{"paper_id":"76674686-d1f5-4b5b-9a14-171d8f203e04","body_text":"Intra-abdominal adhesions contribute significantly to surgical morbidity\nin addition to infertility. Cesarean section (CS) is considered one of the most\ncommonly practiced surgical procedure by obstetricians. This raised the assumption\nthat the prediction of intraabdominal adhesions would lead to decreased morbidity\n[ 1 ]. Intraabdominal adhesions occur\nat a 7% rate after one CS up to 68% with repeated cesareans [ 2 ].\nStriae are linear skin changes in areas of skin stretching that cause\nbothering disfigurement. This occurs because of dermal damage. This stretching\noccurs due to pregnancy, as well as obesity and Cushing syndrome [ 3 ]. By examination, they appear as pink– purple\nand, finally, depressed white lines. Histologically, these areas are characterized\nby a decreased extracellular matrix as well as decreased collagen [ 4 ].\nThe epidermis at the site of the abdominal scars demonstrates delicate\nwell-organized collagen bundles arranged parallel to each other [ 5 ]. However, scars do not heal similarly, raising\nthe suggestion of a possible relationship to intra-abdominal adhesions [ 6 ].\nThe similarity in the formation of these changes raised the possibility\nof using abdominal striae and scar appearance as predictive tools for the severity\nof intra-abdominal adhesions. Because of the conflicting results about the role of\nabdominal striae and cesarean scar characters in the prediction of intra- abdominal\nadhesions [ 7 – 12 ], the current\nstudy was conducted.\n\nThis study was conducted as a case control study after approval of the\nresearch ethics committee of the faculty of medicine, Suez Canal University, in May\n2019 with a number of 3849. We recruited patients over six months. The study was\ncarried out in the obstetrics and gynecology department, Suez Canal University\nHospitals.\nThe study was carried on patients admitted to the ward fulfilling the\nfollowing inclusion and exclusion criteria. Inclusion criteria: - a) patients with\nprevious CS, b) patients presenting for emergency or elective CS delivery. Exclusion\ncriteria: - a) previous midline surgery, b) history of wound complications, c)\nhistory of endometriosis, d) history of pelvic inflammatory disease (PID), e) other\nabdominal operations other than CS, f) keloid scar formation, g) chronic steroid\ntherapy, h) Cushing disease, i) adrenal hyperplasia, j) Ehlers-Danlos syndrome, k)\nMarfan syndrome, l) Skin disease as lichen sclerosis, m) Prolonged progesterone use,\nn) history of multiple pregnancies, o) history of hydramnios, p) history of\nmacrosomic babies and q) family history of striae on other parts of the body\n(breast, hips, and buttocks).\nAfter fulfilling the above criteria, the study included two groups.\nGroup one was assessed for the presence of striae and the degree of intra-abdominal\nadhesions was evaluated during the current CS. Group two included patients without\nevidence of abdominal striae and were evaluated for the severity of adhesions after\nevaluating the previous scar.\nAll participants gave written informed consent before entering the\nstudy. Patients eligible for the study had the following:-  a- Preoperative evaluation: including personal data (age,\nweight, height, BMI, occupation, level of education, contact\ninformation), obstetric history (parity, gestational age, number of\nprevious CS), and any chronic illness. A blood sample for a group\nand save was withdrawn. b- Evaluation of striae: using Davey’s scoring system\n[ 13 ]. In this\nsystem, the abdomen is divided into four quadrants using vertical\nand horizontal lines passing by the umbilicus. Each quadrant is\nexamined for the striae and scored in the following manner: Clear skin, scored as 0 A moderate number of striae scored as 1 Many striae, scored as 2.\nPreoperative evaluation: including personal data (age,\nweight, height, BMI, occupation, level of education, contact\ninformation), obstetric history (parity, gestational age, number of\nprevious CS), and any chronic illness. A blood sample for a group\nand save was withdrawn.\nEvaluation of striae: using Davey’s scoring system\n[ 13 ]. In this\nsystem, the abdomen is divided into four quadrants using vertical\nand horizontal lines passing by the umbilicus. Each quadrant is\nexamined for the striae and scored in the following manner:\nClear skin, scored as 0\nA moderate number of striae scored as 1\nMany striae, scored as 2.\nThis leads to a total score of 0–8. The severity of striae is\nclassified as none (0), mild [ 1 ,\n 2 ], moderate [ 3 ,  4 ], or severe [ 5 – 8 ]. Evaluation of the striae was done by the same researcher\nusing the figure provided by Buchanan et al. [ 13 ]. Evaluation of intraabdominal adhesions was done by another\nresearcher. Both of them were blinded to the results reported by each other.  c- The scar was assessed using the Vancouver Scar Scale\n(VSS). This scale evaluates the scar for pigmentation, vascularity,\npliability, and height [ 14 ]. d- Intraperitoneal adhesions were evaluated by the\nmodified Nair’s scoring system. This system classified adhesions\ninto no adhesions, thin filmy adhesions (either single or two bands\nof adhesions between viscera or from viscera to the abdominal wall),\nand thick, dense adhesions (more than two bands between viscera or\nfrom viscera to the abdominal wall, multiple dense adhesions, or\nviscera directly adherent to the abdominal wall, regardless of the\nnumber or extent of the bands) [ 15 ].\nThe scar was assessed using the Vancouver Scar Scale\n(VSS). This scale evaluates the scar for pigmentation, vascularity,\npliability, and height [ 14 ].\nIntraperitoneal adhesions were evaluated by the\nmodified Nair’s scoring system. This system classified adhesions\ninto no adhesions, thin filmy adhesions (either single or two bands\nof adhesions between viscera or from viscera to the abdominal wall),\nand thick, dense adhesions (more than two bands between viscera or\nfrom viscera to the abdominal wall, multiple dense adhesions, or\nviscera directly adherent to the abdominal wall, regardless of the\nnumber or extent of the bands) [ 15 ].\nStriae and scare characters were evaluated by a researcher who was\nblinded to the extent of intraperitoneal adhesions.\nData were statistically described in terms of mean and standard\ndeviation, frequencies (number of cases), and percentages when appropriate.\n P  values less than 0.05 were considered\nstatistically significant. All statistical calculations were done using computer\nprogram SPSS (Statistical Package for the Social Science; SPSS Inc., Chicago,\nIL, USA) release 22 for Microsoft Windows. Chi-square test was used for\ncategorical variables and (t) test for continuous variables with normally\ndistributed data. Non-normally distributed data were tested using non-parametric\ntests. Receiver operator characteristic curve was constructed for the Davey’s\nand Vancouver scores to have its cutoff point for the prediction of\nintraperitoneal adhesions. Sensitivity and specificity were calculated. For the\nconstruction of logistic regression models for the prediction of intraperitoneal\nadhesions, the dependent variable was the presence or absence of adhesions. This\nwas put against all of the variables that it depended upon; hence, there were\nmultiple simple logistic models each with a significant factor. These\nsignificant factors were put in a model and factors were removed one by one to\nproduce a best-fit multiple logistic model.\n\nWe recruited patients over six months from June to December 2019. The\nstudy group included 203 women, while the control group included 205 women. Data\nwere analyzed according to the grade of Davey’s score (mild, moderate, and severe).\nPatients with no evidence of abdominal striae were considered as controls. Subgroup\nanalysis of the study group was done according to the severity of their Davey’s’\nscore. There were significant differences in the demographic characters of the\nrecruited patients ( p -value 0.001 for almost all\nvariables) (Table  1 ).  Table 1 Patient demographic data according to the distribution of\nabdominal striae Davey’s score grade None Mild Moderate Severe p -value Age (years)\n(Mean ± SD) 27.92 ± 3.1 29.5 ± 5.76 31.96 ± 5.67 33.23 ± 4.68 < 0.001 Parity\n(Mean ± SD) 1.28 ± 0.45 2.17 ± 1.31 2.57 ± 1.53 2.75 ± 1.55 < 0.001 Number of previous CS\n(Mean ± SD) 1.22 ± 0.42 1.72 ± 0.85 1.87 ± 0.91 2.52 ± 1.38 < 0.001 Weight (kg)\n(Mean ± SD) 76.46 ± 11.66 80.14 ± 10.55 86.22 ± 11.05 84.38 ± 13.49 < 0.001 Height (cm)\n(Mean ± SD) 164.98 ± 6.92 162.62 ± 5.38 162.96 ± 5.58 164.71 ± 4.27 < 0.001 Body mass index (kg/m^2)\n(Mean ± SD) 28.11 ± 4.2 30.41 ± 4.47 32.52 ± 4.21 31.05 ± 4.67 < 0.001\nPatient demographic data according to the distribution of\nabdominal striae\nThe mean Davey score in those with mild, moderate, and severe striae\nwas 1.82 ± 0.39, 3.57 ± 0.5, and 6.73 ± 0.94, respectively ( p -value < 0.001). Higher scores for the parameters of the\nVancouver scale were present in patients with severe striae (1.69 ± 1.01,\n1.73 ± 0.57, 2.67 ± 1.23, and 1.35 ± 1.06 for scar vascularity, pigmentation,\npliability, and height respectively with a  p -value of < 0.001 each). Thick intraperitoneal adhesions were noted\nsignificantly in women with severe striae [21 (43.75%),  p -value < 0.001) (Table  2 ).  Table 2 Scare characters and intrabdominal adhesions in relation to\nabdominal striae Davey’s score grade None (205) Mild (109) Moderate (46) Severe (48) p -value Vascularity\n(Mean ± SD) 0.61 ± 0.82 0.89 ± 0.64 1.07 ± 0.8 1.69 ± 1.01 < 0.001 Pigmentation\n(Mean ± SD) 0.84 ± 0.83 1.01 ± 0.73 1.54 ± 0.62 1.73 ± 0.57 < 0.001 Pliability\n(Mean ± SD) 1.11 ± 0.99 1.34 ± 1.05 1.83 ± 1.34 2.67 ± 1.23 < 0.001 Height (mm)\n(Mean ± SD) 0.56 ± 0.76 0.77 ± 0.73 1 ± 0.89 1.35 ± 1.06 < 0.001 Total score (/13)\n(Mean ± SD) 3.12 ± 2.97 4.01 ± 2.52 5.43 ± 2.75 7.44 ± 2.92 < 0.001 Davey’s score\n(Mean ± SD) 0 ± 0 1.82 ± 0.39 3.57 ± 0.5 6.73 ± 0.94 < 0.001 Intraperitoneal adhesions\n(N%) None 171 (83.41%) 24 (22.02%) 9 (19.57) 10 (20.83) < 0.001 Thin\nfilmy 34 (16.59%) 74 (67.89%) 24 (52.17) 17 (35.42) Thick 0 (0%) 11 (10.09%) 13 (28.26) 21 (43.75)\nScare characters and intrabdominal adhesions in relation to\nabdominal striae\nWomen with intraperitoneal adhesions had more vascular, hyperpigmented,\nless liable, and elevated scars than those without ( p -value < 0.001 each) (Table  3 ).  Table 3 Scar characters in women with intraperitoneal\nadhesions Adhesion occurrence No Yes p -value Variable Attribute n (%) n (%) Vascularity Normal 127 (59.35) 32 (16.49) < 0.001 Red 57 (26.64) 114 (58.76) Pink 14 (6.54) 38 (19.59) Purple 16 (7.48) 10 (5.15) Total 214 (100) 194 (100) Pigmentation Normal 96 (44.86) 28 (14.43) < 0.001 Hypopigmented 44 (20.56) 88 (45.36) Hyperpigmented 74 (34.58) 78 (40.21) Total 214 (100) 194 (100) Pliability Normal 66 (30.84) 16 (8.25) < 0.001 Supple 90 (42.06) 83 (42.78) Yielding 47 (21.96) 36 (18.56) Firm 0 (0) 42 (21.65) Ropes 11 (5.14) 8 (4.12) Contracture 0 (0) 9 (4.64) Total 214 (100) 194 (100) Height\n(mm) 0.5 ± 0.75 1.05 ± 0.85 < 0.001 Total score\n(/13) 3.08 ± 3.08 5.28 ± 2.81 < 0.001\nScar characters in women with intraperitoneal\nadhesions\nThe Davey’s and Vancouver scores showed highly significant predictive\nperformance in the prediction of intraperitoneal adhesions ( p -value < 0.001) (Table  4 ).  Table 4 Linear regression model for the prediction of\nintra-peritoneal adhesions Variables β P -value OR 95% CI OR Age\n(years) 0.217 < 0.001 1.243 (1.156–1.335) Education −2.093 < 0.001 0.123 (0.071–0.215) Body mass\nindex 0.083 0.008 1.086 (1.022–1.155) Vancouver\nscore 0.236 < 0.001 1.267 (1.119–1.433) Davey\nscore 0.479 < 0.001 1.615 (1.374–1.898)\nLinear regression model for the prediction of\nintra-peritoneal adhesions\nDavey’s score of ≥1 significantly predicted intraperitoneal adhesions\nwith a sensitivity and specificity of 82.47 and 79.91%, respectively. Also, a\nVancouver score of 2 was highly significant in the prediction of intraperitoneal\nadhesions. It had a sensitivity of 84.02% and specificity of 56.07%\n(Table  5 , Fig.  1 ).  Table 5 Cut- off value for the Davey score and the Vancouver\nscore Variable AUC p -value Cut-off point Sensitivity Specificity PPV NPV LR+ LR- Davey’s score 0.811 < 0.001 1 82.47 79.91 78.8 83.4 4.1 0.22 Vancouver score 0.719 < 0.001 2 84.02 56.07 63.4 79.5 1.91 0.28 Fig. 1 ROC (Receiver Operating Characteristics) curve showing the\ndiagnostic accuracy of the Davey’s and Vancouver’s scores in the\nprediction of intra-abdominal adhesions\nCut- off value for the Davey score and the Vancouver\nscore\nROC (Receiver Operating Characteristics) curve showing the\ndiagnostic accuracy of the Davey’s and Vancouver’s scores in the\nprediction of intra-abdominal adhesions\n\nNearly half of the studied population had abdominal striae. There were\ndiscrepancies in the prevalence of abdominal striae in the previous studies with\nrates of 65.7, 67.7% among Egyptian women [ 7 ,  16 ] and 80, and\n57.9% among Turkish women [ 8 ,\n 17 ]. This would be rendered to\ndifferent sample sizes as well as different races among the studied\npopulations.\nThe subanalysis performed for the study group demonstrated significant\ndifferences in the demographic characters. In the cohort evaluated in a recent\nstudy, there were no differences in the demographic data of the recruited population\n[ 7 ]. However, in the cohort\nevaluated by another researcher, a significant difference was reported between the\nthree groups in age, BMI, weight gain during pregnancy, and fetal weight\n[ 16 ]. Such differences would be\nrendered to different patient grouping (no/mild striae as a group and severe striae\nas the other one in the former, and no, mild and severe striae in the\nlatter).\nThick intraperitoneal adhesions were noted significantly in women with\nsevere striae. This was following the results reported by Abbas et al.; however,\nthey reported that 90% of women with severe striae had thick adhesions with mean\nDavey score of 4.25 ± 3.36 [ 7 ]. Another\nstudy reported close results to the current one (50% of patients with severe striae\nhad dense adhesions) [ 8 ]. This\ndifference would be explained by the different samples included besides; both\nstudies divided patients into two groups only.\nIn contention with the current study, there was no difference in\nperitoneal adhesions in women with or without striae [ 9 ,  10 ]. However,\nanother study reported higher rates of intraperitoneal adhesions in women with no or\nmild striae than those with severe striae (67.3, 65.9, and 36.3%, respectively)\n[ 17 ]. This was explained by the\nfrequent presence of dysfunctional fibroblasts in striae and adhesions. Fibroblasts\nhave an essential role in collagen production in the adhesions; accordingly adhesion\nformation decreases [ 17 ]. Besides, the\ndifferent tools for evaluation of the striae would result in variable results,\nespecially when incorporating the striae color, which was not evaluated in the\ncurrent study.\nThe current study reported intraperitoneal adhesions occurring in 194/\n408 (47.5%) of the studied population. This was lower than reported by others (59.6\nand 54.3%) [ 16 ,  17 ]. However, too much higher rates of\nintraperitoneal adhesions were reported by Abbas et al. and Khalifi et al. (87 and\n73.5%, respectively) [ 7 ,  18 ]. This disparity in results would be rendered\nto differences in surgeons, techniques, and suture materials used in the\noperations.\nWomen with severe striae and those with intraperitoneal adhesions had\nmore vascularized, hyperpigmented, less pliable and elevated CS scars. This\ncontradicted the results reported by previous research, which stated that flat\nunpigmented scars were more prominent in women with striae. They explained this by\nthe overexpression of transforming growth factor- Beta. It leads to deficient\nelastin production, which is a causative factor in the formation of abdominal striae\n[ 9 ].\nTo achieve perfect scar remodeling, collagen fibers are organized in a\nparallel fashion. While, in elevated scars, increased collagen production is noted.\nThis was thought to arise from variability in transforming growth factor-beta, which\nplays an essential role in the formation of hypertrophic scars as well as\nintraperitoneal adhesions [ 17 ]. Scar\nwidth and appearance showed significant association with dense intraperitoneal\nadhesions ( p -value 0.001, and 0.002 respectively)\n[ 10 ]. Depressed hypopigmented scars\nwere also associated with adhesions, which were assumed to arise from the inward\ntraction from the adhesion bands [ 19 ,\n 20 ]. Besides, in a meta-analysis of\nnumerous studies, they reported that flat scars were indicative of absent adhesions\nwhile depressed ones were associated with adhesions [ 11 ]. Conflicting results exist as elevated scars were found to be\nassociated with more adhesions all over the abdomen than flat or depressed ones\n[ 12 ].\nThe Davey’s and Vancouver scores showed a highly significant predictive\nperformance in the prediction of intraperitoneal adhesions. This was similar to the\nresults reported previously, where Davey score of 2 was considered a significant\nrisk factor in predicting intraperitoneal adhesions. Also, the best cut off was ≥3\nwith reported sensitivity and specificity of 64 and 51.3%, respectively\n[ 7 ] with higher results reported by\nthe current study at a cut off ≥1. However, Abdelaal et al. reported that abdominal\nstriae were not considered a predictor for abdominal adhesions while the number of\nprevious CS did [ 16 ].\nThe role of the scar characters in relation to intraperitoneal\nadhesions needs to be evaluated deeply. Further studies evaluating the impact of\nintra- abdominal adhesions on the difficulty of the cesarean delivery are\nrecommended. This would be represented by the total duration of the operation,\nneed for blood transfusion, and possible visceral injury.\n\nStrengths included a large sample size of recruited patients;\nsubanalysis of the patients with striae into mild, moderate and severe provided more\nrobust results, evaluation of the striae and CS scar using simple scoring systems,\nand the recruited population was of the same ethnicity. However, we did not have any\nprevious medical records about the operative notes of the previous deliveries since\nmost of them delivered in private sittings outside the hospital previously. We did\nnot consider the inter-pregnancy interval as a risk factor for adhesion formation.\nAlso, we did not evaluate the color of the striae. We did not evaluate the impact of\nthe dense adhesions on the difficulty of the cesarean delivery.\n\nAbdominal striae and CS scar were significant predictors for\nintraperitoneal adhesions. Women with severe striae had thick intraperitoneal\nadhesions. Women with intraperitoneal adhesions had more vascular, hyperpigmented,\nless pliable and elevated scars.","source_license":"CC-BY-4.0","license_restricted":false}