Abstract system of Atwal. The primary outcome

Abstract

Aim
of the study: to correlate the severity of the striae gravidarum (SG) and the
incidence of episiotomy, vaginal and perineal lacerations.

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Patient
and methods: This cross-sectional multicentre observational study was carried
in Cairo University and Ain Shams University on 534 pregnant females, from
which 466 who fulfilled the inclusion criteria reached the final analysis.
After their enrolment, the SG was examined and its severity was assessed
according to the numerical scoring system of Atwal. The primary
outcome of the study was the relation between the incidence of the
episiotomies, perineal and vaginal lacerations and the severity of the SG.

Results: the incidence of
episiotomy, vaginal and perineal lacerations increased significantly with
higher degrees of TSS. There was also significant relation between the TSS, the
gestational age, EFW, neonatal birth weight, and the vaginal laceration length
with the incidence of the perineal lacerations.

Conclusion: the severity of the
SG assessed prenatally can predict the incidence of episiotomies, vaginal and
perineal lacerations.

Keywords: Episiotomy; Perineal
lacerations; Vaginal delivery; Vaginal lacerations; Striae gravidarum.

 

 

 

 

 

 

Introduction

The overall clinical appearance
of the skin is related to pigmentation, glands, vasculature, and connective
tissue. Cutaneous changes during pregnancy can be best understood by examining
each of these different aspects of skin structure. Where is the reference?

Pigmentation — Almost
all pregnant women develop some degree of increased skin pigmentation. This
usually occurs in discrete, localized areas and may be due to regional
differences in melanocyte density within the epidermis 1.
Occasionally, generalized hyperpigmentation occur with the increase in the level of melancyte
stimulating hormone (MSH) plasma levels, which occur in late gestation 4.

The most frequent cutaneous
pigmentary change is a darkening of the linea alba, which becomes the linea
nigra 5. The increased pigmentation may span from the pubic symphysis to the
xiphoid process, but usually reverts to its normal hypopigmented state
postpartum.

Striae distensae are a common
form of dermal scarring that appears on the skin as erythematous, violaceous,
or hypopigmented linear striations (reference). Synonyms include the terms striae, stretch
marks, and striae atrophicans. Striae gravidarum are striae dispense occurring
secondary to pregnancy. Where is the reference?

There are two main types of
striae gravidarum; striae
rubra and striae alba. Striae rubra are the earliest presentation of
striae gravidarum
and are characterized by an erythematous to violaceous color 6. Over time,
striae rubra evolve into striae alba, which appear hypopigmented, atrophic, and
scar-like. Common locations for striae gravidarum are the abdomen, breasts, medial upper arms,
hips, lower back, buttocks, and thighs 7.

Although typically asymptomatic,
striae gravidarum
may be disfiguring and psychologically distressing to patients 8. Various
topical and procedural modalities have been employed for the their treatment
9. 

Where is the correlation with episiotomy, perineal
tears and lacerations?

The aim of this study was to elicit the relation
between the occurrence of the striae and its severity during pregnancy with the
incidence of episiotomy, vaginal or perineal lacerations following delivery.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patients
and Methods

This
is a cross sectional observational multicentre study conducted in Kasr El Ainy
hospital, Cairo University, and Ain Shams hospital, Egypt, from to . The
study was approved and revised by “The Ethical Research Committee”
prior to its initials start.

Sample size was calculated based
on comparing two proportions from independent samples in a cross sectional
study using Chi test, the ?-error level was fixed at 0.05, the power was set at
80% and the intervention groups (case: control) ratio was set at 1.  The total sample that was calculated to be
included in the study was 413 pregnant mothers. Sample size calculation was
done using PS Power and Sample Size Calculations software, version 3.0.11 for
MS Windows (William D. Dupont and Walton D. Vanderbilt, USA) 10.

The study included pregnant
females, who were admitted in the maternity ward for delivery, and fulfilling
the following inclusion criteria; undergoing non –instrumental vaginal delivery
of a single, vertex, term fetus (completed 37 weeks of gestation to the end of
41 weeks) with expected fetal weight 2- 4 Kg. On the other hand, pregnant
females who did not fulfill the above-mentioned criteria or those who refused
to participate were excluded from the study.

Once the female agreed to
participate in the study, the study was fully explained to her and a written consent
was signed. The participating females underwent full history taking and general
examination including demographic criteria in the form of: age, gravidity and
parity, medical problems, previous deliveries, as well as measuring and recording
Body mass index (BMI).

Also, detailed obstetric
examination to confirm gestational age, fetal position and presentation, as
well as to determine the presence of any of the exclusion criteria.

On admission, it is the protocol
of our hospital to perform a transabdominal sonographic (TAS) scans using Voluson 730 Pro (GE, Fairfield, CT)
apparatus using the abdominal probe 2 – 5 MHz. Performing
the TAS is usually done to confirm the fetal number, position, and amount of
liquor, placental position as well as any abnormalities that may indicate
cesarean delivery. In this study, TAS scan was conducted by single sonographer
to eliminate inter-observer differences.

Then a single resident performed
the striae gravidarum(SG) assessment in all the participants.

The severity scoring of striae
gravidarum was observed and recorded using the numerical scoring system of
Atwal 11. This scoring system provides a rank based on observation of the
most commonly four areas in which the striae is observed (abdomen, hips,
buttocks, and breast) the scale comprises the following criteria; (a) the
number of striae gravidarum at each body site (0=no striae signs, 1=1-4 striae,
2=5-10 striae, 3=more than 10 striae) and (b) the color of the striae
gravidarum which ranges from pale to purple (0=no redness, 1=pink, 2=dark red,
3=purple). The final score for each body site, relating to number and color,
ranges from 0 to 6. Accordingly, the TSS (total striae score) for all four-body
sites ranges from 0 to 24. Consequently cording to the TSS score, women were
divided into 3 grades: a) mild those with TSS score up to 12, b) moderate with
TSS score between13-18 c) severe for females with TSS score more than 18.

The participating pregnant
females then underwent delivery by another resident who was blinded to the
striae grade. The vaginal, perineal tears and mediolateral episiotomies and
their extensions performed during the delivery were also recorded.

Statistical Analyses The data
were entered and analyzed using SPSS 15 (Chicago, IL). The independent
variables were SG scores at each body site; TSS, rise in BMI during pregnancy;
and neonatal birth weight (assessed as continuous variables). The outcome
measure was PT. Data are presented as means standard Deviations. Independent
sample t tests were used to compare the striae scores between women with and
without PT. Pearson correlation was performed to assess the association between
rise in BMI and TSS.

 

 

 

 

 

 

 

 

 

 

 

 

 

Results

A total of 534 pregnant females
attending the maternity ward for delivery were recruited in the study. 36
females refused to participate in the study. 32 females delivered by emergency
cesarean section. These 68 pregnant females were excluded from the study
leaving 466 females reaching the final analysis. This was illustrated in Figure
1.

Table 1 shows the demographic
criteria of the recruited pregnant females.

Considering the relation between
the different variables and the TSS is shown in table 2, and it revealed that the
incidence of episiotomy, vaginal and perineal lacerations increased
significantly with higher degrees of TSS.

Table 3 displayed the different
factors that can affect the incidence of perineal lacerations. It showed that
the TSS, the gestational age, EFW, and neonatal birth weight have significant
relation with the incidence of the perineal lacerations. There is also a
significant relation between vaginal laceration length and the incidence of
perineal lacerations.

 

 

 

 

 

 

 

 

 

 

Discussion:

This
observational study showed that the degree of TSS affects significantly the
incidence of episiotomy, vaginal and perineal lacerations. In other words
pregnant females with high TSS are more prone to have episiotomies, vaginal or
perineal lacerations.

By
analysing the different variables that can play a role in developing of
perineal lacerations, it was found that perineal lacerations are affected
significantly by the severity of TSS in addition to parity, gestational age and
expected fetal weight, fetal presentation, performing episiotomy or not, the
presence of and length of vaginal lacerations, and neonatal birth weight.
Although the deliveries were conducted by senior and junior staff, no
significant difference was observed in the incidence of perineal tears.

The
association between the striae and the perineal lacerations can be explained; as
the striae gravidarum (SG) may present as a sign of decreased skin
elasticity 12,13, this can actually explains the fact that the more severe
the TSS score, the more the incidence of episiotomy, vaginal and perineal
lacerations.

In spite the fact that decreased
skin elasticity has been proposed as a cause for perineal laceration, the
relation between theses two variables has not been established 14,15. In a study
conducted by Kapadia et al., 2014, there was significant correlation between
the degree of striae gravidarum and the perineal tears 10.  Also another study in 2010 concluded that
striae scores can be used as a predictor for perineal tears and should be
included as a part of the obstetric examination 16.

 

Other factors were found to have
significant association with perineal tears as primiparity, gestational age,
EFW, the neonatal birth weight as well as occiptioposterior position. A recent
review, that matched our results, performed a meta-analysis on the different
factors that predispose to perineal tears. Perineal tears were more common in
cases with high neonatal birth weights as well as abnormal cephalic presentation
as occiptoposterior 17. Another study in 2011 correlated the incidence of
severe perineal tears to primiparity, occiptoposterior and heavier birth weights,
which goes with our study 18.

The strength of this study lies
in being multicenter study, and the large number of patients. On the other
hand, the main limitation of this study wasbeing cross- sectional study;
performing a prospective study, in which the patients would be followed up from
the beginning of the pregnancy and to be able to correlate with another
different factors like the amount of weight gain during pregnancy, would have
been better, but unfortunately this is currently difficult to be performed as
the patients are usually not compliant to the regular antenatal care, so follow
up would be somehow difficult.

In conclusion, assessing the
striae degree prior to delivery can help in predicting the incidence of
episiotomy, vaginal and perineal lacerations, which subsequently would be
beneficial in counseling the pregnant females about the risk of developing such
tears during their deliveries.