Cleve Ziegler

Prospective study of intraabdominal adhesions among women of different races with or without keloids

OBJECTIVE We sought to evaluate postsurgical adhesions in women of different races with or without keloids. STUDY DESIGN This was a prospective study evaluating postsurgical adhesions after a cesarean delivery in 429 women with or without keloids. The outcome measures were the prevalence and extent of adhesions in women of different races with or without keloids. RESULTS There was no difference in the prevalence of adhesions and adhesion score in various sites among women of different races. Compared with whites (0.5%), keloids were significantly more common in African Americans (7.1%; P = .007; odds ratio, 16.5) and in Asians (5.2%; P = .02; odds ratio, 11.9). Women with keloids were found to have more dense adhesions between the uterus and the bladder (P = .028; 95% confidence interval, 0-12) and between the uterus and the anterior abdominal wall (P < .0001; 95% confidence interval, 8-12). CONCLUSION The prevalence and degree of postsurgical adhesions in women of different races are comparable. Women with keloids on the cesarean scar have increased adhesions between the uterus and the bladder and between the uterus and the abdominal wall.

Incidence, Indications, and Predictors of Adverse Outcomes of Postpartum Hysterectomies: 20-Year Experience in a Tertiary Care Centre

OBJECTIVE Postpartum hysterectomy is an uncommon yet serious obstetric procedure associated with maternal morbidity and mortality. The objectives of our study were to assess the incidence of and indications for PH and to identify predictors of massive hemorrhage and coagulopathy. METHODS We conducted a retrospective cohort study on all cases of PH performed at the Jewish General Hospital, McGill University, between 1992 and 2011. Data were collected from individual patient charts and logistics regression models were used to evaluate predictors of adverse events. RESULTS Over a 20-year study period, there were 76 938 live births and 67 postpartum hysterectomies for an overall incidence of 0.87/1000. Although overall PH rates increased over time predominantly because of increasing rates of planned PH for placental abnormalities, there was a decrease in unplanned emergency postpartum hysterectomies. The main indications for PH were abnormal placentation (64.2%) and postpartum hemorrhage (26.9%). In adjusted analysis, the risk of requiring massive blood transfusion was increased when PH was performed after vaginal delivery or Caesarean section (OR 102.1; 95% CI 4.22 to 2468) and in association with postpartum hemorrhage (OR 9.1; 95% CI 1.3 to 64.3). The risk of massive hemorrhage was lower if occlusive balloons were placed antenatally in the uterine arteries (OR 0.13; 95% CI 0.03 to 0.68) and if PH was performed by a dedicated experienced surgeon (OR 0.23; 95% CI 0.06 to 0.86). CONCLUSION Although overall rates of PH are increasing, antenatal recognition of placental pathologies have resulted in fewer postpartum hysterectomies being done as emergencies. The use of occlusive balloons in the uterine arteries and having the procedure performed by a dedicated surgeon skilled in performing postpartum hysterectomy can reduce overall serious morbidity.

Clinical relevance of intra-abdominal adhesions in cesarean delivery

The objective of this study was to evaluate the prevalence and extent of intra-abdominal adhesions at cesarean deliveries (CS) and their clinical relevance. We studied 490 cases of primary CS, 430 first repeat, and 106 cases of second or third repeat CS. Using a standard scoring system, the prevalence, extent, and consistency of adhesions were evaluated prospectively. We also examined the incision–delivery interval and the total operating time. At repeat CS, adhesions were found mainly between the uterus and the bladder or the abdominal wall. Dense adhesions to the bladder and to the abdominal wall were significantly more after ≥2 CSs (46.3% and 48.2%) than after one CS (29.8% and 25.6%). The adhesions on these areas were also more severe after ≥2 CSs than after one CS. There was a significant correlation between the adhesion score and the interval between the incision and delivery (r = 0.23, P < 0.0001) and the operating time (r = 0.26, P < 0.0001). CS leads to adhesion formation mainly between the uterus and the bladder and between the uterus and the anterior abdominal wall.