakkale, Turkey. Tel: þ902862635950. Fax: þ902862180516. E-mail: [email protected]
History Received 28 July 2013 Revised 2 October 2013 Accepted 15 October 2013 Published online 12 November 2013
CS delivery is the rupture of the uterine scar. For prediction of uterine scar healing, ultrasonographic assessment of uterine scar thickness has been used [7]. There is no consensus on the evaluation of a patient with a previous CS history to predict either intraperitoneal adhesions (IPA) formation or uterine scar healing. A simple method to identify patients who might have adhesions could help the obstetrician choose the delivery type, organize preoperative preparations and select patients who must be referred to a tertiary care hospital. Therefore, predicting uterine scar healing is important when choosing the mode of delivery. Although the etiology of striae gravidarum (SG) is unknown, its relationship with pelvic relaxation [8] and perineal laceration during vaginal delivery [9,10] has been demonstrated. There may be a shared pathway between SG and adhesion formation. Elastin plays a major role in the development of SG [11], and its protective effect on IPA formation has also been confirmed [12]. Collagen, which is important in SG formation [13], also plays an important role in caesarean scar healing [14–16]. In the current study, we evaluated the predictive power of the SG score on IPA and uterine scar thickness in patients with a history of previous CS operations.
SG predicts adhesions
DOI: 10.3109/14767058.2013.856876
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/06/15 For personal use only.
Methods Fifty-five patients who applied to the Department of Obstetrics and Gynaecology of Canakkale Onsekiz Mart University Hospital with a history of at least one previous CS and who were preoperatively evaluated for elective CS operation were included in the current study and examined by a dermatologist (Dr SO) prior to the procedure. The local ethical committee approved the study, and informed consent was obtained from each patient before the study began. To avoid possible effects of the potential adhesion risk factors, patients with endometriosis, a history of pelvic inflammatory disease or abdominal operations other than CS, such as an appendectomy, were excluded from this study. Patients whose membranes ruptured before the current CS and who had either contractions or cervical dilatation were also excluded to avoid the thinning of the uterine scar tissue. All patients had undergone one or more previous CS deliveries with a pfannenstiel incision and a transverse uterine incision. Socio-demographic properties of the patients (age, education level, occupation, smoking status), possible risk factors for SG formation (parity, body mass index (BMI) prior to the current pregnancy, gestational week of the current CS delivery, the baby’s birth weight, preventional treatment during the pregnancy against SG, and weight gain during the pregnancy), factors that might affect uterine scar healing (diabetic status of the patient, number of previous CS deliveries, time since the last CS), and possible risk factors for adhesion formation (being in labor before the first CS, experiencing rupture of the membranes prior to the previous CS) were noted. Davey scores of patients were calculated [17]. To calculate the Davey score, the abdomen was divided into four quadrants and each part was evaluated for SG formation. If there were no SG, patients received 0 points. If there were a few SG, 1 point was given, and if there were many SG, 2 points were given to that region. All points were summed to obtain the final score. The total score ranged between 0 and 8. Zero points were evaluated as no SG, and 1–2 points were labeled mild SG; 3–8 points were termed severe SG. Beyond the 38th week of gestation, patients delivered by CS electively. During the operation, the participants were evaluated for IPA formation. Patients who had either no or only filmy adhesions were placed in the without IPA group, and those who had dense adhesions were classified into the with IPA group. After the delivery of the baby and the placenta, the thickness of the mid lower segment of the uterine scar from the peritoneum to the endometrium was measured with a sterile ruler. Data were analyzed with the Statistical Package for the Social Sciences (SPSS) for Windows version 11.5 (SPSS Inc., Chicago, IL). Continuous variables were evaluated for a normal distribution using the Kolmogorov–Smirnov test. Descriptive statistics for continuous variables were calculated as mean standard deviation (SD), while those for nominal variables were done by variable count and percent. The Chisquare test was used to evaluate the categorical variables. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of SG status
1313
on IPA formation were calculated. Statistical significance was set at p50.05.
Results A total of 55 women participated in the study. There were 11 patients without SG, 10 patients with mild SG and 34 patients with severe SG. Some patient characteristics are summarized in Table 1. Patients with IPAs in the groups without SG and with mild and severe SG accounted for 9.1%, 30% and 50%, respectively (p ¼ 0.044) (Table 1). The mean thickness of the uterine scar in groups without SG and with mild and severe SG were 3.82 4.05, 5.20 4.13 and 5.18 3.52, respectively (p ¼ 0.561) (Table 1). There were no significant differences in factors that might affect SG formation among the groups, such as parity, usage of an ointment against SG, gestational week at delivery, newborn birth weight, BMI before pregnancy and weight gain during pregnancy (Table 2). Factors that might affect adhesion formation status and caesarean scar healing are summarized in Table 3. When patients were subdivided into two groups (patients without SG or with mild SG, and patients with severe SG), 19% (4/21) of the former group and 50% (17/34) of the latter group had IPA (p ¼ 0.021). The sensitivity of the modality was 80.95%, the specificity was 50%, and the PPV was 50%, while the NPV was 80.95%. The accuracy of the test was 61.82%. Table 1. Some characteristic properties of patients according to Davey Score. No striae (n ¼ 11)
Mild striae (n ¼ 10)
Severe striae (n ¼ 34)
p
Age 35.18 4.14 31.00 5.56 29.53 4.72 0.005a Education 5 Year 3 (27.3%) 2 (20%) 14 (41.4%) 0.218 Housewife 7 (63.6%) 7 (70%) 29 (85.3%) 0.209 Smoking 1 (9.1%) 1 (10%) 7 (20.6%) 0.559 2 (18.2%) 0 (0%) 4 (11.8%) 0.397 Patients with gestational diabetes With intraperitoneal 1 (9.1%) 3 (30%) 17 (50%) 0.044a adhesions Uterine scar 3.82 4.05 5.20 4.13 5.18 3.52 0.561 thickness a
Difference between groups without striae and with severe striae is significant.
Table 2. Factors that might affect striae formation.
Parity Usage of ointment against striae during pregnancy Gestational week at delivery Newborn birth weight BMI before pregnancy Weight gain during pregnancy
No striae (n ¼ 11)
Mild striae (n ¼ 10)
1.00 0.00 5 (45.5%)
1.20 0.42 3 (30%)
Severe striae (n ¼ 34)
p
1.06 0.24 0.194 9 (26.5%) 0.495
38.36 0.62
38.34 0.57 38.36 0.57
0.993
3202 368
3002 429
3296 430
0.155
23.90 3.94
23.17 4.22 25.85 5.05
0.210
11.09 4.09
13.20 5.43 13.94 5.91
0.338
1314
A. N. C. Gungor et al.
J Matern Fetal Neonatal Med, 2014; 27(13): 1312–1315
Table 3. Factors that might affect cesarean scar healing or intraperitoneal adhesion formation. No striae (n ¼ 11)
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/06/15 For personal use only.
Labor before first CS delivery Premature rupture of membranes before first CS delivery Duration since last delivery Number of previous CS
Mild striae Severe striae (n ¼ 10) (n ¼ 34)
p
6 (54.5%)
4 (40%)
14 (41.2%)
0.715
6 (54.5%)
3 (30%)
12 (35.3%)
0.438
5.45 2.95 5.90 3.10
5.94 2.99 0.894
1.00 0.00 1.20 0.42
1.06 0.24 0.194
Subdividing our participants into two different groups (patients without SG and patients with SG) revealed that 9.1% (1/11) of the former group and 45.5% (20/44) of the latter group had IPA (p ¼ 0.025). The sensitivity of the modality was 95.2%, and the specificity was 29.4%. The PPV and NPV were 45.5% and 90.9%, respectively, and the accuracy of the test was 54.5%.
Discussion IPA formation and caesarean scar healing are two major topics of concern for physicians after CS operations because they may cause major complications in the patient’s later reproductive life. Markers that might predict these factors have been studied in the literature frequently. However, there is no gold standard modality to predict either IPA or caesarean scar healing. In the current study, although we demonstrated that the SG status of the patients might be used to predict the presence of IPA caused by prior surgeries, we failed to show a relationship between SG status and caesarean scar healing. Using a cheap, quick and easy evaluation such as SG status, patients with a previous CS delivery might be screened for adhesion formation. While having no SG was highly sensitive (95.2%) and can be used as a screening test, having severe SG was less sensitive but more specific (50%) in predicting adhesion formation. Borzellino et al. [18] performed US before laparoscopy to identify IPA in patients with a history of laparotomy. They concluded that the diagnostic accuracy of US was 88.5%, the specificity was 31.8% and the sensitivity was 100%. We found that having severe SG was more specific than using US to predict IPA. Evaluating SG status is also an easier, quicker and cheaper modality than US. Moreover, a gravid uterus might interfere with the evaluation of intraabdominal organs by US, which could affect results. Piccolboni et al. [3] evaluated 60 patients with a previous operation history and showed that high-resolution US had an accuracy of 93.3% for detecting IPA. Zinther et al. [4] examined 60 patients; 30 had a risk factor for IPA, and 30 had no risk factors. They used both US and cine-magnetic resonance imaging (cineMRI) for predicting IPA. The sensitivity, specificity, accuracy, PPV and NPV values of transabdominal US in detecting IPA were 23.97%, 97.85%, 81.30%, 76.32% and 81.67%, respectively; these same results were 21.49%, 87.11%, 72.41%, 82.5% and 79.35% for cineMRI. The SG status of the patient was more sensitive
but less specific when compared with both modalities. Therefore, SG status evaluation might be a better screening test but not a good diagnostic tool for detecting IPA. Although it is known that MRI is safe for pregnant women, the MRI may also be technically difficult to obtain during pregnancy because of the patient’s large abdominal circumference. SG status was therefore cost-effective, accessible, affordable and easy when compared with MRI. CS scar healing of the skin might help to predict the presence of IPA [5,6]. It is also a cheap, easy modality, along with evaluating SG status. By using both the SG status and CS scar properties of the skin, the predictive value might be increased. We failed to show a relationship between SG status and US, which may have been due to the differences in the underlying pathophysiologic mechanisms between scar healing and SG formation. There might also be a shared pathway between SG formation and adhesion formation, which could be based on elastin. A major limitation of our study was the small sample size. With larger studies, our study’s findings could be strengthened. One major limitation of our study was not accessing the previous caesarean epicrisis so that we cannot be sure about the operation method such as closure or not closure of the peritoneum. Another limitation of the current study was that we did not evaluate filmy adhesions because of their lesser clinical importance. In conclusion, the SG status of a patient with a previous caesarean delivery might be used as a screening test for predicting IPA. This information can be helpful for surgeons when planning a new abdominal operation, particularly a CS or a laparoscopy. Further studies will be needed to clarify the relationship between SG and IPA.
Declaration of interest The authors report no declarations of interest.
References 1. Awonuga AO, Fletcher NM, Saed GM, Diamond MP. Postoperative adhesion development following cesarean and open intra-abdominal gynecological operations: a review. Reprod Sci 2011;18: 1166–85. 2. Murphy DJ, Stirrat GM, Heron J. ALSPAC Study Team. The relationship between Caesaean section and subfertility in a population-based sample of 14 541 pregnancies. Hum Reprod 2002;17:1914–17. 3. Piccolboni D, Ciccone F, Settembre A. High resolution ultrasound for pre-operative detection of intraperitoneal adhesions: an invaluable diagnostic tool for the general and laparoscopic surgeon. J Ultrasound 2009;12:148–50. 4. Zinther NB, Zeuten A, Marinovskij E, et al. Detection of abdominal wall adhesions using visceral slide. Surg Endosc 2010;24:3161–6. 5. Tulandi T, Al-Sannan B, Akbar G, et al. Prospective study of intraabdominal adhesions among women of different races with or without keloids. Am J Obstet Gynecol 2011;204:132.e1–4. 6. Dogan NU, Haktankacmaz SA, Dogan S, et al. A reliable way to predict intraabdominal adhesions at repeat cesarean delivery: scar characteristics. Acta Obstet Gynecol Scand 2011;90:531–4. 7. Landon MB. Predicting uterine rupture in women undergoing trial of labor after prior cesarean delivery. Semin Perinatol 2010;34: 267–71. 8. Salter SA, Batra RS, Rohrer TE, et al. Striae and pelvic relaxation: two disorders of connective tissue with a strong association. J Invest Dermatol 2006;126:1745–8.
DOI: 10.3109/14767058.2013.856876
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/06/15 For personal use only.
9. Wahman AJ, Finan MA, Emerson SC. Striae gravidarum as a predictor of vaginal lacerations at delivery. South Med J 2000;93: 873–6. 10. Halperin O, Raz I, Ben-Gal L, et al. Prediction of perineal trauma during childbirth by assessment of striae gravidarum score. J Obstet Gynecol Neonatal Nurs 2010;39:292–7. 11. Mitts TF, Jimenez F, Hinek A. Skin biopsy analysis reveals predisposition to stretch mark formation. Aesthet Surg J 2005;25: 593–600. 12. Hoban LD, Pierce M, Quance J, et al. Use of polypentapeptides of elastin to prevent postoperative adhesions: efficacy in a contaminated peritoneal model. J Surg Res 1994;56:179–83. 13. Lee KS, Rho YJ, Jang SI, et al. Decreased expression of collagen and fibronectin genes in striae distensae tissue. Clin Exp Dermatol 1994;19:285–8.
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14. Pollio F, Staibano S, Mascolo M, et al. Uterine dehiscence in term pregnant patients with one previous cesarean delivery: growth factor immunoexpression and collagen content in the scarred lower uterine segment. Am J Obstet Gynecol 2006;194:527–34. 15. Buhimschi CS, Buhimschi IA, Yu C, et al. The effect of dystocia and previous cesarean uterine scar on the tensile properties of the lower uterine segment. Am J Obstet Gynecol 2006;194:873–83. 16. Buhimschi CS, Zhao G, Sora N, et al. Myometrial wound healing post-Cesarean delivery in the MRL/MpJ mouse model of uterine scarring. Am J Pathol 2010;177:197–207. 17. Davey CM. Factors associated with the occurrence of SG gravidarum. J Obstet Gynaecol Br Commonw 1972;79:1113–14. 18. Borzellino G, De Manzoni G, Ricci F. Detection of abdominal adhesions in laparoscopic surgery. A controlled study of 130 cases. Surg Laparosc Endosc 1998;8:273–6.
ORIGINAL ARTICLE
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/06/15 For personal use only.
Predictive value of striae gravidarum severity for intraperitoneal adhesions or uterine scar healing in patients with previous caesarean delivery Ayse Nur Cakir Gungor1, Sevilay Oguz2, Servet Hacivelioglu1, Selda Isik2, Ahmet Uysal1, Meryem Gencer1, and Emine Cosar1 1
Department of Obstetrics and Gynecology and 2Department of Dermatology, Faculty of Medicine, Canakkale Onsekiz Mart University, Canakkale, Turkey Abstract
Keywords
Objective: Previous abdominal operations might cause severe intraperitoneal adhesions (IPA), which can complicate caesarean section (CS) procedures. When selecting the mode and timing of delivery, obstetricians are also curious about uterine scar healing if the previous operation was a CS. Uterine scar thickness is an indicator of uterine scar healing. We aimed to evaluate the possible predictive value of striae gravidarum (SG) on IPA formation and uterine scar thickness (UST). Methods: Fifty-five women with a previous CS history were evaluated for SG Davey Score. They were investigated for IPAs and lower segment uterine scar thickness during the current CS operation. Results: Out of the patients with no SG (n ¼ 11), mild SG (n ¼ 10) and severe SG (n ¼ 34), 1 (9.1%), 3 (30%) and 17 (50%) had IPA, respectively (p ¼ 0.044). The mean uterine scar thicknesses in the no SG, mild SG and severe SG groups were 3.82 4.04, 5.20 4.13 and 5.18 3.52, respectively (p ¼ 0.561). Conclusions: To the best of our knowledge, this was the first study to investigate the relationship between SG and IPA and uterine scar thickness. The SG status of a patient with a previous delivery and abdominal operation history might help predict IPA status before planning a new operation.
Caesarean scar, intraabdominal adhesions, stretch marks
Introduction A history of previous abdominal surgeries is a risk factor for a new abdominal operation. One or more previous caesarean section (CS) surgeries might complicate any type of abdominal operation, particularly laparoscopic procedures and CSs [1] and also might cause infertility [2]. Several methods have been used to predict adhesions after abdominal operations. High-resolution ultrasonography (US) [3], magnetic resonance imaging (MRI) [4] and scar healing properties [5,6] were the methods that were evaluated in the English literature for this study. Another adverse effect of a CS operation that might complicate any subsequent deliveries is uterine scar formation. Prediction of uterine scar healing is substantial, especially for selecting the mode of delivery; one of the most important but infrequent complications of vaginal birth after
Address for correspondence: Ayse Nur Cakir Gungor, Department of Obstetrics and Gynecology, Faculty of Medicine, Canakkale Onsekiz Mart University, Canakkale, Turkey. Tel: þ902862635950. Fax: þ902862180516. E-mail: [email protected]
History Received 28 July 2013 Revised 2 October 2013 Accepted 15 October 2013 Published online 12 November 2013
CS delivery is the rupture of the uterine scar. For prediction of uterine scar healing, ultrasonographic assessment of uterine scar thickness has been used [7]. There is no consensus on the evaluation of a patient with a previous CS history to predict either intraperitoneal adhesions (IPA) formation or uterine scar healing. A simple method to identify patients who might have adhesions could help the obstetrician choose the delivery type, organize preoperative preparations and select patients who must be referred to a tertiary care hospital. Therefore, predicting uterine scar healing is important when choosing the mode of delivery. Although the etiology of striae gravidarum (SG) is unknown, its relationship with pelvic relaxation [8] and perineal laceration during vaginal delivery [9,10] has been demonstrated. There may be a shared pathway between SG and adhesion formation. Elastin plays a major role in the development of SG [11], and its protective effect on IPA formation has also been confirmed [12]. Collagen, which is important in SG formation [13], also plays an important role in caesarean scar healing [14–16]. In the current study, we evaluated the predictive power of the SG score on IPA and uterine scar thickness in patients with a history of previous CS operations.
SG predicts adhesions
DOI: 10.3109/14767058.2013.856876
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/06/15 For personal use only.
Methods Fifty-five patients who applied to the Department of Obstetrics and Gynaecology of Canakkale Onsekiz Mart University Hospital with a history of at least one previous CS and who were preoperatively evaluated for elective CS operation were included in the current study and examined by a dermatologist (Dr SO) prior to the procedure. The local ethical committee approved the study, and informed consent was obtained from each patient before the study began. To avoid possible effects of the potential adhesion risk factors, patients with endometriosis, a history of pelvic inflammatory disease or abdominal operations other than CS, such as an appendectomy, were excluded from this study. Patients whose membranes ruptured before the current CS and who had either contractions or cervical dilatation were also excluded to avoid the thinning of the uterine scar tissue. All patients had undergone one or more previous CS deliveries with a pfannenstiel incision and a transverse uterine incision. Socio-demographic properties of the patients (age, education level, occupation, smoking status), possible risk factors for SG formation (parity, body mass index (BMI) prior to the current pregnancy, gestational week of the current CS delivery, the baby’s birth weight, preventional treatment during the pregnancy against SG, and weight gain during the pregnancy), factors that might affect uterine scar healing (diabetic status of the patient, number of previous CS deliveries, time since the last CS), and possible risk factors for adhesion formation (being in labor before the first CS, experiencing rupture of the membranes prior to the previous CS) were noted. Davey scores of patients were calculated [17]. To calculate the Davey score, the abdomen was divided into four quadrants and each part was evaluated for SG formation. If there were no SG, patients received 0 points. If there were a few SG, 1 point was given, and if there were many SG, 2 points were given to that region. All points were summed to obtain the final score. The total score ranged between 0 and 8. Zero points were evaluated as no SG, and 1–2 points were labeled mild SG; 3–8 points were termed severe SG. Beyond the 38th week of gestation, patients delivered by CS electively. During the operation, the participants were evaluated for IPA formation. Patients who had either no or only filmy adhesions were placed in the without IPA group, and those who had dense adhesions were classified into the with IPA group. After the delivery of the baby and the placenta, the thickness of the mid lower segment of the uterine scar from the peritoneum to the endometrium was measured with a sterile ruler. Data were analyzed with the Statistical Package for the Social Sciences (SPSS) for Windows version 11.5 (SPSS Inc., Chicago, IL). Continuous variables were evaluated for a normal distribution using the Kolmogorov–Smirnov test. Descriptive statistics for continuous variables were calculated as mean standard deviation (SD), while those for nominal variables were done by variable count and percent. The Chisquare test was used to evaluate the categorical variables. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of SG status
1313
on IPA formation were calculated. Statistical significance was set at p50.05.
Results A total of 55 women participated in the study. There were 11 patients without SG, 10 patients with mild SG and 34 patients with severe SG. Some patient characteristics are summarized in Table 1. Patients with IPAs in the groups without SG and with mild and severe SG accounted for 9.1%, 30% and 50%, respectively (p ¼ 0.044) (Table 1). The mean thickness of the uterine scar in groups without SG and with mild and severe SG were 3.82 4.05, 5.20 4.13 and 5.18 3.52, respectively (p ¼ 0.561) (Table 1). There were no significant differences in factors that might affect SG formation among the groups, such as parity, usage of an ointment against SG, gestational week at delivery, newborn birth weight, BMI before pregnancy and weight gain during pregnancy (Table 2). Factors that might affect adhesion formation status and caesarean scar healing are summarized in Table 3. When patients were subdivided into two groups (patients without SG or with mild SG, and patients with severe SG), 19% (4/21) of the former group and 50% (17/34) of the latter group had IPA (p ¼ 0.021). The sensitivity of the modality was 80.95%, the specificity was 50%, and the PPV was 50%, while the NPV was 80.95%. The accuracy of the test was 61.82%. Table 1. Some characteristic properties of patients according to Davey Score. No striae (n ¼ 11)
Mild striae (n ¼ 10)
Severe striae (n ¼ 34)
p
Age 35.18 4.14 31.00 5.56 29.53 4.72 0.005a Education 5 Year 3 (27.3%) 2 (20%) 14 (41.4%) 0.218 Housewife 7 (63.6%) 7 (70%) 29 (85.3%) 0.209 Smoking 1 (9.1%) 1 (10%) 7 (20.6%) 0.559 2 (18.2%) 0 (0%) 4 (11.8%) 0.397 Patients with gestational diabetes With intraperitoneal 1 (9.1%) 3 (30%) 17 (50%) 0.044a adhesions Uterine scar 3.82 4.05 5.20 4.13 5.18 3.52 0.561 thickness a
Difference between groups without striae and with severe striae is significant.
Table 2. Factors that might affect striae formation.
Parity Usage of ointment against striae during pregnancy Gestational week at delivery Newborn birth weight BMI before pregnancy Weight gain during pregnancy
No striae (n ¼ 11)
Mild striae (n ¼ 10)
1.00 0.00 5 (45.5%)
1.20 0.42 3 (30%)
Severe striae (n ¼ 34)
p
1.06 0.24 0.194 9 (26.5%) 0.495
38.36 0.62
38.34 0.57 38.36 0.57
0.993
3202 368
3002 429
3296 430
0.155
23.90 3.94
23.17 4.22 25.85 5.05
0.210
11.09 4.09
13.20 5.43 13.94 5.91
0.338
1314
A. N. C. Gungor et al.
J Matern Fetal Neonatal Med, 2014; 27(13): 1312–1315
Table 3. Factors that might affect cesarean scar healing or intraperitoneal adhesion formation. No striae (n ¼ 11)
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by Nyu Medical Center on 06/06/15 For personal use only.
Labor before first CS delivery Premature rupture of membranes before first CS delivery Duration since last delivery Number of previous CS
Mild striae Severe striae (n ¼ 10) (n ¼ 34)
p
6 (54.5%)
4 (40%)
14 (41.2%)
0.715
6 (54.5%)
3 (30%)
12 (35.3%)
0.438
5.45 2.95 5.90 3.10
5.94 2.99 0.894
1.00 0.00 1.20 0.42
1.06 0.24 0.194
Subdividing our participants into two different groups (patients without SG and patients with SG) revealed that 9.1% (1/11) of the former group and 45.5% (20/44) of the latter group had IPA (p ¼ 0.025). The sensitivity of the modality was 95.2%, and the specificity was 29.4%. The PPV and NPV were 45.5% and 90.9%, respectively, and the accuracy of the test was 54.5%.
Discussion IPA formation and caesarean scar healing are two major topics of concern for physicians after CS operations because they may cause major complications in the patient’s later reproductive life. Markers that might predict these factors have been studied in the literature frequently. However, there is no gold standard modality to predict either IPA or caesarean scar healing. In the current study, although we demonstrated that the SG status of the patients might be used to predict the presence of IPA caused by prior surgeries, we failed to show a relationship between SG status and caesarean scar healing. Using a cheap, quick and easy evaluation such as SG status, patients with a previous CS delivery might be screened for adhesion formation. While having no SG was highly sensitive (95.2%) and can be used as a screening test, having severe SG was less sensitive but more specific (50%) in predicting adhesion formation. Borzellino et al. [18] performed US before laparoscopy to identify IPA in patients with a history of laparotomy. They concluded that the diagnostic accuracy of US was 88.5%, the specificity was 31.8% and the sensitivity was 100%. We found that having severe SG was more specific than using US to predict IPA. Evaluating SG status is also an easier, quicker and cheaper modality than US. Moreover, a gravid uterus might interfere with the evaluation of intraabdominal organs by US, which could affect results. Piccolboni et al. [3] evaluated 60 patients with a previous operation history and showed that high-resolution US had an accuracy of 93.3% for detecting IPA. Zinther et al. [4] examined 60 patients; 30 had a risk factor for IPA, and 30 had no risk factors. They used both US and cine-magnetic resonance imaging (cineMRI) for predicting IPA. The sensitivity, specificity, accuracy, PPV and NPV values of transabdominal US in detecting IPA were 23.97%, 97.85%, 81.30%, 76.32% and 81.67%, respectively; these same results were 21.49%, 87.11%, 72.41%, 82.5% and 79.35% for cineMRI. The SG status of the patient was more sensitive
but less specific when compared with both modalities. Therefore, SG status evaluation might be a better screening test but not a good diagnostic tool for detecting IPA. Although it is known that MRI is safe for pregnant women, the MRI may also be technically difficult to obtain during pregnancy because of the patient’s large abdominal circumference. SG status was therefore cost-effective, accessible, affordable and easy when compared with MRI. CS scar healing of the skin might help to predict the presence of IPA [5,6]. It is also a cheap, easy modality, along with evaluating SG status. By using both the SG status and CS scar properties of the skin, the predictive value might be increased. We failed to show a relationship between SG status and US, which may have been due to the differences in the underlying pathophysiologic mechanisms between scar healing and SG formation. There might also be a shared pathway between SG formation and adhesion formation, which could be based on elastin. A major limitation of our study was the small sample size. With larger studies, our study’s findings could be strengthened. One major limitation of our study was not accessing the previous caesarean epicrisis so that we cannot be sure about the operation method such as closure or not closure of the peritoneum. Another limitation of the current study was that we did not evaluate filmy adhesions because of their lesser clinical importance. In conclusion, the SG status of a patient with a previous caesarean delivery might be used as a screening test for predicting IPA. This information can be helpful for surgeons when planning a new abdominal operation, particularly a CS or a laparoscopy. Further studies will be needed to clarify the relationship between SG and IPA.
Declaration of interest The authors report no declarations of interest.
References 1. Awonuga AO, Fletcher NM, Saed GM, Diamond MP. Postoperative adhesion development following cesarean and open intra-abdominal gynecological operations: a review. Reprod Sci 2011;18: 1166–85. 2. Murphy DJ, Stirrat GM, Heron J. ALSPAC Study Team. The relationship between Caesaean section and subfertility in a population-based sample of 14 541 pregnancies. Hum Reprod 2002;17:1914–17. 3. Piccolboni D, Ciccone F, Settembre A. High resolution ultrasound for pre-operative detection of intraperitoneal adhesions: an invaluable diagnostic tool for the general and laparoscopic surgeon. J Ultrasound 2009;12:148–50. 4. Zinther NB, Zeuten A, Marinovskij E, et al. Detection of abdominal wall adhesions using visceral slide. Surg Endosc 2010;24:3161–6. 5. Tulandi T, Al-Sannan B, Akbar G, et al. Prospective study of intraabdominal adhesions among women of different races with or without keloids. Am J Obstet Gynecol 2011;204:132.e1–4. 6. Dogan NU, Haktankacmaz SA, Dogan S, et al. A reliable way to predict intraabdominal adhesions at repeat cesarean delivery: scar characteristics. Acta Obstet Gynecol Scand 2011;90:531–4. 7. Landon MB. Predicting uterine rupture in women undergoing trial of labor after prior cesarean delivery. Semin Perinatol 2010;34: 267–71. 8. Salter SA, Batra RS, Rohrer TE, et al. Striae and pelvic relaxation: two disorders of connective tissue with a strong association. J Invest Dermatol 2006;126:1745–8.
DOI: 10.3109/14767058.2013.856876
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9. Wahman AJ, Finan MA, Emerson SC. Striae gravidarum as a predictor of vaginal lacerations at delivery. South Med J 2000;93: 873–6. 10. Halperin O, Raz I, Ben-Gal L, et al. Prediction of perineal trauma during childbirth by assessment of striae gravidarum score. J Obstet Gynecol Neonatal Nurs 2010;39:292–7. 11. Mitts TF, Jimenez F, Hinek A. Skin biopsy analysis reveals predisposition to stretch mark formation. Aesthet Surg J 2005;25: 593–600. 12. Hoban LD, Pierce M, Quance J, et al. Use of polypentapeptides of elastin to prevent postoperative adhesions: efficacy in a contaminated peritoneal model. J Surg Res 1994;56:179–83. 13. Lee KS, Rho YJ, Jang SI, et al. Decreased expression of collagen and fibronectin genes in striae distensae tissue. Clin Exp Dermatol 1994;19:285–8.
SG predicts adhesions
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14. Pollio F, Staibano S, Mascolo M, et al. Uterine dehiscence in term pregnant patients with one previous cesarean delivery: growth factor immunoexpression and collagen content in the scarred lower uterine segment. Am J Obstet Gynecol 2006;194:527–34. 15. Buhimschi CS, Buhimschi IA, Yu C, et al. The effect of dystocia and previous cesarean uterine scar on the tensile properties of the lower uterine segment. Am J Obstet Gynecol 2006;194:873–83. 16. Buhimschi CS, Zhao G, Sora N, et al. Myometrial wound healing post-Cesarean delivery in the MRL/MpJ mouse model of uterine scarring. Am J Pathol 2010;177:197–207. 17. Davey CM. Factors associated with the occurrence of SG gravidarum. J Obstet Gynaecol Br Commonw 1972;79:1113–14. 18. Borzellino G, De Manzoni G, Ricci F. Detection of abdominal adhesions in laparoscopic surgery. A controlled study of 130 cases. Surg Laparosc Endosc 1998;8:273–6.
