Prophylactic subcutaneous drainage for prevention of wound complications after cesarean delivery--a metaanalysis

A systematic literature review and meta-analysis of published data evaluating the effectiveness of prophylactic subcutaneous drainage to prevent wound complications in women undergoing cesarean delivery was performed. We identified 6 randomized trials of prophylactic subcutaneous drainage after cesarean delivery. Meta-analysis was performed and Peto odds ratios were calculated for each study outcome. The use of prophylactic subcutaneous drainage was not associated with a reduction in the rate of wound disruption (odds ratio 0.74, 95% CI: 0.39-1.42, P = .36, infection (odds ratio 1.15, 95% CI: 0.70-1.90, P = .58), hematoma (odds ratio 1.05, 95% CI: 0.33-3.30, P = .94), or seroma (odds ratio 0.44, 95% CI: 0.14-1.43, P = .17) when compared with women who were not receiving subcutaneous drainage. Prophylactic use of subcutaneous drainage does not prevent significant wound complications after cesarean delivery.     

Risk factors for wound complications in morbidly obese women undergoing primary cesarean delivery

Objective: To determine factors influencing separation and infectious type wound complications (WCs) in morbidly obese women undergoing primary cesarean delivery (CD). Methods: Retrospective cohort study evaluating infectious and separation WC in morbidly obese (body mass index [BMI] > 35 kg/m²) women undergoing primary CD between January 1994 and December 2008. Chi-square, Fisher’s exact and Student’s t tests used to assess associated factors; backward logistic regression to determine unadjusted and adjusted odds ratios. Results: Of 623 women, low transverse skin incisions were performed in 588 (94.4%), vertical in 35 (7%). Overall WC rate was 13.5%, which varied by incision type (vertical 45.7% vs. 11.6% transverse; p < 0.01), but not BMI class. Incision type and unscheduled CD were associated with infection risk, while incision type, BMI, race and drain use were associated with wound separation. Conclusion: In morbidly obese women both infectious and separation type WC are more common in vertical than low transverse incisions; therefore transverse should be preferred.     

Severe secondary postpartum hemorrhage 3 weeks after cesarean section: alternative etiologies of uterine scar non-union

A case of secondary postpartum hemorrhage that occurred 3 weeks after cesarean section requiring total abdominal hysterectomy is reported. The patient's history and pathologic features of the removed uterus did not allow the authors to clearly recognize a previous reported cause of this potentially life-threatening complication. Alternative causes of the non-union of the uterine incision are suggested.     

Management of wound complications from cesarean delivery

Multiple factors account for the increasing number of cesarean delivery wound complications in the United States; among them are an increase in cesarean delivery and an increase in the number of overweight and obese patients. This article reviews the pathophysiology of acute wound healing. Risk factors for cesarean delivery wound complications are identified and described. Clinical practices that can reduce the risk of developing wound complications, including Centers for Disease Control and Prevention guidelines, are considered. Treatment guidelines to accelerate wound healing such as secondary closure and negative pressure wound therapy in disrupted wounds are proposed. Older guidelines for management of wounds using secondary intention are critiqued. Historical methods of wound care such as the practice of using certain cleansers and the practice of wet to dry dressings are outdated. Modern wound healing products are described. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader should be able to describe the effects of obesity on cesarean delivery wound healing, to improve methods of wound healing in the obese patient, and to explain why wet to dry dressing changes are not effective wound management.     

The legendary superior strength of the Pfannenstiel incision: a myth?

OBJECTIVE: This study was undertaken to determine whether there is a difference in the frequency of fascial dehiscence between midline vertical lower abdominal and Pfannenstiel incisions among women undergoing obstetric and gynecologic operations. STUDY DESIGN: A case-control study of 48 cases of fascial dehiscence complicating 17, 995 major operations (8950 cesarean deliveries and 9405 gynecologic procedures) during a 6-year period at Wayne State University Hutzel Hospital, Detroit, was performed. Univariate analysis identified significant independent variables related to fascial dehiscence. Stepwise logistic regression analysis then identified those risk factors that were independently associated with fascial dehiscence. RESULTS: Among the 48 patients who underwent repair of fascial dehiscence after a major obstetric or gynecologic operation, 27 were from the obstetric service and 21 were from the benign and cancer gynecologic services. Wound dehiscence occurred in 10 vertical incisions and 17 Pfannenstiel incisions among the obstetric patients and in 12 vertical and 9 Pfannenstiel incisions among the gynecologic patients. The risk for dehiscence with vertical lower abdominal incisions was not increased with respect to that associated with Pfannenstiel incisions (P =.39, 2-tailed). This finding was true for all patients (odds ratio, 1.3; 95% confidence interval, 0.7-2.6), obstetric patients (odds ratio, 1.3; 95% confidence interval, 0.5-3.4), and gynecologic patients (odds ratio, 1.5; 95% confidence interval, 0.5-4.0). Forty-seven of the 48 case patients had documented wound infections, compared with 1 of the 144 control subjects (P <.0001, odds ratio, 37.8; 95% confidence interval, 14.8-96.8). CONCLUSION: Wound infection was the most important risk factor for fascial dehiscence among women who underwent major obstetric and gynecologic operations. Our results do not support the long-held belief that Pfannenstiel incisions are stronger than lower abdominal vertical incisions and reduce the risk for fascial dehiscence.     

Risk factors for wound disruption following cesarean delivery

Abstract

Objective: Risk factors for post-cesarean wound infection, but not disruption, are well-described in the literature. The primary objective of this study was to identify risk factors for non-infectious post-cesarean wound disruption.

Methods: Secondary analysis was conducted using data from a single-center randomized controlled trial of staple versus suture skin closure in women ≥24 weeks’ gestation undergoing cesarean delivery. Wound disruption was defined as subcutaneous skin or fascial dehiscence excluding primary wound infections. Composite wound morbidity (disruption or infection) was examined as a secondary outcome. Patient demographics, medical co-morbidities, and intrapartum characteristics were evaluated as potential risk factors using multivariable logistic regression.

Results: Of the 398 randomized patients, 340, including 26 with disruptions (7.6%) met inclusion criteria and were analyzed. After multivariable adjustments, African-American race (aOR 3.9, 95% CI 1.1–13.8) and staple – as opposed to suture – wound closure (aOR 5.4, 95% CI 1.8–16.1) remained significant risk factors for disruption; non-significant increases were observed for body mass index ≥30 (aOR 2.1, 95% CI 0.6–7.5), but not for diabetes mellitus (aOR 0.9, 95% CI 0.3–2.9). Results for composite wound morbidity were similar.

Conclusions: Skin closure with staples, African-American race, and considering the relatively small sample size, potentially obesity are associated with increased risk of non-infectious post-cesarean wound disruption.     

Continuous local bupivacaine wound infusion with neuraxial morphine reduces opioid consumption after cesarean delivery

Abstract

Background: As a part of a quality improvement program, maternal postoperative opioid use and pain scores were compared between those receiving continuous infusion of bupivacaine for local incisional pain control with multimodal pain management and neuraxial morphine versus multimodal pain management with neuraxial morphine alone.

Objective: We compared postoperative opioid use and pain scores between the multimodal pain management group with neuraxial morphine and the group receiving multimodal pain management, neuraxial morphine, and continuous infusion of bupivacaine for local incisional pain control.

Study design: A retrospective cohort analysis of cesarean deliveries from January of 2015 through March of 2016 was undertaken. Deliveries were grouped by utilization of continuous infusion of bupivacaine for local incisional pain control. For each postoperative day, the average daily opioid use, antiemetic use and pain scores were determined. Patients received 1–2 tablets oxycodone–acetaminophen (5–325?mg) every 4?h as needed with oxycodone 5–10?mg immediate release tablets every 4?h as needed for breakthrough pain in addition to acetaminophen and ibuprofen. Total dose of narcotic, antiemetic use, and pain scores was compared between groups utilizing t-test for continuous variables and chi square for categorical data. A linear mixed model with unstructured covariance was utilized to analyze the daily dose of narcotic and pain scores from postoperative day 1 through day 4.

Results: Patients in the standard multimodal group with neuraxial morphine used more opioids versus those receiving continuous wound infusion of bupivacaine in total postoperative dosing (122.79?±?61.92?mg versus 89.88?±?51.38?mg, p?=?.0063). There was a statistically significant difference between the standard group and local infusion of bupivacaine group on postoperative days 1 and 2 (32.79?±?15.56?mg versus 22.13?±?15.73?mg, p?=?.0011 and 40.25?±?19.84?mg versus 29.13?±?14.58?mg, p?=?.0018, respectively). There was no difference in narcotic use for postoperative days 3 and 4. There was a higher mean number of antiemetic doses in the standard group (0.31?±?0.70 versus 0.10?±?0.30, p?=?.0396). Pain scores did not differ between groups, although there was a correlation between opioid dosing and pain scores. The standard group received more IV ketorolac (87.72?±?42.01?mg versus 64.50?±?53.3?mg, p?=?.0165) and more IV acetaminophen (634.89?±?706.42?mg versus 375.0?±?490.29?mg, p =?.0315) within the first 24?h postoperatively. In addition, the standard group received more oral acetaminophen (6969.67?±?3230.14?mg versus 5248.75?±?2711.71?mg, p?=?.0064). No difference was seen in regard to ibuprofen between groups. These results remained constant when adjusted for differences in gestational age, variation in intraoperative opioid dosing, as well as differences in uterine incision type.

Conclusion: We found a significant reduction in postoperative opioid use when continuous infusion of bupivacaine for local incisional pain control was added to our standard pain management with neuraxial morphine after cesarean delivery. As a result of this quality improvement initiative, we have implemented this intervention universally as a part of our multimodal postoperative pain management strategy.     

剖宫产子宫切口感染的防治

子宫切口感染是剖宫产术后严重并发症之一,近年来,随着剖宫产率升高,剖宫产子宫切口因感染导致围生期不良结局的报道有增加的趋势。文章通过复习文献,并进一步阐述子宫切口感染的相关因素、诊断、治疗及预防措施,希望能引起足够的关注,采取有效的防范措施。     

外阴癌手术切口愈合不良的防治

外阴癌手术后切口愈合不良一直是妇科肿瘤医生所面临的挑战和难题。根据肿瘤特点和病情需要制定适宜的手术范围和手术方式,并在术前、术中及术后各个环节做好预防工作,是促进外阴癌手术切口愈合、减少切口相关并发症的根本措施。本文在分析切口愈合不良影响因素的基础上提出预防切口愈合不良的建议和措施,以供临床借鉴和参考。     

Effect of subcutaneous tissue closure technique in cesarean section on postoperative wound complications in obese Egyptian women

Subcutaneous tissue closure technique is a wide area of interest for obstetricians who perform cesarean section especially on obese women while many observers studied in an extensive manner postoperative pain and wound cosmetic results.

Aim of the work: The main goal of our work was to display the differences in wound outcome results as regard postoperative wound complications comparing the two widely implemented techniques in subcutaneous tissue closure (interrupted versus continuous methods).

Results: A comparative analysis between continuous and interrupted techniques regarding wound complications (gapping, seroma, erythema, and infection) showing statistical significant differences in all four wound complications presented with p values?=?.019, .011, .015, and .001, in consecutive order with odds ratio in wound gapping?=?5.239, wound seroma OR?=?9.429, wound erythema OR?=?3.709, and wound infection OR?=?6.136.

Conclusions: Subcutaneous wound closure using interrupted technique of suturing in obese patients is superior to continuous technique as regard wound complications.

Clinical trials.gov ID Identifier (NCT 03354078).     

The utility of midtrimester ultrasound assessment of the subcutaneous space in predicting cesarean wound complications

Objective: To evaluate the association between cesarean wound complications and thickness of the subcutaneous space within the anterior abdomen at the midtrimester fetal anatomical survey.

Methods: In this case-control study, cases were identified using an ICD9 code for wound complications of cesarean delivery. For each case, we identified the woman with the next consecutive midtrimester ultrasound who had a cesarean delivery without a wound complication, matched on age and race, as the control. A blinded investigator measured subcutaneous space at three distinct suprapubic levels in the midsagital plane.

Results: Of 7228 women with a cesarean delivery, 123 (1.7%) had a wound complication. Seventy-nine cases were eligible. Midline suprapubic subcutaneous thickness did not differ between cases and controls at the superior, middle or inferior locations (p?≥?0.35). Body mass index was moderately correlated with ultrasound-derived measurements (r?≥?0.63; p?p?≤?0.046). There was no significant increase in wound complication risk with increasing subcutaneous space thickness, even after adjustment (p?≥?0.34).

Conclusion: Prenatal ultrasound can quantify the subcutaneous space. Vertical skin incision, stapled wound closure, and a classical hysterotomy were associated with cesarean wound complication, but midtrimester subcutaneous thickness was not.     

Risk factors for post-operative wound infection in the setting of chorioamnionitis and cesarean delivery

Objective: The objective of this study was to identify factors associated with an increased risk of post-operative wound infection in women with chorioamnionitis who undergo cesarean delivery.

Methods: We conducted a retrospective cohort study of women with clinical chorioamnionitis who underwent cesarean delivery at a tertiary-care center between June 2010 and May 2013. Demographic data, labor and delivery details and post-operative outcomes were collected. Women with and without post-operative wound infections were compared.

Results: Of 213 women with clinical chorioamnionitis who underwent cesarean delivery, 32 (15%) developed wound infections. Women with wound infection were more likely to have a body mass index (BMI) greater than or equal to 40 (p?=?0.04), chronic hypertension (p?=?0.03), leukocytosis on presentation (p?=?0.046) or use tobacco (p?=?0.002). Women who received ertapenem postpartum were less likely to develop wound infection than those who did not receive antibiotics (p?=?0.02) or those that received ampicillin, gentamicin and clindamycin (p?=?0.005).

Conclusions: Elevated BMI, tobacco use, chronic hypertension and leukocytosis at admission were associated with an increased risk of wound infection. Ertapenem appeared to reduce the risk of post-operative wound infections in women who had chorioamnionitis and underwent cesarean delivery. This could be considered as a treatment option for this high-risk population.     

Maternal morbidity following a trial of labor after cesarean section vs elective repeat cesarean delivery: a systematic review with metaanalysis

This study reviewed maternal morbidity following trial of labor (TOL) after cesarean section, compared with elective repeat cesarean delivery (ERCS). Articles were pooled to compare women planning vaginal birth after cesarean (VBAC) with those undergoing ERCS with regard to maternal morbidity (MM), uterine rupture/dehiscence (UR/D), blood transfusion (BT), and hysterectomy. The former group was subdivided into successful VBAC (S-VBAC) and failed TOL (F-TOL). VBAC was successful in 17,905 of 24,349 patients (73%). MM, BT, and hysterectomy were similar in women planning VBAC or ERCS, whereas UR/D was different (1.3%; 0,4%). MM, UR/D, BT and hysterectomy were more common after F-TOL (17%, 4.4%, 3%; 0.5%) than after S-VBAC (3.1%, 0.2%, 1.1%; 0.1%) or ERCS (4.3%, 0.4%, 1%; 0.3%). Outcomes were more favorable in S-VBAC than ERCS. These findings show that a higher risk of UR/D in women planning VBAC than ERCS is counterbalanced by reduction of MM, UR/D. and hysterectomy when VBAC is successful.     

Effect of skin coverage method following subcuticular suturing on wound infection rates at cesarean delivery*

Objective: The objective of this study was to determine whether the use of cyanoacrylate skin glue following subcuticular skin closure was associated with a decrease in wound outcomes in comparison with subcuticular closure plus Steri-strips at cesarean delivery.

Methods: This was a retrospective cohort study of patients undergoing cesarean delivery at a single center over a two-year period. The primary outcome of wound infection and secondary outcomes of wound separation and composite wound complication rate were assessed throughout the six-week postpartum period.

Results: Of 660 women who met inclusion criteria, 35 (5.3%) experienced a wound infection and 90 (13.6%) experienced a wound separation. The composite wound complication rate was 16.4% (n?=?108). Of the 515 cases with a skin coverage method noted, use of skin glue was associated with a marginal decrease in wound infections (p?=?0.057), as well as a significantly reduced incidence of wound separation (p?=?0.03) and composite wound complications (p?=?0.006).

Conclusion: Cyanoacrylate skin glue may be superior to Steri-strips for wound separation and composite wound complication rates when utilized with subcuticular suture at the time of cesarean delivery and may yield some benefit for prevention of wound infection.     

Re-laparotomy after cesarean section: operative complications in surgical delivery

OBJECTIVE: To determine the risk factors causing re-laparotomy and the indications, management and outcomes of re-laparotomy after a cesarean section. METHODS: We had, during the study period of January 2002 to January 2007, 28,799 cesarean sections and 35 cases with re-laparotomy. We studied the patients' age, parity, indications for cesarean section and indications for re-laparotomy, time interval after cesarean section to reopening of the abdomen, type of surgery, need for blood transfusion and span of hospital stay. RESULTS: The incidence of re-laparotomy was 0.12%. Cases with placental abruption and previous cesarean >/=3 had a higher risk for re-laparotomy. Procedures that were performed at re-laparotomy were drainage and resuturing of hematomas (n = 8), resuturing of uterus and securing hemostasis with stitches (n = 10), bladder repair (n = 1), herniation repair (n = 1), total abdominal hysterectomy (n = 2), subtotal abdominal hysterectomy (n = 5), and draining and resuturing of broad ligament, parametrium, abdominal wound, and cutaneus and subcutaneous tissue due to infection and abscess formation (n = 8). Two cases required admission into the intensive care unit. We had one case with maternal mortality. Majority of the complications were revealed at an early period and these were hemorrhagic cases mostly. CONCLUSION: Although the rate of re-laparotomy after cesarean section is low, several actions must be undertaken to decrease the need for re-laparotomy. In particular, cases with placental abruption and previous cesarean >/=3 are with higher risk for re-laparotomy and have a 15-fold risk for re-laparotomy after cesarean section.