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ABSTRACT & COMMENTARY

Clinical Briefs

April 1, 2013
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By John C. Hobbins, MD, Professor of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, is Associate Editor for OB/GYN Clinical Alert.

Dr. Hobbins reports no financial relationships relevant to this field of study.

Synopsis: Three recent studies have shown that subcuticular closure with sutures, while adding more cesarean operative time, results in fewer wound disruptions than using staples; that discharge on post-op day 1 for planned cesarean section results in no greater morbidity and patient satisfaction than day 2 discharge; and that 17 alpha-hydroxyprogesterone caproate does not seem to decrease the rate of preterm birth in those with short cervices and no previous preterm deliveries.

During the past few months, there has been a pleth-ora of articles published with important clinical implications, and I have found it difficult to pick just one to review. Therefore, in an effort to pack in as many important nuggets as possible, I have resorted this month to a method I used a few years ago — “quick hits.” The first two studies involve an operative technique1 and length of stay2 for patients having cesarean sections, and the third study involves the use of 17 alpha-hydroxyprogesterone for the prevention of preterm birth.3

Study 1: Staples vs Suture Closure for Cesarean Section

Figueroa et al compared outcomes in 390 patients randomized to either staples (n = 190) or subcutical sutures (n = 200) for skin closure at the time of cesarean section.1 Outcomes were evaluated at the time of discharge (3-4 days post-op) and again at the postpartum visit (4-6 weeks post-surgery).

The staples group had a 7.1% incidence of wound disruption and/or infection at time of discharge vs 0.5% for the absorbable sutures, and 14.5% vs 4.9% at 4-6 weeks post-op, respectively. Average operative time was increased by 10 minutes for suture closure (58 minutes vs 48 minutes) but there were no differences in patient satisfaction, pain perception, or “cosmesis score.”

Commentary

Quite simply, using staples cuts operative time by 10 minutes, but comes with some costs. There was a 14-fold increase in wound morbidity at the time of discharge and a 3-fold increase at 4 to 6 weeks postoperatively in the staple group. All other factors were essentially the same, including the cosmesis score, but I don’t understand how an infected or disrupted scar can be as pretty as an unaffected one.

Study 2: Hospital Stays After Planned Cesarean Sections

A group from Malaya addressed the emerging practice of early discharge after planned cesarean.2 These investigators compared outcomes after randomizing women to discharge on postoperative day 1 (n = 142) or postoperative day 2 (n = 148). The authors were interested in a variety of outcome variables but focused primarily on patient satisfaction and the desire/ability to breastfeed exclusively through 6 weeks postpartum.

The results showed that both groups had a high satisfaction rate (85%) and identical rates of continued breastfeeding (44%). In addition, there were no differences in maternal morbidities.

Commentary

When most of us were born, our mothers generally spent at least 1 week in the hospital following delivery. However, over the last 3 decades, post-op hospital stays have decreased appreciably. For example, in 1975 in England, 68% of patients who had cesarean sections stayed in the hospital for 3 days or more. This decreased to a point where less than 10% of those having a cesarean section in 2011 stayed in the hospital for 3 or more days.4 Similar trends have occurred in the United States, where cost is a motive for early discharge. However, there also is another benefit of shorter hospitalizations. One recent study5 shows that during an average hospital stay for medical patients (not even those having surgery), there is a 5.5% risk of adverse drug reactions and 17.6% chance of being infected by hospital-borne pathogens.6 For every extra hospital day, the rates of the above problems rise by 0.5% and 1.6%, respectively.

To be fair, the Malaysian population may not represent a typical U.S. sampling, since the Malaysian mothers tended to go directly from the hospital to their parents’ homes, where there was family help available for the post-op patients. Nevertheless, this study did not show that outcomes and patient acceptability suffered from discharge only 1 day after cesarean section.

Study 3: 17 Alpha-hydroxyprogesterone Caproate and Preterm Birth in Patients with Short Cervices

In 2003, a sentinel study emerged suggesting that weekly intramuscular injections of 17 alpha-hydroxyprogesterone caproate (17P) significantly decreased the rate of early delivery in patients with a history of preterm birth (PTB).7 Later, some studies surfaced showing a possible benefit of vaginal progesterone in those patients with a short cervix, with and without a history of PTB.8,9 These last studies highlighted the potential of universal screening with ultrasound for cervical length (CL). Based on these studies, there is debate as to the inferiority or superiority of vaginal vs intramuscular administration.

To address this question, Grobman et al conducted a multicenter (NICHD network) randomized trial in which 327 nulliparous patients with CLs of < 3 cm were given 17P and another 320 patients with short CLs were randomized to placebo.3 The risk of PTB at less than 37 weeks was 25.1% vs 24.2%, respectively, and no significant differences were noted in adverse composite neonatal outcome (7% vs 9.1%) — thus showing no clear benefit of 17P in this group of patients.

Commentary

It is still unclear whether the dissimilar results in previous studies were due to differences in the chemical makeup of the compounds or the route of delivery. This study does not support using 17P to treat patients without a history of PTB but with short cervices. Interestingly, some have assumed that 17P is a similar compound to, if not an identical twin of, vaginal progesterone preparations. However, it is not — 17P is less like a twin and more like a distant cousin of natural progesterone. Although controversial, the Hassan study9 has galvanized a movement toward universal screening for PTB with transvaginal sonography. However, based on Grobman’s data,3 this recommendation would never gain clinical traction if 17P was the only option for PTB prevention since 17P did not show benefit. Time and time again, one study does not tell the whole story. Grobman’s study3 and the recent vaginal progesterone study9 in singletons with short cervices will need to be repeated before expensive and ambitious diagnostic and therapeutic methods are universally applied to all pregnant patients.

References

  1. Figueroa D, et al. Surgical staples or subcuticular suture for skin closure after cesarean delivery: A randomized controlled trial. Obstet Gynecol 2013;121:33-38.
  2. Chiong Tan P, et al. Hospital discharge on the first compared with the second day after a planned cesarean delivery: A randomized controlled trial. Obstet Gynecol 2013;120:1273-1282.
  3. Grobman WA, et al. 17 alpha-hydroxyprogesterone caproate to prevent prematurity in nulliparas with cervical length less than 30 mm. Am J Obstet Gynecol 2012;207:390. e1-8.
  4. Caritis SN, et al. Relationship between 17-hydroxyprogesterone caproate concentrations and gestational age at delivery in twin gestation. Am J Obstet Gynecol 2012;207:396.
  5. NHS. The Information Centre for Health and Social Care. NHS Maternity Statistics, England 2010-2011. Available at: http://www.ic.nhs.uk/pubs/maternity1011. Accessed Feb. 23, 2013.
  6. Hauck K, Zhao X. How dangerous is a day in the hospital? A model of adverse events and length of stay for medical inpatients. Med Care 2011;49:1068-1075.
  7. Meis PJ, et al. Prevention of recurrent preterm delivery by 17 alpha-hydroxyprogesterone caproate. N Engl J Med 2003;348:2379-2385.
  8. Fonseca EB, et al. Progesterone and the risk of preterm birth among women with a short cervix. N Engl J Med 2007;357:462-469.
  9. Hassan SS, et al. Vaginal progesterone reduces the rate of preterm birth in women with sonographic short cervix: A multicenter, randomized, double-blind, placebo-controlled trial. Ultrasound Obstet Gynecol 2011;38:18-31.