Suprapannicular Incision Technique for Cesarean Delivery in obese patients

A case series published in September issue of the Journal of Obstetrics and Gynecology describes an alternative suprapannicular skin incision technique for cesarean delivery in obese patients. Lakhi et al. used this technique on 17 obese patients and observed no intraoperative complications or wound complications. The incision permitted easy access to the lower uterine segment thereby eliminating the need for a vertical hysterotomy.

In this technique, an assistant exerts caudal traction on the overhanging panniculus with Allis clamps, and a transverse skin incision was made below the umbilicus, at a point 3 cm below the line joining the anterosuperior iliac crests. Once opening the abdomen, retractors were used for easy access to the lower uterine segment and delivery of the baby.

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With the rising global obesity rates, the obstetrician is increasingly faced with a decision to perform cesarean in obese and morbidly obese patients with large pannus.  However, the use of Pfannenstiel incision in obese patients with a moist region below the panniculus results in increased rate of surgical site infection, and it has been long debated.

Cases of fat necrosis of the abdominal pannus following cesarean section has been reported which may be secondary to pressure applied to the retracted pannus during surgery. Furthermore, this incision also limits access to the lower uterine segment due to overhanging pannus.

Obesity significantly increases the rate of cesarean section, and Weiss et al. report a cesarean section rate of 20.7% in a normal weight control group as compared to 33.8% in obese women, and 47.4% in morbidly obese women (BMI>35kg/m2).

A review of the literature showed that Tixier et al. have reported a case series of 18 patients using the suprapannicular infraumbilical transverse incision with no intraoperative or postoperative complications.

So far there are only case series and case reports about the alternative choice of the incision in obese patients. Currently, a randomized clinical trial comparing Wound Complication Rates Between Low Transverse, Midline Vertical, and High Transverse Skin Incisions in Women with a BMI of 40 or Above Undergoing a Cesarean Section for Delivery is underway at Albany Medical College, New York.

Prospective trials with enough power are needed before a recommendation is made regarding the choice of skin incision in obese and morbidly obese patients.

Abstract

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New study quantifies the risk of developing type 2 Diabetes in women with PCOS

Women with Polycystic Ovarian Syndrome (PCOS) are diagnosed with diabetes 4 years earlier and are at 4 times higher the risk of getting the disease as compared to controls, reports the result of a new study published in the Endocrine Society’s Journal of Clinical Endocrinology & Metabolism.  

PCOS is prevalent in 7-8% of women of childbearing age and it is the most common cause of infertility. In USA, an estimated 5 to 6 million women have PCOS.

Dorte Glintborg, M.D., Ph.D., of the Odense University Hospital in Denmark said, “Many women with PCOS are obese, but the risk for the development of diabetes in PCOS is unknown.”

In this Prospective population-based cohort study researchers studied two groups of women with PCOS. The larger cohort consisted of all pre-menopausal women with a diagnosis of PCOS (18,477 women) picked up from National Patient Register, Denmark and a smaller local cohort of 1,162 women with PCOS who were examined at Odense University Hospital in Denmark. 

Women in the local group were examined and tested for insulin and glucose levels, cholesterol, triglycerides and testosterone levels.

Three age matched women were included as control for each study participant with a diagnosis of PCOS. The main outcome of interest was time and number of participants to develop diabetes.

The women were followed up for median 11.1 years.

The Hazard Ratio for development of T2D was 4.0 in PCOS Denmark (p<0.001), while the total event rate of T2D was 8.0 per 1000 patient years in PCOS Denmark vs. 2.0 per 1000 patient years in controls (p<0.001).

The women also developed diabetes 4 years earlier as compared to controls (31 years vs. 35 years).

BMI, fasting blood glucose, HbA1c, 2-hour blood glucose, insulin resistance, and triglycerides all were good predictors of risk of developing diabetes in future while having multiple children was protective against development of T2D.

The increased risk of developing T2D in PCOS is an important finding,” Glintborg said. “Diabetes may develop at a young age and screening for diabetes is important, especially in women who are obese and have PCOS.”

Access Abstract, Press Release by Endocrine Society