Risks factors FOR wound complications after cesarean section

Awareness of scar management post lower segment caesarean section - A survey

OBJECTIVE

Unhealed caesarean section scars accompany risks of complications which can lead to morbidity, mortality, and complications in future pregnancies. Thorough knowledge of scar healing and management strategies in females undergoing caesarean section is of utmost importance. Our study aims to study the level of awareness of scar healing, management, and scar precaution in females undergoing C-sections.

METHODOLOGY

330 females who underwent C-sections from 2019to to 2021 were included. A self-administered validated questionnaire translated into regional languages was used. The questionnaire assessed level of awareness in 3 domains-scar healing, scar management, and scar precautions.

RESULTS

59% of females were aware of scar management strategies. 52% of females gained knowledge concerning scar healing, management, and precaution through relatives and friends; followed by 35% by gynaecologists/medical camps. Multigravida females were more aware of domains of scar healing and management strategies, whereas primigravida were more aware of precautions concerning caesarean scar.

CONCLUSION

Awareness regarding overall scar management will aid in coping with physical stressors postpartum and its complications. Awareness programs should be initiated by health-care professionals to increase awareness among females undergoing C-sections. Primigravida's should be enlightened regarding scar healing and treatment strategies while multigravida should be explained thoroughly regarding scar precautions.

Cefazolin versus placebo for surgical antibiotic prophylaxis in low-risk cesarean delivery: a feasibility blinded randomized controlled trial

BACKGROUND

Pre-incisional antibiotics are recommended for all patients having cesarean delivery, despite emerging concerns regarding effects on the infant. In this feasibility blinded randomized controlled trial we aimed to test research processes in low-risk women receiving cefazolin or placebo prior to elective cesarean delivery.

METHODS

The trial was prospectively registered (ACTRN12619001705178). Eligible women were aged ≥ 18 and < 40 years, ≥ 37 weeks gestation, at low risk of surgical site infection (SSI) and recruited from a single tertiary centre. We reported proportions of women eligible and consenting; adherence to perioperative infection prevention; blinding adequacy of staff using Bang's blinding index; SSI surveillance and diagnosis according to the Centre for Disease Control definitions and patient reported outcome measures using validated questionnaires up to 90 days.

RESULTS

We screened 1651 women, with 1245 (75%) ineligible based on body mass index or presence of diabetes. Of 287 eligible women, 30 were randomized (11%) with 15 in each group. Reasons for non-participation included "wanting antibiotics" (68, 27%), "no reason" (62, 25%) and lack of research staff (33, 13%). Compliance with perioperative infection prevention occurred in 5 of 7 steps. Spontaneous placental separation occurred in 25 (83%) and Comfeel dressing in 29 (97%). Blinding was adequate for all staff groups. SSI surveillance occurred in 156 of 210 (74%) timepoints. SSI occurred in two patients who received pre-incisional cefazolin and were successfully treated as outpatients. Patient reported outcome questionnaires were completed at 136 of 180 (76%) timepoints. There was no difference in maternal health-related quality of life between the groups.

CONCLUSIONS

Feasibility was impacted by the high-risk population and patient desire for antibiotics. Adherence to perioperative infection prevention practices were high but incomplete. These study processes could be effectively applied in a larger population, targeting low risk maternity patients.

TRIAL REGISTRATION

Prospectively registered 4/12/2019 with the Australian New Zealand Clinical Trials Registry (ACTRN12619001705178).

Maternal epilepsy and pregnancy, delivery and neonatal outcomes: A population-based retrospective cohort study

OBJECTIVE

To investigate associations between maternal epilepsy and pregnancy, delivery and neonatal outcomes.

METHODS

A population-based retrospective cohort study was conducted using the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (HCUP-NIS) database, between 2004-2014. Through logistic regression analysis, we compared associations between epilepsy and pregnancy-related outcomes while adjusting for demographic characteristics and comorbidities.

RESULTS

Of 9,096,788 pregnancies, 25,044 were in pregnant women with epilepsy (PWWE). PWWE were more likely to be younger, white or black, have a lower income and to be insured through Medicare or Medicaid. Furthermore, PWWE were more likely to have been diagnosed with obesity, chronic hypertension, gestational diabetes, thyroid disease and HIV, and to have smoked tobacco during pregnancy or used illicit drugs. Pregnancy and delivery outcomes associated with epilepsy include pregnancy-induced hypertension(adjusted OR(aOR):1.26, 95 %CI:1.21-1.32), preeclampsia(aOR:1.33, 95 %CI:1.26-1.41), eclampsia(aOR:8.34, 95 %CI:7.14-9.74), superimposed preeclampsia/eclampsia(aOR:1.29, 95 %CI:1.14-1.47), placenta previa(aOR:1.24, 95 %CI:1.06-1.44), preterm delivery(aOR:1.27, 95 %CI:1.21-1.32), abruptio placenta(aOR:1.24, 95 %CI:1.12-1.36), chorioamnionitis(aOR:1.12, 95 %CI:1.02-1.23), cesarean section(aOR:1.29, 95 %CI:1.25-1.33), hysterectomy(aOR:1.79, 95 %CI:1.31-2.45), postpartum hemorrhage(aOR:1.12, 95 %CI:1.05-1.21), wound complications(aOR:1.38, 95 %CI:1.17-1.63), maternal death(aOR:3.42, 95 %CI:1.79-6.53), transfusion(aOR:1.67, 95 %CI:1.53-1.83), maternal infection(aOR:1.18, 95 % CI:1.09-1.28, p < 0.001), deep vein thrombosis(aOR:2.11, 95 %CI:1.43-3.10), pulmonary embolism(aOR:2.98, 95 %CI:1.87-4.76), venous thromboembolism(aOR:2.25, 95 %CI:1.65-3.08) and disseminated intravascular coagulation(aOR:1.48, 95 %CI:1.19-1.83). Epilepsy-linked neonatal complications include small for gestational age(aOR:1.52, 95 %CI:1.43-1.62), intrauterine fetal demise(aOR:1.20, 95 %CI:1.02-1.41) and congenital anomalies(aOR:2.76, 95 %CI:2.47-3.07).

CONCLUSIONS

PWWE have significantly higher risk of nearly every pregnancy, delivery and neonatal complication investigated, including maternal death and intrauterine fetal demise. PWWE should be considered high risk patients and be carefully followed during pregnancy.

Comparison of complications and surgery outcomes in skin closure methods following cesarean sections

PURPOSE

This study aimed to assess the impact of absorbable subcutaneous staples for skin closure in cesarean delivery (CD) on maternal morbidity.

METHODS

A retrospective cohort study was conducted at a single tertiary university-affiliated medical center between January 2011 and April 2022. In 2020, a new technique involving absorbable subcutaneous staples for skin closure in CD was introduced. We compared surgical outcomes among three groups: non-absorbable staples, absorbable subcutaneous staples, and absorbable subcutaneous sutures. Data were compared between the three groups and demographic, obstetric, and surgical characteristics were analyzed using univariate and multivariate analysis.

RESULTS

During the study period, 31,660 CDs were performed in our center. The data of 31,419 CDs were available for analysis. Absorbable subcutaneous staples were associated with a significantly shorter surgery time in comparison to non-absorbable staples and sutures (52 min vs 53 min vs 60 min, p < 0.001). No differences were found in rates of wound infections or any surgical site surgery in the 45 days following CD. In a multivariate analysis: the use of absorbable subcutaneous staples was associated with a significantly lower risk for prolonged hospitalization > 5 days (OR 0.6, p < 0.001) and re-admission within 45 days (OR 0.8, p = 0.04).

CONCLUSION

The use of absorbable subcutaneous staples for skin closure during CD is associated with shorter surgery times and a lower risk of prolonged hospitalization and readmission within 45 days.

Abdominal wound dehiscence after appendectomy during pregnancy treated by negative pressure wound therapy with subsequent vaginal delivery: A case report and literature review

Negative pressure wound therapy (NPWT) is a very effective method in the treatment of dehiscent, infected, and non-healing wounds. Difficult wound healing occurs especially in late pregnancy due to the rapid enlargement of the uterus and the constantly increasing tension of the entire abdominal wall. In cases of dehiscence of the surgical wound during pregnancy, proper subsequent treatment is needed, where it is necessary to consider the safety of the mother as well as the fetus. We report the case of a 30-week pregnant patient who was surgically treated for acute appendicitis in pregnancy with an open appendectomy approach. Postoperative complications resulted in wound dehiscence with complete defect in fascia, which was treated with negative V.A.C. ATS® Therapy System. The therapy was started in the 30th week of pregnancy and continued until delivery with regular check-ups and regular redressing of the vacuum-assisted closure (VAC) system. At 38 weeks of pregnancy, the patient delivered vaginally with continued VAC therapy in situ. The final suture took place 3 days after vaginal delivery. Non-healing wounds with abdominal wall defects should be treated using a multidisciplinary approach, and NPWT can be used. This therapy can also be used during pregnancy. Vaginal delivery is preferred because it reduces the risk of further formation or deepening of the abdominal wall defect after a sufficient time interval from the start of the treatment. This complex case with a literature review of surgical complications in pregnancy treated with NPWT therapy highlights the advantage of a multidisciplinary approach.

Wound Healing After Vaginal Delivery, Episiotomy, and Cesarean Section Delivery Among Women With IBD: Results From the PIANO Registry

BACKGROUND

Women with inflammatory bowel disease (IBD) face complexities of disease management during pregnancy and childbirth. Apprehension regarding vaginal delivery in pregnant individuals with IBD persists due to concern for perianal disease and perineal trauma. The incidence of poor wound healing after obstetric anal sphincter injury is approximately 4% in the general population. In an IBD population, risk of developing and difficulty healing perineal tears and episiotomy is not well described.

METHODS

In a multicenter prospective cohort of pregnant individuals with IBD, we collected demographic information, IBD disease and treatment history, pregnancy and labor history, and reports of delayed wound healing >1 month from episiotomy, vaginal tear, or Cesarean (C-) section. Prospective data were collected using questionnaires that were administered each trimester of pregnancy, at delivery, and in the year postpartum.

RESULTS

There were 743 patients in the PIANO registry who answered questions pertaining to postpartum wound healing, with 330 (44%) reporting a C-section and 413 (56%) reporting a vaginal delivery. Of 119 C-section deliveries assessed for delayed wound healing, only 1 (0.8%) patient reported this complication. Episiotomies were reported in 59 (14%) patients, with 9 (15%) reporting delayed wound healing. Vaginal tears were reported in 252 (64%) patients. Delayed wound healing from vaginal tear was reported in 9% of patients. Use of immunomodulators was associated with delayed wound healing from episiotomy (33% vs 0% for those on no medications, P = .024). No difference was seen in wound healing time for episiotomy with other medications, including corticosteroids, anti-tumor necrosis factor, or anti-integrin use. Delayed wound healing from vaginal tear was not associated with any class of IBD medication.

CONCLUSIONS

Episiotomy was a common occurrence in patients with IBD. Immunomodulator, but not biologic, use was found to be associated with delayed wound healing. This association could reflect a direct medication effect on episiotomy wound healing or inadequate treatment of underlying active disease prior to delivery. Vaginal tears were also common but delayed wound healing was not associated with IBD therapy. C-section occurred at high rates, particularly in Crohn's disease patients, with no reported delays in postpartum wound healing.

Postpartum obstetric complications: a guide for radiologists

The puerperium refers to the 6-8 weeks following delivery, and is a dynamic period in which maternal anatomy and physiology are restored to their prepregnant state. Postpartum complications can be divided into non-obstetric and obstetric. The latter are the topic of this article and can be further classified as infectious, thrombotic, hemorrhagic or cesarean-related. Transvaginal US is often the initial modality in the evaluation of puerperal disorders. CT is probably the most valuable imaging technique when life-threatening conditions are suspected. Pelvic MRI is being increasingly used in cases of inconclusive findings or if further characterization is needed, especially in the setting of postsurgical complications or placental disorders. Diagnostic and interventional radiologists play a pivotal role in the evaluation and management of a variety of puerperal complications. Many of these conditions pose a diagnostic challenge, as imaging findings often overlap with normal postpartum changes, so keeping in mind the patient's clinical information is key.

Continuous versus disrupted subcutaneous tissue closure in cesarean section: A retrospective cohort study

OBJECTIVES

To compare rates of surgical-site infections following continuous, as compared with interrupted, subcutaneous tissue closure technique during cesarean delivery (CD).

METHODS

A retrospective cohort study during 2008-2018. The study group included women who underwent either elective or emergent CD with continuous subcutaneous tissue closure, while the control group comprised those with interrupted subcutaneous tissue closure. We excluded women with suspected infectious morbidity before CD. The primary outcome was surgical-site infection (SSI) rate.

RESULTS

The final analysis included 6281 women. We performed continuous subcutaneous tissue closure in 37.4% (1867/4988) of scheduled CD, and 45.8% (592/1293) of emergent CD. The rate of SSI was significantly lower following continuous than interrupted subcutaneous tissue closure, in both elective CD (2.7% versus 4.5%, respectively, P = 0.031) and emergent CD (3.2% versus 5.4%, respectively, P = 0.036) in nulliparous and multiparous women. Similarly, secondary outcomes such as re-admission rates, postoperative maternal fever, and need for antibiotic treatment were significantly lower following continuous subcutaneous closure.

CONCLUSIONS

Continuous subcutaneous closure technique during CD yields a lower rate of surgical-site complications compared with the interrupted technique.

Clinical application of absorbable collagen thread and cosmetic suture technique in emergency treatment of children's facial trauma

AIM

To explore the effect of absorbable collagen thread and cosmetic suture technique on scar inhibition after emergency facial trauma in children, and to explore the application value of absorbable collagen thread in emergency facial trauma.

METHODS

Children who received emergency treatment of facial trauma in plastic surgery department from January 2021 to January 2022 were analysed retrospectively, and were divided into absorbable collagen thread group and non-absorbable nylon thread group. The general data, scar appearance and local symptoms of the two groups were analysed, and the scar appearance was scored by scar beauty rating scale and non-inferiority test was analysed statistically.

RESULTS

A total of 632 children with facial trauma were included in this study, including 458 patients with absorbable collagen thread and 174 patients with non-absorbable nylon thread. The SCAR score of the absorbable collagen thread group (3.03 ± 1.57) was similar to that of the non-absorbable nylon thread group (2.98 ± 2.39) (95% confidence interval), and the final scar outcome score was not statistically different (P > 0.05). All families of the patients were satisfied with the results of the procedure, 95% very satisfied.

CONCLUSION

The use of absorbable collagen thread and cosmetic suture technique to treat the wounds of children with facial emergency trauma, resulted in good wound healing, little scar expansion, low incidence of erythema and pigment abnormality, no obvious surgical trace, and no scar hypertrophy or atrophy. The overall impression was good, the pain of stitch removal was avoided for children's patients, and the satisfaction of family members was high. Cosmetic suture technique with absorbable sutures is worthy of clinical application.

Incidence and risk factors for surgical wound complications in women with body mass index >30 kg/m2 following cesarean delivery: a secondary analysis

BACKGROUND

OBJECTIVE

STUDY DESIGN

RESULTS

CONCLUSION

Risk Factors for Postpartum Disease Activity in Women With Inflammatory Bowel Disease: A Systematic Review and Meta-analysis

BACKGROUND

Women with inflammatory bowel disease (IBD) have an increased risk of postpartum disease activity. We aimed to systematically determine the effect of various risk factors on postpartum IBD disease activity.

METHODS

Electronic databases were searched through January 2021 for studies that reported risk of postpartum disease activity in women with IBD. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for the impact of IBD phenotype, disease activity, therapy de-escalation, mode of delivery, and breastfeeding on postpartum disease activity. Study bias was determined using the Quality in Prognostic Studies tool.

RESULTS

Twenty-seven observational studies (3825 patients) were included, 15 of which had a high risk of confounding bias. The pooled incidence of women with postpartum active IBD was 31.9% (95% CI, 25.6-38.1). Similar results were seen with ulcerative colitis and Crohn's disease (CD; OR, 0.96; 95% CI, 0.58-1.59). Those with stricturing (OR, 3.64; 95% CI, 1.31-10.08) and penetrating (OR, 4.25; 95% CI, 1.11-16.26) CD had higher odds of postpartum active IBD. Active disease at conception (OR, 10.59; 95% CI, 1.48-76.02) and during pregnancy (OR, 4.91; 95% CI, 1.82-13.23) increased the odds of postpartum disease activity. Similarly, biologic discontinuation in the third trimester (OR, 1.77; 95% CI, 1.01-3.10) and therapy de-escalation after delivery (OR, 7.36; 95% CI, 3.38-16.0) was associated with postpartum disease activity.

CONCLUSIONS

Complicated Crohn's disease, disease activity at conception and during pregnancy, and de-escalation of biologics during pregnancy or after delivery are associated with postpartum disease activity in women with IBD.