Atwal Striae Gravidarum Score for Prediction of Perineal Tears During Vaginal Delivery: A Cross- Sectional Study
Abstract
Objective: To evaluate the value of Atwal striae gravidarum (SG) score for prediction of occurrence of perineal tears (PT) during vaginal delivery.
Methods: A cross-sectional study conducted between October 2016 and April 2018 included all multiparous women presented in the active phase of labor. Assessment of SG score was done using Atwal score in the abdomen, hips, breasts and buttocks. According to the total striae score (TSS) women were classified into two groups; group (I): mild SG (TSS ≤12) and group (II) moderate/severe SG (TSS >12). The primary study outcome was the rate of PT in both groups.
Results: The study included 421 women; 188 in group I and 233 in group II. The rate of PT was significantly higher in group II than group I (56.2% vs. 3.2% respectively, p<0.001). Additionally, para-urethral, vaginal and cervical tears were more common in group II (p=0.029, 0.025 and 0.047 respectively). Additionally, we found significantly higher TSS among women with PT versus those without PT (17.07±3.56 vs. 7.93±6.94, p <0.001). Multivariate regression analysis revealed that the presence of abdominal striae and the TSS >12 were associated with increased risk of PT.
Conclusion: Assessment of Atwal SG score could precisely predict the occurrence of PT in multiparous women during vaginal delivery.
Keywords: Striae gravidarum; Perineal tears; Vaginal delivery; Atwal score
Introduction
Perineal trauma is common during vaginal delivery varied from minor superficial mucosal lacerations to major tears involving the musculature of the perineum and rectum [1]. It can lead to a numerous complication as hemorrhage, dyspareunia, perineal abscess with subsequent rectovaginal fistula and incontinence which have a major negative effect on physical, psychological aspects and women’s quality of life [2].
During vaginal delivery, the fetal head exerts considerable pressure on the vaginal and perineal tissues. This could lead to tissue tears even with a small baby and apparently easy delivery [3]. Others can deliver with intact perineum in spite of large babies or malpresentation.
Striae gravidarum (SG) are stretch marks occurred during pregnancy that may be an indicator of poor skin elasticity [4]. Women who does not have SG may have better skin elasticity and less liable to have vaginal or perineal tears during delivery [5]. SG is caused by changes in the structural connective tissue as a result of a hormonal elect on the alignment and reduced elastin and fibrillin in the dermis [6]. SG usually occurs on the hips, buttocks, abdomen, breasts, and thighs and usually appears after the 24th week of gestation [7]. The incidence of SG is variable ranges between 43% to 88% [8].
Scoring of SG severity was published using the numerical scoring system of Atwal [9]. This score provides a rank based on observation of four common areas of SG (abdomen, hips, buttocks, and breast). The final score for each body area ranges from 0 to 6 according to the number and color of SG. The total striae score (TSS) ranges from 0 to 24. Women having TSS score ≤12 indicated mild striae, TSS score (13-18) indicated moderate striae and TSS >18 indicated severe striae [9].
In a previous study by Halperin et al., 2010 reported a significant association between the degree of PT and severity of SG. Additionally, SG especially on the hips and breast predicted the occurrence of first- and second-degree PT [5].
Therefore, the aim of the present study is to determine the value of assessment of Atwal SG score in laboring women for prediction of the occurrence of PT during vaginal delivery.
Patients and Methods
The current study was a cross-sectional study conducted in a central hospital between October 2016 and April 2018. The Institutional ethical review board approved the study protocol and informed written consent was obtained from all participants after discussing the nature of the study.
Eligible participants
All multiparous women attended the reception unit of the hospital in the active phase of labor were invited to participate in the study if they met our inclusion criteria. We included women aged 18-40 years, has spontaneous onset of labor, singleton pregnancy, fetus with cephalic presentation at gestational age 37-40 weeks and estimated fetal weight by ultrasound (2500-4000gm). We excluded women with multiple pregnancy, scarred uterus, malpresentation, suspected fetal macrosomia, preterm labor, medical disorders as diabetes or hypertension and those refused to participate in the study.
Recruitment
A detailed history was taken from all women included age, parity, gestational age, residency, educational level, previous miscarriages, previous episiotomy, gestational weight gain and body mass index (BMI) was calculated for each participant.
Intervention
Inspection of the four body areas described in the Atwal SG score (abdomen, hips, buttocks, and breast) was done and the TSS was calculated for each woman [9]. The score includes the following criteria (a) the number of SG 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 SG 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 ranges from 0 to 24. Women having TSS score up to 12 were considered to be having mild SG, TSS score (13-18) indicated moderate SG and TSS more than 18were considered to be having severe SG.
According to the TSS, women were classified into two groups:
Group (I): women with no or mild SG (TSS ≤12)
Group (II): women with moderate or severe SG (TSS >12)
All study participants were followed until the second stage of labor using the portogram. All women were delivered by the same obstetrician through slow assisted delivery of fetal head with perineal support. Examination of the birth canal after delivery of the placenta with the active method was done. Any perineal tear was documented as regards the degree, location, number and length. The length of perineal tear was measured by a metal graduated and sterilized ruler. Presence of any other vaginal or cervical tears was recorded. Additionally, the neonatal data (Apgar score, weight, admission to pediatric intensive care unit) was recorded.
Study outcomes
The primary outcome was the difference in the rate of PT between both groups. Secondary outcomes included the rate of perineal tears according to each degree, number and length of perineal tears, the rate of para-urethral, vaginal and cervical tears in both groups.
Statistical analysis
Data were collected, tabulated, statistically analyzed by computer using SPSS version 22 (SPSS Inc., Chicago, IL), two types of statistics were done: Quantitative data were expressed as the mean, and standard deviation (SD). Qualitative data were expressed as frequencies and percentage. Normality of the quantitative variables was assessed using the Kolmogorov-Smirnov test. Chisquare (x2) and independent t-test were used to compare both groups if the data were normally distributed. Otherwise, Mann- Whitney and Fisher’s exact tests were used. A multivariate logistic regression model was performed for the predictors of occurrence of PT including, presence of SG at each body site, parity >3, BMI>30 Kg/m2, duration of second stage of labor >5 minutes, and TSS >12. P-value <0.05 was considered statistically significant.
Receiver operating characteristics (ROC) curve was performed to detect the best cut-off value for Atwal score for prediction of PT generally, and 3rd, 4th degree PT specifically. The best cut-off on the ROC curve has the highest true positive rate together with the lowest false positive rate.
Results
Five hundred twenty-three women were approached to participate in the study. We excluded 41 cases as they did not meet the inclusion criteria. The remaining 482 women were classified according to TSS into two groups: group (I) included 217 women with TSS ≤12 and group (II) included 265 women with TSS >12. Twenty-nine women in group (I) and 32 women in group (II) were excluded from the final analysis as they did not deliver vaginally. Therefore, 188 women in group (I) and 233 women in group (II) were included in the final analysis (Figure 1).
The mean age of the study participants was 26.26±4.6 years. The mean parity was 2.84±1.7 and the mean gestational age at inclusion was 38.31±1.52 weeks. SG were present in 88.1% of the study participants. The mean TSS of the whole participants was 10.91±7.41. Of the included 421 women, 50 women (11.9%) had no striae, while 138 (32.6%), 159 (37.8%) and 74 (17.7%) women had mild, moderate and severe striae, respectively. The most common site of SG was the abdomen (85.7%); other sites were hips (63.9%), buttocks (57.7%) and breasts (49.2%).
No statistically significant difference between the baseline characteristics of both study groups (Table 1). The duration of second stage was quite similar in both study groups (5.05±1.24 vs. 5.21±1.14 min, p=0.175). No difference between both study groups regarding the neonatal birth weight (p=0.945), Apgar score at 5 minutes (p=0.072), and the need for pediatric intensive care unit admission (p=0.307) (Table 1).
Indexing List of
Iris Publishers: https://medium.com/@irispublishers/what-is-the-indexing-list-of-iris-publishers-4ace353e4eee
Iris publishers google scholar citations: https://scholar.google.co.in/scholar?hl=en&as_sdt=0%2C5&q=irispublishers&btnG=
For More Information:https://irispublishers.com/wjgwh/fulltext/atwal-striae-gravidarum-score-for-prediction-of-perineal-tears-during-vaginal-delivery.ID.000587.php
No comments:
Post a Comment