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.

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Vaginal cleansing with antiseptic solution before cesarean section brings down postoperative infection: Cochrane review

A simple and inexpensive intervention of vaginal cleaning with the chlorhexidine-based or iodine-based solution immediately before cesarean section probably reduces the risk of endometritis after the procedure. The benefit could be more for women who underwent cesarean section while in labor or after rupture of membranes reports the results of a Cochrane review published 17 July 2018.

The current review is the fifth update on vaginal preparation before cesarean section and risk of subsequent infection by Cochrane; the first review was published in 2010 and subsequently updated in 2012, and twice in 2014.

Cesarean section is the most commonly performed operation in obstetrics, with 1 in 3 babies being born by cesarean section. Nearly 25% of women have endometritis and 10% of women develop skin infection after C-section.

Pre-op or intra-op antibiotic prophylaxis has not been able to bring down the rate considerably.

The Cochrane researchers searched the Cochrane Pregnancy and Childbirth’s Trials Register, the WHO International Clinical Trials Registry Platform (ICTRP) (10 July 2017), ClinicalTrials.gov, and reference lists of retrieved studies.

The review included 11 trials with a total of 3403 women in whom vaginal preparation was done immediately before the start of the cesarean section. Most of the trials used Povidone-iodine (n=8), while the rest used chlorhexidine (n=2) and benzalkonium chloride (n=1).

The control group included women with no vaginal antisepsis preparation (eight trials) or those in whom saline vaginal preparation (three trials) was used.

Vaginal preparation with the antiseptic solution immediately before cesarean delivery probably reduced the risk of endometritis by 64% (average risk ratio (RR) 0.36, 95% confidence interval (CI) 0.20 to 0.63).

It was not possible to separately analyze the risk reduction in a subgroup of women who were in labor or in women whose membranes had ruptured when antiseptics were used. 

Risk of postoperative fever or surgical wound complications may also be brought down by the use of vaginal antisepsis, but the confidence interval around the effects for both outcomes was very wide consistent with insufficient data.

Composite outcome of wound complication or endometritis was reduced by 54% in two trials consisting of 499 women (RR 0.46, 95% CI 0.26 to 0.82).

No adverse effects were reported with either the povidone-iodine or chlorhexidine vaginal cleansing.

The quality of evidence using GRADE was moderate for all reported outcomes. The authors downgraded the outcome for post-cesarean endometritis and composite of wound complications or endometritis because of bias in the involved study and broader CI.

The recommend that healthcare providers may continue using vaginal antisepsis preparation by either using povidone-iodine or chlorhexidine before performing a cesarean delivery.

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Use of Monocryl for subcutaneous skin closure minimizes wound complications in cesarean sections

courtesy: https://www.esutures.com/product/images/full/IMG-6441.jpg

courtesy:http://media.xn--benersttning-lcb.se/2012/05/vicryl1.jpg

Subcuticular skin closure after cesarean delivery with poliglecaprone 25 suture IMONOCRYL) decreases the rate of cesarean wound complications by 39% as compared with polyglactin 910 suture (Coated VICRYL) says the result of randomized control trial published ahead of print in Journal Obstetrics and Gynecology.

Monocryl is monofilament, absorbable suture which dissolves slowly and loses strength while Vicryl is braided, absorbable suture that dissolves quickly but maintain strengths.

The type of skin suture and rate of wound infection after cesarean section has not been widely studied. In this study, the researchers compared the two sutures in term of subsequent wound complication rates (SSI, hematoma, seroma, wound separation) after a cesarean section through a Pfannenstiel skin incision followed by subcuticular closure.

This single center RCT conducted at Montefiore Medical Center, New York recruited about 520 women over a course of 1.25 years. About 263 women were randomized to receive the wound closure with monocryl while in 209 women the wound was closed with vicryl.

The groups were similar in terms of demographics, medical comorbidities and perioperative characteristics. They were followed up for a period of 30 days for wound gaping of > 1 cm in length, hematoma or seroma and surgical site infections as per Centers for Disease Control and Prevention criteria’s.

Use of monocryl was associated with significant less infection as compared to vicryl (8.8% compared with 14.4% (relative risk 0.61, 95% CI 0.37-0.99; P=.04).

The researchers concluded that,” Closure of the skin after cesarean delivery with poliglecaprone 25 suture decreases the rate of wound complications compared with polyglactin 910 suture.”

The study was also presented at the 37th annual meeting of Society for Maternal-Fetal Medicine, January 23-28 Las Vegas.

Vaginal cleaning before cesarean delivery significantly reduces infection: A Systematic Review and Meta-analysis.

A simple and inexpensive intervention of vaginal cleaning with an antiseptic solution before cesarean delivery brings down the rate of endometritis note the results of a Systematic Review and Meta-analysis published August 4 in Journal of Obstetrics and Gynecology.

The effect was significantly more in patients in labor or with ruptured membranes at the time of the procedure.

Claudia Caissutti, MD, from the Department of Experimental Clinical and Medical Science, Clinic of Obstetrics and Gynecology, University of Udine, Italy, and colleagues searched MEDLINE, Ovid, EMBASE, Scopus, Clinicaltrials.gov, and Cochrane Library from their inception to January 2017.

They included randomized trials comparing vaginal cleaning with any antiseptic against placebo or no cleaning at all. The final data for review came from 16 RCTs, with a total of 4,837 women in whom vaginal preparation was done immediately before the start of cesarean section.

Most of the trials used povidone–iodine (n = 11) as the cleaning agent, while rest used chlorhexidine diacetate solution n = 3) , metronidazole vaginal gel prep ( n =1), and Cetrimide ( n =1) .

The observed incidence of endometritis in women who received preoperative vaginal cleansing was nearly 50% less as compared to women with placebo or no cleaning (4.5% vs 8.7%; relative risk [RR], 0.52; 95% confidence interval [CI], 0.37 - 0.72). These group also had significantly lower incidence of postoperative fever (9.4% compared with 14.9%; RR, 0.65).

No significant difference was observed in postoperative wound infection among the groups.

In a separate planned subgroup analysis, the observed difference in rates of endometritis was only seen in women who were in active labor and for patients with rupture of membranes. Four trials stratified the data according to women were in labor or not and three trials looked into women with and without ruptured membranes.

When the data was stratified according to type of cleaning agent and prophylactic antibiotics, the results were in according to the overall analysis.

Women who received prophylactic antibiotics had a 67% decrease in endometritis incidence. The authors opined, "Surgical prophylaxis with intravenous antibiotics before cesarean delivery has been clearly demonstrated as beneficial in reducing postoperative infection morbidity, Thus, it is the standard of care and these findings could translate to current practice."

The results of study have confirmed the findings of earlier Cochrane database systematic review published in 2013.

Data is needed to assess the effect of vaginal cleaning in women not in labor and without ruptured membranes.

The authors concluded that, “Vaginal cleansing immediately before cesarean delivery in women in labor and in women with ruptured membranes reduces the risk of postoperative endometritis. We recommend preoperative vaginal preparation before cesarean delivery in these women with sponge stick preparation of povidone-iodine 10% for at least 30 seconds.”

Similar results obtained after use of Glue or subcutaneous Monocryl for cesarean wound closure -- News from SMFM 2017, Las Vegas.

Skin glue: Ethicon.com 

Monocryl 

Use of Glue(Dermabond ) or subcutaneous  Monocryl results in same outcome in terms of safety, healing,  wound complications or cosmetic appearance. The choice of using one over another depends on surgeons’ choice and patient’s preference.

The study will be presented at the 37th  annual meeting of Society for Maternal-Fetal Medicine , January 23-28 , Las Vegas. Cesarean sections rates are on rise, it is the most common surgery performed in U.S. hospitals. Roughly, every one in three baby is born by Cesarean Section. In-spite this, there is still no consensus or evidence about best method for skin closure in Cesarean section.

Yari Daykan and his colleagues from Dept. of Obstetrics and Gynecology at Meir Medical Center in Kfar Saba and the Sackler School of Medicine in Tel Aviv conducted a RCT, in which women undergoing a scheduled Cesarean section were randomized to either have the wound glued using Dermabond or wound closed by using subcuticular Monocryl. [1]

The scars were assessed after 2 months by using Patient and Observer Scar Assessment Scale (POSAS) scores.   The POSAS is a comprehensive scale that is designed for the evaluation of all types of scars by professionals and patients.[2]

The scar site was also evaluated at 1 month for infection, discharge, redness or dehiscence as secondary outcome of the study.

Both the study groups were comparable in terms of indications for C-section, length of surgery, BMI and other demographics.

It was seen that at 8 weeks, scars were comparable in terms of patient score, physician score and subcutaneous thickness, wound infection or wound dehiscence.

Researchers concluded that both methods are safe, equally effective and the choice depends on surgeon and patient's preferences.

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[1] http://www.smfmnewsroom.org/2017/01/skin-closure-options-for-cesarean-delivery-glue-versus-subcuticular-sutures/#more-1584

[2] http://www.posas.org/

Use of Monocryl suture minimizes wound complications in cesarean sections - News from SMFM 2017, Las Vegas.

courtesy: https://www.esutures.com/product/images/full/IMG-6441.jpg

courtesy:http://media.xn--benersttning-lcb.se/2012/05/vicryl1.jpg

Use of poliglecaprone 25 (Monocryl) subcutaneous suture for abdominal wound closure in Cesarean Section reduces the wound complication rate by nearly 50 % as compared to use of polyglactin 910 (coated Vicryl) according to a study that will be presented at the 37th  annual meeting of Society for Maternal-Fetal Medicine , January 23-28 , Las Vegas.[i]

Monocryl is monofilament, absorbable suture which dissolves slowly and loses strength while Vicryl is braided, absorbable suture  that dissolves quickly but maintain strengths.

The first ever Randomized control trial was conducted by Dr. Arin Buresch and her colleagues from Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY.[ii]

Over a course of little more than a year, 550 patients undergoing non-emergency cesarean section were recruited and randomly allocated to either receive poliglecaprone(275() or 275 receiving polyglactin for subcutaneous wound closure of the Pfannenstiel abdominal incision.

The groups were comparable demographically. These patients were evaluated and compared at 30 days for wound gaping of > 1 cm in length, hematoma or seroma and surgical site infections as per Centers for Disease Control and Prevention criteria’s.

8.8% patient had wound complication in poliglecaprone 25 (Monocryl) group as opposed to 14.4% patient in Vicryl group (p=.04).

Dr. Arin Buresch concluded “The difference in wound complications may occur due to the braiding in vicryl suture which conceivably allows bacterial growth in small nooks and crevices. In the future, we hope our study will help guide the decision-making on which suture type is used when closing the skin in cesarean births.”

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[i] https://www.smfm.org/meetings/2-37th-annual-pregnancy-meeting/registration

[ii] http://www.smfmnewsroom.org/2017/01/comparing-skin-closure-options-for-cesarean-delivery-to-determine-which-method-causes-the-least-wound-complications/#more-1609

Preincisional Azithromycin cuts postcesarean maternal infection by half.

The CesareanSection Optimal Antibiotic Prophylaxis (C/SOAP) study is a large pragmatic multi-center randomized clinical trial designed to evaluate the comparative effectiveness and safety of azithromycin-based extended-spectrum antibiotic prophylaxis (azithromycin plus standard narrow-spectrum cephalosporin) relative to standard single-agent cephalosporin (preferably prior to surgical incision) to prevent post-cesarean infection.

Paired with standard prophylactic antibiotics, broad-spectrum intravenous azithromycin was highly effective, with a number needed to treat of 17 to prevent one postsurgical infection, and 43 to prevent one case of endometritis, Dr. Alan Tita reported at the 36^th annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.

“We also saw fewer maternal adverse events, and the protocol was safe for the newborn,” said Dr. Tita, who is a professor of obstetrics and gynecology at the University of Alabama, Birmingham.

This trial enrolled 2,013 women at 14 sites, who had singleton pregnancy of at-least 24 weeks, not scheduled for elective LSCS and underwent surgery after being in active labor for at-least 4 hours or 4 hours after rupture of membranes.

All women received standard preoperative antibiotic prophylaxis with either cefazolin or clindamycin. The women were than randomized to receiving either preincisional intravenous azithromycin 500 mg or a placebo.

As the study was multicentric, skin preparation was done according to standard protocols at each center.

The primary outcome measures were composite of endometritis and/or wound infection and/or other post-cesarean infections (occurring within 6 weeks of delivery) and the secondary outcomes were individual post-cesarean infections: Endometritis, wound infection (including necrotizing fascitis), other infections including abscess, septic thrombosis, pneumonia, pyelonephritis and breast infection.

The neonatal outcome was a composite of death; primary or suspected sepsis; and serious neonatal morbidities, including respiratory distress syndrome, necrotizing enterocolitis, periventricular leukomalacia, intraventricular hemorrhage of grade 3 or higher, and bronchopulmonary dysplasia.

It was seen that the rate of primary composite outcome was reduced by half in the study group (6% vs. 12%; relative risk, 0.49). Wound infection decreased by 65% (2.4% vs. 6.6%; RR, 0.35). 

Azithromycin significantly improved the maternal outcome like fever, readmission, revisit also.

The use of azithromycin was safe for neonates too and the researchers did not see much difference for the composite neonatal safety outcome in study vs the placebo group.   The rates for treatment and placebo groups were not different for suspected or confirmed sepsis (11.8% vs. 12.5%), serious neonatal morbidities (4.4% vs. 3.4%), or NICU admission (16.8% vs. 17%).

No maternal deaths were reported, 11 patients had allergic reaction, while five women admitted to intensive care, and five other had suspected cardiac events.

Concerns regarding the alteration of the fetal microbiome by brief systemic exposure to azithromycin were raised at the conference.

“We have collected additional information and specimens and we will be looking at these to try and answer this. We also hope to get funding to do a long-term evaluation of these kids. I will say that we collected adverse event data on them for 3 months and we did not see anything concerning, but I agree more needs to be done,” he said. “Having said that, azithromycin is something we already use quite a lot in obstetrics, and overall it has been shown to be safe for the newborn.”

Dr. Tita reported having no financial disclosures.

References:

https://clinicaltrials.gov/show/NCT01235546

https://www.smfm.org/meetings/1-smfm-36th-annual-meeting