Date Published: June 27, 2019
Publisher: Public Library of Science
Author(s): Michael Dias, Allyn Dick, Rebecca M. Reynolds, Marius Lahti-Pulkkinen, Fiona C. Denison, Andrew Sharp.
The optimal surgical approach for caesarean section is uncertain in women with very severe obesity (body mass index (BMI) >40kg/m2). We aimed to assess maternal and surgical predictors of surgical site skin infection (SSSI) in very severely obese women and to undertake an exploratory evaluation of clinical outcomes in women with a supra-panniculus transverse compared to an infra-panniculus transverse skin incision.
Using a retrospective cohort design, case-records were reviewed of very severely obese women with a singleton pregnancy delivered by caesarean between August 2011 and December 2015 (n = 453) in two maternity hospitals in Scotland. Logistic regression analysis was used to determine predictors for SSSI. Outcomes were compared between women who had a supra-panniculus transverse compared to infra-panniculus transverse skin incision.
Lower maternal age was predictive of SSSI, with current smoking status and longer wound open times being marginally significant. Maternal BMI, suture method and material demonstrated univariate associations with SSSI but were not independent predictors. Women with a supra-panniculus transverse skin incision were older (32.9 (4.4), vs. 30.6 (5.7), p = 0.002), had higher BMI (49.2 (7.1), vs. 43.3 (3.3), p<0.001), shorter gestation at delivery (days) (267.7 (14.9), vs. 274.8 (14.5), p<0.001) and higher prevalence of gestational diabetes mellitus (42.6% vs. 21.9%, p = 0.002). SSSI rates did not differ between supra-panniculus transverse (13/47; 27.7%) and infra-panniculus transverse (90/406; 22.2%; p = 0.395) skin incisions. SSSI rates are high in very severely obese women following caesarean section, regardless of location of skin incision.
Caesarean section (CS) rates are rising with it being the most common operation undertaken on women of reproductive age. In Scotland, it is estimated 31.1% of singleton births were delivered by CS in 2015/2016, with planned and emergency section rates being 14.3% and 16.9%, respectively . Rates of CS are higher in the obese, with the risk of elective and emergency CS increasing with maternal body mass index (BMI) [2–6].
We have demonstrated that SSSIs are common in women with severe obesity, and have identified some potentially modifiable risk factors. In an exploratory analysis, we also demonstrate that although a lower segment caesarean section was possible in every case of supra-panniculus transverse incisions, maternal intra- and post-operative morbidity was increased and there was no difference in SSSI rates compared to supra-panniculus transverse incisions. Given the high burden of post-operative morbidity, rising levels of maternal obesity, high CS rates and multifactorial nature of SSSIs, our study highlights the need for further research to reduce the burden of morbidity in women with Class III obesity undergoing caesarean delivery and patient experience in relation to different surgical approaches.