INTRODUCTION: skin pigmentation. This for the most part happens

INTRODUCTION:

The
general clinical appearance of skin is identified with pigmentation, glands,
vasculature, and connective tissue. Cutaneous changes amid pregnancy can be
best comprehended by looking at each of these diverse parts of skin structure
1.

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Pigmentation
— almost every single pregnant woman builds up some level of expanded skin
pigmentation. This for the most part happens in discrete, restricted areas and
might be because of provincial contrasts in melanocyte thickness inside the
epidermis 1. Occasionally, generalized hyperpigmentation occurs 2.

It
has been shown that the pigmentary changes occur early in pregnancy and before
the elevation in alpha-melancyte stimulating hormone (MSH) plasma levels, which
occur in late gestation 3.

The
most regular cutaneous pigmentary change is darkening of the linea alba, which
turns into the linea nigra 4. The expanded pigmentation may traverse from the
pubic symphysis to the xiphoid process, yet for the most part returns to its
typical hypopigmented state after delivery 5.

Striae
distensae are a common form of dermal scarring that appear on the skin as
erythematous, violaceous, or hypopigmented linear striations. Synonyms include
the terms striae, stretch marks, and striae atrophicans. Striae gravidarum are
striae dispense occurring secondary to pregnancy 6.

There
are two principle types of striae distensae, striae rubra and striae alba.
Striae rubra are the most punctual introduction of striae distensae and are
portrayed by an erythematous to violaceous shading 7. After some time, striae
rubra advance into striae alba, which seem hypopigmented, atrophic, and
scar-like. Basic areas for striae distensae are the abdomen, breasts, medial
upper arms, hips, lower back, buttocks, and thighs 8.

 Although typically asymptomatic, striae
distensae may be disfiguring causing psychological stress to patients 9. Different
topical and procedural modalities have been introduced for the treatment of
striae distensae 10.

Stretch
marks are thin and disorganized all over the body, fibrils are
trophoelastin-rich, which is likely due to uncoordinated synthesis 11.

Under
light microscopy, there is flattening of the epidermis with atrophy and loss of
rete ridges and increased glycosaminoglycans 12.

 The severity and progression of affected areas
varies from patient to another, which indicates a variable genetic
predisposition 13. Striae gravidarum is a sign for decreased skin elasticity which
in turn makes it more vulnerable to vaginal and perineal lacerations 14.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATIENTS
& METHODS:

This
cross-sectional multicentre observational study was carried out in Egypt over a
period of 5 months, on 534 pregnant females, who gave birth in Cairo, Ain Shams
Universities’ hospitals, in addition to a private hospital. Out of 534 women,
466 women who fulfilled the inclusion criteria reached the final analysis. The
ethical committee, National Research Centre endorsed its approval before
starting the study. Written consents have been signed by the patients before
enrolment in the study. Women who refused to participate
were excluded from the study.

Our inclusion criterion was; primiparous vaginal
delivery of a single, vertex, term fetus (completed 37 weeks of gestation to
the end of 41 weeks) with expected fetal weight 2- 4 Kg.

Women who had any of the following criteria were
excluded from the study; multiparous, need for instrumental delivery,
non-vertex presentation, EFW < 2kg or > 4 kg, preterm delivery < 37 weeks gestational age, fetal distress, shoulder dystocia. All participating females were subjected to full history taking including demographic criteria in the form of: age, gravidity, parity, any chronic medical problems, previous deliveries, as well as measuring and recording Body mass index (BMI). Obstetric examination was performed by a senior obstetrician to confirm gestational age, fetal position and presentation, as well as to determine the presence of any of the exclusion criteria. On admission, it is the protocol of our hospitals to perform a transabdominal sonographic (TAS) scans as many of the women included in the study never attended for any antenatal visits and did not have any antenatal notes. TAS was done to confirm the fetal number, presentation, position, amount of liquor, placental position and any abnormalities that may indicate cesarean delivery. TAS scan was performed by a senior sonographer using Voluson 730 Pro (GE, Fairfield, CT) machine using the abdominal probe 2 – 5 MHz. The severity scoring of striae gravidarum was observed by middle grade obstetrician and recorded using the numerical scoring system of Atwal 10. This scoring system provides a rank based on observation of the most commonly four areas in which the striae is observed (abdomen, hips, buttocks, and breast) the scale comprises the following criteria; (a) the number of striae gravidarum 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 striae gravidarum 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 (total striae score) for all four-body sites ranges from 0 to 24. Consequently, according to the TSS score, women were divided into 3 grades: a) mild: those with TSS score up to 12, b) moderate: with TSS score between 13-18 and  c) severe: for females with TSS score more than 18. Delivery was then performed by another obstetrician who was blinded to the striae grade. The extent of vaginal and perineal tears, in addition to  mediolateral episiotomies if needed during the delivery were also recorded. In our study, the sample size was calculated based on comparing two proportions from independent samples in a cross sectional study using Chi test, the ?-error level was fixed at 0.05, the power was set at 80% and the intervention groups (case: control) ratio was set at 1.  The total sample that was calculated to be included in the study was 413 pregnant mothers. Sample size calculation was done using PS Power and Sample Size Calculations software, version 3.0.11 for MS Windows (William D. Dupont and Walton D. Vanderbilt, USA) 11.   DATA ANALYSIS: Statistical Analyses The data were entered and analyzed using SPSS 15 (Chicago, IL). The independent variables were SG scores at each body site; TSS, rise in BMI during pregnancy; and neonatal birth weight (assessed as continuous variables). The outcome measure was PT. Data are presented as means standard Deviations. Independent sample t tests were used to compare the striae scores between women with and without PT. Pearson correlation was performed to assess the association between rise in BMI and TSS.   RESULTS: In the present study, we initially recruited a total number of 534 pregnant women attended to the labour ward for delivery and fulfilled the inclusion criteria. 36 women apologized on participating in the study, another 32 females delivered by emergency cesarean section for obstetric reasons. Those 68 women have been excluded from the study leaving 466 females reached the final analysis.   When analyzing the demographic criteria of the recruited pregnant females. The mean age, parity and weight of the participating women were 28 ± 6.4 years, 1.1 ± 1.23,and 82.4 ± 14.4 kg, respectively. The mean gestational age was 37.68 ± 2.3 weeks.(Table 1)   When correlating the incidence of vaginal and perineal lacerations and the need for episiotomy, to the total stria score (TSS),we found out that with higher TSS the incidence of vaginal and perineal lacerations and the need for episiotomy increased significantly (p<0.05).(table 2).   Table 3, displayed the different factors that can affect the incidence of perineal lacerations. It showed that the TSS, the gestational age, EFW, and neonatal birth weight have significant relation with the incidence of the perineal lacerations. There is also a significant relation between vaginal laceration length and the incidence of perineal lacerations (p<0.05).   DISCUSSION: According to our knowledge and after searching in the literature, we found some studies which have been done on the same topic. However, it is the first time to be observed on Egyptian females with different skin structure and appearance that may be influenced according to ethnicity. The results of our observational study showed that the degree of TSS affected significantly the incidence of vaginal and perineal lacerations that may occur during delivery and the increased need for episiotomy. In other words, pregnant females with high TSS are more prone to have vaginal or perineal lacerations, in addition to the need for episiotomy.   By analysing the different variables that can play a role in developing of perineal lacerations, it was found that perineal lacerations are affected significantly by the severity of TSS in addition to parity, gestational age and expected fetal weight, fetal presentation, performing episiotomy or not, the presence of and length of vaginal lacerations, and neonatal birth weight. Although the deliveries were conducted by senior and junior staff, this did not significantly affect the incidence of perineal tears.   The relationship between the striae and the perineal trauma could be clarified; as the striae gravidarum (SG) may present as an indication of diminished skin elasticity 17,18, this can actually explains the fact that the more severe the TSS score, the increased incidence for episiotomies, vaginal and perineal lacerations. In spite the fact that decreased skin elasticity has been proposed as a cause for perineal laceration, the relation between those two variables has not been established 19,20. In a study conducted by Kapadia et al., 2014, there was significant correlation between the degree of striae gravidarum and the perineal tears 15.  Also another study in 2010 concluded that striae scores can be used as a predictor for perineal tears and should be included as a part of the obstetric examination 21.   Different elements were found to have marked relationship with perineal tears as primiparity, gestational age, EFW, the neonatal birth weight and also occiptioposterior position. A recent review that coordinates with our outcomes carried out a meta-analysis on the distinctive factors that may predispose to perineal tears. Perineal tears were more typical in cases with high neonatal birth weights and abnormal cephalic position as occiptoposterior. 22.   Another study in 2011 correlated the incidence of severe perineal tears to primiparity, occiptoposterior and heavier birth weights, which goes with our study 23. The strength of this study lies in being multicenter study, and the large number of patients. On the other hand, the main limitation of this study was being cross- sectional observational study; performing a prospective study, in which the patients would be followed up from the beginning of the pregnancy and to be able to correlate with another different factors like the amount of weight gain during pregnancy, would have been better, but unfortunately this is currently difficult to be performed as the patients are usually not compliant to the regular antenatal care, so follow up would be somehow difficult. AKM,MK lso, observing the striae and recording the score was done subjectively by different obstetricians. In fact, it was not possible for s a single obstetrician to observe all those numbers participated in the study; especially it was done on three different sites. In conclusion, assessing the striae degree prior to delivery may help in predicting the occurrence of vaginal and perineal lacerations and need for episiotomy, which subsequently would be beneficial in counseling the pregnant females about the risk of developing such tears during their deliveries