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888: Continuous versus Interrupted subcutaneous tissue closure during

cesarean delivery

Article  in  American Journal of Obstetrics and Gynecology · January 2020

DOI: 10.1016/j.ajog.2019.11.901

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Roy Lauterbach Dana Vitner

Rambam Medical Center University of Toronto
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Poster Session IV
888 Continuous versus Interrupted subcutaneous
tissue closure during cesarean delivery
Roy Lauterbach1, Dana Vitner1, Chen Ben David1,
Gal Bachar1, Yuval Ginsberg2, Nadir Ganem1, Ron Beloosesky1,
Zeev Weiner1, Yaniv Zipori3
1
Rambam Health Care Campus, Haifa, Israel, 2Rambam Healthcare Campus,
Haifa, Israel, 3Rambam Health Care Campus, Binyamina, Israel
OBJECTIVE: Interrupted Subcutaneous Tissue Closure (i-STC) during
cesarean delivery (CD) reduces risk of wound disruption in women
with fat thickness greater than 2 cm. It does not alter the incidence
of wound infection. We aimed to compare the effects of the standard
i-STC to an alternative technique, namely the Continuous Subcu-
taneous Tissue Closure (c-STC).
STUDY DESIGN: A retrospective study between 2008-2018. Group
allocation was based on type of STC. Eligible for analysis were term
singleton pregnancies who underwent either elective or emergent
CD. Metal staple skin closure was the rule. Performance of i-STC/c-
STC was up to surgeon discretion. We excluded women with sus-
pected infectious morbidity prior to CD. The primary outcome was
surgical site infection (SSI) rate, defined as localized tenderness with
or without maternal fever >38 C, and at least one of the following:
purulent drainage from the superficial incision, culture positive or
incision opened by the surgeon. Secondary outcome included re-
admission rates due to suspected SSI within 90 days.
RESULTS: Maternal characteristics (age, BMI, gestational age at de-
livery and number of previous CDs) were comparable between
groups. The final analysis included 6,281 women. A total of 4,988
(79.4%) underwent elective CD, of which 1,867 (37.4%) had c-STC.
Of the 1,293 that underwent emergent CD, 592 (45.8%) had c-STC.
The rate of SSI was significantly lower after c-STC compared to i-
STC in both elective (2.7% vs. 4.5%, P¼0.031) and emergent CD
(3.2% vs. 5.4%, P¼0.036). Similarly, re-admission rates due to
suspected SSI were also significantly lower after c-STC compared to
i-STC in both elective (0.9% vs. 1.7%, P¼0.0025) and emergent CD
(1.5% vs. 3.2%, P< 0.0001). When stratified into nulliparous or
multiparous, significant findings were in favor of the c-STC group as
well.
CONCLUSION: c-STC appears to yield a lower rate of CD SSI com-
plications compared to i-STC. This might imply that c-STC is su-
perior to i-STC in prevention of surgical scar complications. A
prospective randomized controlled trial is currently being launched
to validate these findings.
S554 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2020
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ajog.org
890 Best gestational diabetes therapy to reduce
adverse maternal outcomes. A network
meta-analysis
Julio Mateus1, Luis Sanchez Ramos2, Kathryn Gonzalez3,
Melanie Mitta4, Jared Roeckner5
1
Atrium Health, Charlotte, NC, 2University of Florida Health Science Center,
Jacksonville, FL, 3University of Florida Health Science, Jacksonville, FL, 4UF
Health, Jacksonville, FL, 5University of South Florida Morsano College of
Medicine, Tampa, FL
OBJECTIVE: Although insulin is considered the first line therapy for
gestational diabetes mellitus (GDM), the use oral hypoglycemic
agents is increasing. Our objective was to compare pre-selected
adverse maternal outcomes in women with GDM treated
pharmacologically.
STUDY DESIGN: This is a systematic review and network meta-
analysis of randomized controlled trials (RCTs) published until
May 2019 of women treated for GDM comparing: 1) insulin
versus a single oral agent, 2) single oral agent versus another
single oral agent, or 3) any therapy combination. Pre-specified
maternal outcomes were hypertensive disorders of pregnancy
(HDOP) defined as preeclampsia or gestational hypertension,
primary cesarean delivery, and spontaneous preterm delivery
(SPTB) < 37 0/7 weeks. Glycemic control assessed by HbA1c
levels prior to delivery was evaluated. A random-effects network
meta-analysis was conducted within a frequentist setting to es-
timate direct and indirect comparisons of treatments in selected
trials employingStata SE version 15.0; (Stata Corp College Sta-
tion, TX). Treatments were ranked based on the estimated
probability of being the most and least effective.
RESULTS: A total of 30 RCTs including 5,299 women were selected
for analyses. HDOP was significantly lower in women treated
with metformin versus insulin (odds ratio (OR) 0.67; 95%
confidence interval (CI); 0.50, 0.90). Metformin with insulin
resulted in the best treatment choice to reduce HDOP (84%).
Insulin was significantly better than metformin to reduce SPTB
< 37 0/7 weeks (OR 0.69; 95% CI; 0.50, 0.90) and was the best
treatment choice for this outcome (87%). Primary cesarean de-
livery rates were not significantly different among therapy groups
(Table). HbA1c prior to delivery did not differ significantly
across the studied treatments. Metformin favored reduction of
HBA1c levels, ranking first among all (63.1%).
CONCLUSION: Metformin combined with insulin and insulin alone
were the best choices to reduce HDOP and SPTB < 37 0/7 weeks,
respectively. A single or a combined therapy was not consistently
superior across studied maternal outcomes.