ABSTRACT
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Aim: To call our acquaintance in supraumbilical cesarean deliveries in acutely and morbidly adipose patients (body accumulation basis > 35 kg/m2) with a abundant belly panniculus. Methods: A attendant abstraction in France amid January 2009 and May 2014. Every woman who underwent a cesarean commitment with a supraumbilical atrium was included through her agenda medical record. A chief doctor fabricated the accommodation for a supraumbilical bark atrium afterwards accurate assay of the patient’s anatomical conditions. Results: Twenty patients were included, for a absolute of 21 cesarean deliveries. Their beggarly analysis accumulation basis 50 (40 - 61.7). Nineteen of them (95.0%) had an belly panniculus in collapsed “apron” position. Twelve patients (57.1%) had a aching uterus. During the cesarean section, 14 (66.7%) had a segmentary hysterotomy. The average accessible time was 49 account (32 - 70). Four patients (19.1%) had a postpartum drain and 4 (19.1%) a postpartum communicable complication, none of which were severe. Conclusions: In this specific citizenry of acutely adipose women ability cesarean procedures, variations in analysis crave anniversary patient’s atrium best to be individualized. In women with a abundant panniculus the supraumbilical bark atrium seems to action an able acknowledgment to the peritoneal atrium and the lower uterine segment, accordingly acceptance to cautiously backpack out the procedure. However a -to-be abstraction on a beyond sample charcoal all-important to analyze this address to the classical cesarean procedure.
1. Introduction
Obesity has been authentic by the World Health Organization as a analysis accumulation basis (BMI = weight in kg/[height in cm]2) of 30 or added [1] . Its prevalence is accretion worldwide. In France, 15.0% of adults were adipose in 2012, and 4.3% were acutely so (BMI of added than 35), compared to 8.6% and 1.6% appropriately in 1997 [2] [3] . Adipose abundant women arise to accept added adverse abundance outcomes compared to women with a BMI inferior to 30: added risks of gestational hypertension, preeclampsia, gestational diabetes, anemia, consecration of labor, active delivery, cesarean section, and astringent postpartum drain [4] [5] [6] [7] . Moreover their aggravation amount increases with their BMI [4] [5] [8] [9] . Aback they accept a cesarean delivery, these women accept added postoperative complications compared to non-obese patients: postpartum drain (34.9% of massively adipose patients against 9.3% [10] ), parietal infections (adjusted OR = 4.8 [3.3 - 7.0] [6] , 30% of anguish infections [11] ) and endometritis (32.6% for massively adipose patients against 4.9% contrarily [6] [10] [11] ). It is why the gynecological affiliation has been developing addition surgical address to try to abate the aggravation risks, the accepted advertence actuality the axle subumbilical atrium [12] . These techniques alter from the bark atrium for both blazon and site: axle or vertical, subumbilical or supraumbilical [13] [14] [15] [16] . To our ability there is currently no accord on the surgical admission nor best of belly atrium in the adipose women ability cesarean delivery.
The cold of this abstraction was to call our acquaintance in managing cesarean deliveries in acutely adipose patients and to address complications accompanying to this accurate surgery.
2. Methods
We conducted a anecdotic and attendant abstraction in a universitary Hospital in Caen, France, amid January 2009 and May 2014. The Ethics Comity on Analysis in Obstetrics and Gynecology accustomed this abstraction (CEROG OBS 2016-06-23). Every woman who underwent a cesarean commitment with a supraumbilical atrium was included. They were articular through their agenda medical annal application the 4D software with the key?words “cesarean” and again “supraumbilical” amid women who had cesarean deliveries. Their characteristics were again collected: medical accomplishments (age, BMI afore the accepted abundance and at delivery, preexisting diabetes), accomplished obstetrical history (parity and accomplished cesarean commitment if multipara), abundance characteristics (gestational diabetes or preeclampsia), commitment (gestational age in gestational weeks (GW), adumbration of the cesarean section, peroperative contest and complications, continuance of operation, fetal bearing weight, Apgar account and affectionate postpartum characteristics (postoperative aggravation and its managing, ambiguous pregnancy).
The adumbration for a supraumbilical bark atrium was absitively by one out of three chief practitioners afterwards accurate assay of the patient: aback the accommodating was lying on her back, her belly panniculus would accept to be in the “apron” position, that is to say that the umbilicus was beneath the basic band formed by abutting the two antecedent aloft iliac spines (Figure 1). The decider did not charge to be the surgeon on the day of the delivery.
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3. Results
Twenty patients were included (Figure 2).
Table 1 shows our patients’ medical characteristics. Table 2 presents the abundance and delivery’s characteristics, and Table 3 the postpartum complications.
(a) (b)
Figure 1. Illustration of the adapted landmarks with a abundant panniculus. (a) Side angle [15] ; (b) Front perspective.
Table 1. Patients preexisting characteristics, N = 21 pregnancies for 20 patients N (%) for bifold and absolute variables, average (minimum-maximum) for connected variables.
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aHistory of accept dystocia and 4rth amount perineal laceration; bTear of the annular bond of the uterus.
Four patients (19.0%) had an emergency cesarean action (Table 2): three for astringent preeclampsia and one for abortion of consecration for gestational diabetes. Alone that closing had an intrapartum cesarean delivery, all the added were prelabor.
One of our patients had a additional cesarean commitment two years afterwards the aboriginal one. The aboriginal cesarean adumbration was gestational diabetes with suspicion of aloft fetal macrosomia, a narrowed abdomen (a computed tomography pelvimetry was performed because the patient’s acme was 1m50), and aberrant obesity. The surgeon did not accept any adversity during the additional supraumbilical operation, but the accommodating had a postoperative subcutaneous abscess advised by bounded antibacterial cares and did not charge addition surgery. The additional cesarean area was done application the aforementioned bark incision. Adhesions amid epiploic and the belly bank were removed with electric scalpel. An active exhaustion abstraction was adapted because of the ambit amid the fetal arch and the segmentary hysterotomy associated with the impossibility of operating chiral burden on the uterus due to the array of the affectionate belly wall. She had a postoperative ileus in the aboriginal postpartum period, and was adequate afterwards 48 hours with a nasogastric tube. Despite those complications, the accommodating declared herself to be annoyed with the procedures and is currently abundant for the third time. The time amid bark atrium and fetal abstraction seems a acceptable archetype to appraise the accessible difficulties and the average time in our abstraction was 9.5 account (range 4 - 24). The alone accessible aggravation was a breach of the annular bond of the uterus that bare a simple ligation.
However in the postoperative aeon four patients (19.1%) presented a postpartum drain (Table 3) that was chock-full with the administering of sulprostone (a Prostaglandin E2 analog recommended by the French National College of Gynecology and Obstetrics [17] ). Two (9.5%) patients had parietal communicable complications (one case of ad-lib reopening of the atrium of four cm on the seventh day and one parietal abscess-the one declared earlier-) and two (9.5%) presented an endometritis (one non-severe 12 canicule afterwards commitment and one that acquired a septicemia afterwards catchbasin shock due to Citrobacter Frundeii). None of them bare a additional anaplasty and alone the septicemic accommodating had to be rehospitalized for intravenous antibiotics.
Concerning our three cases of cesarean deliveries performed afore term: one took abode at 29 GW for astringent preeclampsia and intrauterine advance brake (the mother had preexisting hypertension), the additional at 33 GW for preeclampsia and a accomplished cesarean delivery, and the third one at 34 GW and 5 canicule for a accomplished history of intrauterine fetal afterlife at 35 GW, preexisting diabetes and a accomplished cesarean delivery.
4. Discussion
The patients in our abstraction had altered characteristics from the accepted citizenry of abundant women, as apparent by comparing them to the abstracts from the French National Survey of 2010 [18] : they were earlier (33.3% were over 35 years old against 22.9%), had added generally preexisting diabetes (38.1% against 0.5%) and were added generally multipara (81.0% against 72.3%). During their abundance they had added gestational diabetes (47.6% against 7.2%) and preeclampsia (14.3% against 2.8%). We had called a specific citizenry of women, and accordingly their administration had to be appropriate.
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There is currently no accord about this management. Medical abstract diverges in its methods and its conclusions, and is actual poor apropos this specific blazon of bark incision, as assured Tipton et al. in 2011 in their abstract analysis [19] . Houston and Raynor conducted a case-control abstraction in Atlanta (USA) from 1989 to 1995 comparing 15 women with a accomplished cesarean commitment with a vertical supraumbilical atrium to 54 women with a Pfannenstiel atrium (subumbilical low axle incision) [20] . They did not acquisition any cogent aberration amid the two groups’ complications (OR = 0.65 [0.12 - 3.06] for endometritis, OR = 1.25 [0.22 - 6.38] for anguish separation) but their BMI differed significantly, which was a aloft bias. Bell et al. additionally compared the outcomes afterwards cesarean deliveries with vertical sub or supraumbilical atrium (N = 41) to cesarean with low axle atrium (N = 383) in a attendant accomplice from 2004 to 2006 in Georgia (USA) [21] . Women who had a vertical bark atrium had added generally a vertical anatomical hysterotomy (65.9% against 7.3%, p < 0.001), added claret admixture (9.8% against 1.6%, p = 0.01) and anguish infections (14.6% against 7.6%, p = 0.03). However the two groups differed for the BMI and the age (the patients who had a vertical bark atrium were decidedly added and older), and the statistical affiliation abolished afterwards acclimation on age, gravidity, BMI, antecedent cesarean section, anesthesia blazon and gestational age at delivery. Marrs et al. additionally compared vertical to axle bark incisions in a abstraction including 3200 patients, but the axle were low subumbilical incisions, appropriately with added communicable complications (p < 0.01) [22] .
Gunatilake and Perlow did a analytical abstract analysis in 2011 apropos the administration of adipose patients, before, during and afterwards their abundance [23] . They declared and compared the altered possibilities of bark atrium aback a cesarean area was needed. They begin a college aggravation amount aback a vertical atrium was performed compared to a axle atrium (34.6% against 9.4%, p < 0.01). Bank in 2003 additionally begin an affiliation amid a vertical bark atrium and anguish aggravation (adjusted OR = 12.4 [3.9 - 39.3]) [24] . That is why they appropriate that the atrium armpit (subumbilical or supraumbilical) may be called according to the accommodating analysis [23] . This cessation was articular with our present approach.
Concerning women with a aching uterus we begin a lower amount of communicable complications compared to Chauhan et al.: they had 28% to 53% of communicable anguish depending on whether the cesarean took abode appropriately in prepartum or intrapartum, amid which 20% to 30% of endometritis and 8% to 23% of anguish infection [25] . This alterity may be explained by the aberration of our populations, abnormally because their beggarly BMI (respectively 57.5 ± 9.8 and 56.8 ± 8.4).
Tixier et al. led a anecdotic attendant abstraction in 2003-2008 in France in which they declared the two types of bark incisions to favor with astringent adipose patients (BMI > 40) [15] . The aim was to advance the admission to the lower uterine articulation by authoritative the atrium two finger-widths aloft the bump of the pubic symphysis. Accordingly 13 patients had a archetypal Pfannenstiel atrium and 5 had a axle supraumbilical incision, which they declared in detail for the aboriginal time. They had a low postoperative aggravation amount compared to the ahead cited studies: alone one case of postpartum drain amid 18 patients and 2 accessory hematomas of the belly bank with ad-lib resorption, but they do not specify if those complications happened afterwards a Pfannenstiel or a supraumbilical incision. Our abstraction differs from Tixier’s for assorted reasons. All of our patients had a supraumbilical atrium (21 cases against 5 of their patients). Our aggravation amount is higher, but few are severe. We would like to point out that our citizenry had altered drain and infection accident factors. For instance, the BMI differ: our patients beggarly BMI was 50.3 (range 40 - 61.7) against 47.7 (range 40.1 - 60.8), and up to 57.1% had a aching uterus against 38.9% of their patients. The band-aid would be to conduct a abstraction with acclimation on those confounders (age, BMI, parity, preexisting diabetes, preeclampsia and fetal macrosomia).
Our anatomical hysterotomy amount was college (Table 2). Amid those women, one had an emergency cesarean area at 29 GW for astringent preeclampsia and intrauterine advance restriction; in that specific bearings the lower uterine articulation was not developed abundant to do a segmentary hysterotomy. In the 6 added cases, the women had had a antecedent cesarean delivery; this implies that they will systematically accept an accepted cesarean area in any ambiguous abundance because of their two antecedent cesarean sections and astringent obesity. Knowing this the surgeon chose to do a anatomical hysterotomy to facilitate the fetus abstraction aback the admission to the lower uterine articulation was not easy. If the airiness of a anatomical hysterotomy and the uterine breach accident is able-bodied accepted (6% to 12%) [26] , this accident charcoal aberrant out of the activity contractions. They additionally were all added than 35 years old, and 4 of them were added than 38. Moreover because of common peritoneal adhesions, admission to the uterine bulk was simpler than to the lower segment. All these arguments fabricated the accommodation of a anatomical hysterotomy easier.
Regarding postoperative complications in adipose women compared to women with a accustomed BMI, Perlow et al. conducted a case-control abstraction amid 1987 and 1991 in California, USA, and compared 43 massively adipose women to 43 about called non-obese ascendancy patients [10] . The massively adipose accumulation was at decidedly added accident for emergency cesarean area (32.6% against 9.3%, p = 0.02), claret accident of added than 1000 ml (34.9% against 9.3%, p = 0.009) and postoperative endometritis (32.6% against 4.9%, p = 0.002). In allegory our aggravation amount is low (see Table 3), but our citizenry is different; for instance the patients in Perlow’s abstraction had to counterbalance added than 300 pounds (136.8 kg) to be included admitting 136 kg was our beggarly weight (range 100 - 187).
With 20 patients, this assignment is the better French abstraction that describes this blazon of specific atrium and its complications. Tixier et al. had absolutely 18 patients but alone 5 of them had a axle supraumbilical atrium [15] . Stirrat et al. presented a alternation of 10 morbidly adipose patients operated additionally with this address and appropriate that a suprapannus atrium may account their surgical and analgesic administration [27] . Nonetheless our assignment charcoal of baby size, afterwards controls to analyze them to in agreement of adverse outcomes. We may accept underestimated the cardinal of acceptable patients according to our criteria, because the accommodation to do this blazon of atrium was neither fabricated in an emergency bearings if the surgeon was not accomplished in this procedure, nor by anyone added than a chief doctor who was. However in our unit, the surgeons who accept performed this address would not go aback to axle subumbilical incisions for adipose women with an important panniculus: the easier admission to the peritoneal cavity, the surgeon’s abundance and the lower postoperative aggravation amount in this citizenry has assertive our team.
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