10.5826/dpc.1303a175
Introduction: Alterations in collagen subtypes and matrix can potentially cause fluid loss in surgery which are important in terms of liqud loss.
Objectives: The study aimed to analyze stria gravidarum (SG) and its severity in pregnant who had undergone cesarean section (CS) and to evaluate surgical fluid loss (SFL) that occurred during CS operation.
Methods: The research was designed as a prospective clinical cohort study to compare the amount of SFL in the second cesarean section with the severity of SG at 34-37 weeks pregnant (n:308). The severity of SG was evaluated in the preoperative period using the Davey scoring. All patients were defined none, mild stria and severe stria. The SFL was calculated by weighing the pre-and post-operative weights of the sponges.
Results: The weight gain (p=0,008) and BMI (p=0,017) gradually increased toward severe SG. In correlation analysis of SFL, a positive correlation was found with Davey (r=0.791; p=0.0001), weight gained during pregnancy (r=0.328;p=0.0001), BMI (r=0.453;p=0.001) and newborn’s weight (r=0.139;p=0.003). In the ROC for the predictability of SG severity on SFL, severe SG showed a potential for SFL with %95.1 specificity and %93.2 sensitivity at 791 cut-offs (Area Under the Curve:0,987; p=0.00001; %95 Confidence Interval: 0.977-0.997).
Conclusion: The SG severity and SFL showed a very strong relationship, which was a very important finding that would affect the approach of the surgeons to the patients with SG in terms of fluid loss in CS.
text/xml
2160-9381
2799
en
Tufan Arslanca
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Davey score
Can Stria Gravidarum Predict Surgical Fluid Loss in Cesarean Section?
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-07-31
2022-08-31
2023-07-31
2023-08-24
e2023175
Dermatol Pract Concept
Introduction: Alterations in collagen subtypes and matrix can potentially cause fluid loss in surgery which are important in terms of liqud loss.
Objectives: The study aimed to analyze stria gravidarum (SG) and its severity in pregnant who had undergone cesarean section (CS) and to evaluate surgical fluid loss (SFL) that occurred during CS operation.
Methods: The research was designed as a prospective clinical cohort study to compare the amount of SFL in the second cesarean section with the severity of SG at 34-37 weeks pregnant (n:308). The severity of SG was evaluated in the preoperative period using the Davey scoring. All patients were defined none, mild stria and severe stria. The SFL was calculated by weighing the pre-and post-operative weights of the sponges.
Results: The weight gain (p=0,008) and BMI (p=0,017) gradually increased toward severe SG. In correlation analysis of SFL, a positive correlation was found with Davey (r=0.791; p=0.0001), weight gained during pregnancy (r=0.328;p=0.0001), BMI (r=0.453;p=0.001) and newborn’s weight (r=0.139;p=0.003). In the ROC for the predictability of SG severity on SFL, severe SG showed a potential for SFL with %95.1 specificity and %93.2 sensitivity at 791 cut-offs (Area Under the Curve:0,987; p=0.00001; %95 Confidence Interval: 0.977-0.997).
Conclusion: The SG severity and SFL showed a very strong relationship, which was a very important finding that would affect the approach of the surgeons to the patients with SG in terms of fluid loss in CS.
Tufan Arslanca
2023/07/31
10.5826/dpc.1303a175
e2023175
Department of Gynecologic Oncology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
2160-9381
Davey score
en
e2023175
Xu J, Rodriguez D, Petitclerc E, et al. Proteolytic exposure of a cryptic site within collagen type IV is required for angiogenesis and tumor growth in vivo. J Cell Biol. 2001;154(5):1069-1079. DOI: 10.1083/jcb.200103111. PMID: 11535623.PMCID: PMC2196184.
Can Stria Gravidarum Predict Surgical Fluid Loss in Cesarean Section?
https://dpcj.org/index.php/dpc/article/download/2799/2190
    Can Stria Gravidarum Predict Surgical Fluid Loss
                 in Cesarean Section?
       Seyma Banu Arslanca1, Ozgur Sahin2, Ugurkan Erkayıran3, Zehra Ozturk Basarır4,
                                     Tufan Arslanca4


1 Department of Obstetrics and Gynecology, Etlik Zübeyde Hanım Maternity and Women’s Health Teaching and Research Hospital, Ankara,
  Turkey
2 Department of Obstetrics and Gynecology, Canakkale State Hospital, Canakkale Turkey
3 Department of Obstetrics and Gynecology, Sutcu Imam University, Faculty of Medicine, Kahramanmaras, Turkey
4 Department of Gynecologic Oncology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey



Key words: Stria gravidarum, surgical fluid loss, cesarean section, Davey score
Citation: Arslanca SB, Sahin O, Erkayıran U, Basarır ZO, Arslanca T. Can Stria Gravidarum Predict Surgical Fluid Loss in Cesarean
Section? Dermatol Pract Concept. 2023;13(3):e2023175. DOI: https://doi.org/10.5826/dpc.1303a175
Accepted: November 7, 2022; Published: July 2023
Copyright: ©2023 Arslanca et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Tufan Arslanca, Department of Gynecologic Oncology, Ankara City Hospital, University of Health Sciences,
Ankara, Turkey. ORCID:0000-0001-9686-1603 E-mail: drtufanarslanca@hotmail.com




  ABSTRACT             Introduction: Alterations in collagen subtypes and matrix can potentially cause fluid loss in surgery
                       which is important in terms of liquid loss.
                       Objectives: The study aimed to analyze stria gravidarum (SG) and its severity in pregnant women
                       who had undergone cesarean section (CS) and to evaluate surgical fluid loss (SFL) that occurred
                       during CS operation.
                       Methods: The research was designed as a prospective clinical cohort study to compare the amount
                       of SFL in the second cesarean section with the severity of SG at 34-37 weeks pregnant (N 308). The
                       severity of SG was evaluated in the preoperative period using the Davey scoring. All patients were de-
                       fined none, mild stria and severe stria. The SFL was calculated by weighing the pre-and post-operative
                       weights of the sponges.
                       Results: The weight gain (P = 0.008) and body mass index (BMI, P = 0.017) gradually increased to-
                       ward severe SG. In correlation analysis of SFL, a positive correlation was found with Davey (r=0.791;
                       P = 0.0001), weight gained during pregnancy (r=0.328; P = 0.0001), BMI (r=0.453; P = 0.001) and
                       newborn weight (r=0.139; P = 0.003). In the receiver operating characteristic for the predictability of
                       SG severity on SFL, severe SG showed a potential for SFL with 95.1% specificity and 93.2% sensitiv-
                       ity at 791 cut-offs (area under the curve:0.987; P = 0.00001; 95% confidence interval: 0.977-0.997).




Original Article | Dermatol Pract Concept. 2023;13(3):e2023175                                                                      1
                      Conclusions: The SG severity and SFL showed a very strong relationship, which was a very important
                      finding that would affect the approach of the surgeons to the patients with SG in terms of fluid loss
                      in CS.




Introduction                                                         pregnant women who had undergone cesarean section (CS)
                                                                     and to evaluate the relationship of these values with the
As a result of immunological, metabolic, endocrine, and              surgical fluid loss (SFL) that occurred during CS operation.
vascular changes that occur during pregnancy, various phys-          Thus, we focused to understand the relationship between the
iological and pathological processes occur in the skin and           severity of SG and the amount of SFL during the CS.
skin appendages of the pregnant woman [1,2]. Among the
physiological skin changes seen in pregnant women such as
weight gain [3], stria gravidarum (SG) is considered to be the       Methods
most common skin change [4]. After birth, the skin color is
                                                                     Study Design
characterized by bands that turn into hypopigmented, atro-
                                                                     The study was designed as a prospective clinical cohort study
phic lines, and appear on the abdomen, thighs, distal fem-
                                                                     to compare the amount of SFL in the second cesarean section
oral areas, inguinal region, and breasts after an average of
                                                                     with the severity of SG in 34-37 weeks pregnant women. The
24 weeks of gestation [2,5]. These lesions, whose exact cause
                                                                     study included healthy pregnant women over the age of 18
is unknown, are thought to develop as a result of connective
                                                                     who gave birth to a single newborn in their second CS at the
tissue changes such as a decrease in the amount of elastin
                                                                     Medical Center between 2020 and 2022. The study was ap-
and fibrillin in the dermis [6,7]. After birth, it is less visible
                                                                     proved by the review board of the institution (14.10.2022-
with a pale and cream-colored, atrophic appearance over
                                                                     07-363) and conducted following the Helsinki declaration,
time, but it does not disappear completely [8,9].
                                                                     a set of ethical principles regarding human experimentation.
    Although striae are not a serious condition that will risk
                                                                     All the participants read and signed the informed consent
health, they can cause complaints such as itching and burn on
                                                                     about the study.
the skin, and these physical changes can cause serious anx-
iety in pregnant women [10]. Local retinoic acids, glycolic
                                                                     Study Participants
acid, and vitamin C may be beneficial after pregnancy [11].
                                                                     All pregnant women who attended the hospital and were
Benefiting from these supplements is one of the strongest in-
                                                                     scheduled for CS were invited to enroll in the study. Inclu-
dications of how critical a collagen deficiency or disorder
                                                                     sion criteria were to be admitted for the second cesarean sec-
plays in SG [12,14]. Collagen is not only the crucial com-
                                                                     tion with the severity of SG in 34-37 weeks pregnant women
ponent of the extracellular-matrix, maintaining the dermis
                                                                     who had a history of only one cesarean section. Reluctance
structure but also an important molecule for coagulation
                                                                     to participate in the study, not meeting the admission crite-
systems [15-17]. Although the formation of the vascular tube
                                                                     ria, having a chronic disease, and having any complications
takes place in a polymerized 3D collagen lattice, endothe-
                                                                     in the previous cesarean section were accepted as exclusion
lial cells cannot be organized into capillary-like structures
                                                                     criteria. In addition to 7 women who were not willing to
on a hard plastic surface [18]. It is unclear how damage to
                                                                     participate in the study for various personal reasons, 42 peo-
the collagen matrix triggers endothelial cell organization in
                                                                     ple with a midline incision, suspected preoperative placenta
a vascular network and what factor might be involved. Cell-
                                                                     accreta, using corticosteroids, history of abdominopelvic
to-cell interactions in the vascular structure are essential for
                                                                     surgery and/or wound infection, endometriosis or pelvic in-
the endothelial cell organization to transform into a luminal
                                                                     flammatory disease were excluded from the study.
structure and may be associated with SG due to altered col-
lagen fibers and a collagen matrix [19].
                                                                     Stria-Davey Scoring and Groups
                                                                     For study planning, one of the researchers consulted all eli-
Objectives
                                                                     gible participants to obtain detailed anamnesis; CS history,
We acknowledged that alterations in collagen subtypes and            age, body mass index, gestational age, parity, previous mis-
matrix can potentially cause fluid loss and this issue has not       carriage, etc. The severity of SG was evaluated in the pre-
been investigated in terms of SG and its severity. The pres-         operative period using the four body regions (abdominal,
ent study aimed to analyze the SG data and its severity in           hip, hip, and breast) where SG is most common and using



2                                                                        Original Article | Dermatol Pract Concept. 2023;13(3):e2023175
the Davey scoring system. The abdomen was divided into            meeting the inclusion/exclusion criteria. The 308 pregnant
4-quadrants concerning a line drawn horizontally from             were defined by Davey score into three subgroups: group-I
the midline and the navel, and each quadrant was given a          included 71 as none, group II included 107 as mild, and
score: score 0=clear skin, score 1=moderate (1–3), and score      group III included 130 women as severe. The mean age was
2=many striae (4 and more). According to this calculation,        28.7± 6.07 years and did not differ for groups (P = 0.566).
the scores of all four quadrants were added together to ob-       The weight gain (P = 0.008) and body mass index (BMI,
tain the total, and patients with none (score 0) were defined     P = 0.017) gradually increased toward severe SG. H
                                                                                                                   ­ emoglobin
as the group I, mild (score1-2) were defined as II and severe     (pre/postoperative), platelet, PT, aPTT, AST, ALT, BUN,
(score 3-8) were defined as III.                                  ­creatinine, and fibrinogen were similar for groups. There
                                                                  was no significant difference in the baseline characteristics
C/S Operation and SFL Amount                                      of both study groups, as seen in Table 1.
                                                                      In the correlation analysis performed with the amount of
All CS included in the study was performed and the data
                                                                  SFL, a positive correlation was found with Davey (r=0.791;
were recorded by two experienced residents and blinded to
                                                                  P = 0.0001), weight gained during pregnancy (r=0.328;
the results of the Davey score assessment. Surgeons were
                                                                  P = 0.0001), BMI (r=0.453; P = 0.001) and newborn weight
asked to measure and report the amount of SFL after per-
                                                                  (r=0.139; P = 0.003). Other parameters we analyzed did not
forming the surgery. They calculated the amount of SFL by
                                                                  show a significant relationship with the SFL. The stepwise
weighing the pre-and post-operative weights of the sponges
                                                                  linear regression analysis of SFL showed Davey score-SG se-
we used in the cesarean section in the operating room and
                                                                  verity as the most dominant parameter (62.2±3.3; beta:0.67,
looking at the hemoglobin difference. We used sponges af-
                                                                  P = 0.0001, adjusted R2= 0.68) affecting its linearity as seen
ter the delivery of the baby and placenta and thus, excluded
                                                                  in Table 2. BMI, ALT, weight gain, age, and creatine were
amnion and bleeding due to c/s. In addition, the amount of
                                                                  the other strongest parameters effective over SFL after SG
blood measured with sponge was considered to be insig-
                                                                  severity.
nificant, since there was no difference at preoperative and
                                                                      In the ROC analysis, we did for the predictability of SG
postoperative values of the hemoglobin and hematocrit. In
                                                                  severity on SFL, severe SG showed a predictive potential for
this way, the weight difference between sponges reflects the
                                                                  SFL with 95.1% specificity and 93.2% sensitivity at 791 cut-
amount of SFL.
                                                                  off value (area under the curve:0.987; P = 0.00001; 95%
                                                                  confidence interval: 0.977-0.997). BMI and delta hemoglo-
Statistical Analysis
                                                                  bin were also analyzed for the predictability of SG severity,
After the data were collected, they were turned into an excel     as seen in Figure 1. Although the delta hemoglobin did not
spreadsheet and the data were transferred to SPSS©Statistics      predict the SG severity (P = 0.696), the BMI showed a po-
v22 (IBM© Corp.) and analyzed with proper methods. While          tential for it (area under the curve:0.744; P = 0.008; 95%
quantitative data were presented as mean and standard devi-       confidence interval: 0.689-0.798).
ation, qualitative data were presented as frequency and per-
centage. The Mann-Whitney test compared the Skewed data
while the unpaired t-test evaluated the normally distributed
                                                                  Conclusions
quantitative data such as SFL amount. Categorical data were       The present research assessed stria severity in pregnant
compared using the chi-square test or Fisher exact test if ap-    women with CS and its relationship with the amount of
propriate. Correlation analysis of the amount of SFL and          SFL that occurred during CS operation. Although the dif-
severity was performed in the groups determined according         ference in punch weights before and after the operation was
to the Davey score. In addition, we performed a stepwise lin-     inconsistent with blood parameters indicating the bleeding
ear regression model for predictors. The receiver operating       status, the SG severity and the fluid loss measured during the
characteristics (ROC) curve was constructed to determine          operation showed a very strong relationship, which was a
the best cut-off value for the amount of SFL and SG sever-        very important finding that would affect the approach of the
ity diagnostic fit. The best cut-off in the ROC curve has the     surgeons to the patients with SG in terms of fluid loss in CS.
highest true positive rate along with the lowest false positive       The emergence of SG in pregnant individuals occurs as
rate. A P-value less than 0.05 was considered significant.        a result of pathological and histological changes as a result
                                                                  of mechanical tissue tension, mast cell degranulation due

Results                                                           to elastolysis in the mid-dermis, and macrophage stimula-
                                                                  tion [7,17]. Gradual changes occur and collagen, elastin,
Three hundred fifty-seven women were evaluated to partic-         and fibrillin fibers are markedly reduced. As the epidermis
ipate and 49 cases did not join the present study due to not      thins and flattens, the distance between the collagen bundles



Original Article | Dermatol Pract Concept. 2023;13(3):e2023175                                                                3
                              Table 1. Demographics and clinical details of the participants.
                  Variables                      None                        Mild                      Severe              P value
 Age, years                                     27.4±5.3                   29.3±6.1                   30.0±6.0               0.566
              2
 BMI, kg/m                                      26.9±3.7                   29.9±4.0                   32.5±4.4               0.017
 Weight gain, kg                                9.2±3.6                    11.2±4.5                   13.7±5.3               0.008
 Pregnancy, week                                38.4±1.1                   38.4±1.5                   38.3±1.2              0..874
 Newborn weight, kg                           3110±487.5                 3161±566.2                  3345±596                0.302
 Newborn Gender, m/f                             34 / 37                    61 / 46                    71 / 59               0.478
 Stria History, n/m/s                          37 / 31 / 3               44 / 44 / 19                13 / 42 /75             0.001
 Term Status, p/e/f/l                        1 / 39 / 28 / 3            6 / 54 /37 /10              3 / 76 / 44 / 7          0.401
 Hb – preoperative                              11.6±1.4                   11.6±1.5                   11.8±1.5               0.121
 Hb – postoperative                             10.2±1.4                   10.1±1.5                   10.4±1.6               0.407
 Platelet count x103                            238±74                     246±75                      240±76                0.714
 PT, sec                                        9.7±1.47                   9.72±1.5                  9.78±1.78               0.847
 aPTT, sec                                      27.7±4.4                    28.2±4                     27.3±4                0.622
 AST, U/L                                       17.8±6.9                  19.2±11.5                   18.7±5.4               0.609
 ALT, U/L                                      9.15±4.96                  11.2±9.86                  11.9±6.71               0.297
 BUN, mg/dL                                     10.1±9.2                    8.8±5                      8.9±5.3               0.438
 Creatinine, mg/dL                              0.5±0.15                   0.5±0.12                  0.49±0.14               0.899
 Fibrinogen, g/L                                390±52                     401±58                      415±73                0.856

ALT = alanine aminotransferase; aPTT = activated partial thromboplastin time AST = aspartate aminotransferase; BUN = blood urea
nitrogen; Hb = hemoglobin; N/M/S = None/Moderate/Severe; P/E/F/L = Pre/Early/Full/Late Term; PLT = platelet; PT = prothrombin Time.



                    Table 2. The stepwise linear regression analysis of surgical fluid loss (SFL).
             Model                    B           SE           Beta            t           P value            Lower          Upper
 Constant                           87.4        63.13            -            1.38          0.167            -36.7         211.7
 Davey Score                        62.2         3.33          0.67         18.63           0.0001            55.6           68.7
              2
 BMI, kg/m                           8.5         1.84          0.16           4.59         0.0001                4.86        12.1
 ALT, U/L                            2.18        1.09          0.06           2.002         0.046                0.03         4.33
 Weight gain, kg                     4.11        1.64          0.08           2.506         0.013                0.88         7.33
 Age, years                          3.43        1.37          0.08           2.491         0.013                0.72         6.14
 Creatine, mg/dL                    -8.73        4.03          -0.07         -2.16          0.031            -16.67          -0.79

ALT = Alanine aminotransferase; BMI = body mass index; SE = standard error.
Dependent: The amount of SFL was defined thgrough pre/postop measurements of punches.
Predictors: Age, pregnancy week, davey score, family history, BMI, weight gained during pregnancy, smoking, baby gender, baby weight,
hemoglobin, pulse, diastolic/sistolic blood pressure, platelet, protrombin time, active partial tromboplastine time, INR, AST, ALT, BUN,
creatinine, fibrinogen.



increases with the dilatation of the blood vessels, and the               Physiologically, the formation of the vascular tube occurs
elastic fibers are separated [2]. As collagen and elastin are          in a polymerized 3d collagen lattice. However, the organi-
the two major components of the arterial wall, they are                zation of vascular endothelial cells into capillary-like struc-
passive mechanical components of soft tissues and their                tures does not occur on a hard surface, even if the surface
molecular structures regulate the characteristic response of           is covered with a suitable matrix component [23,24]. The
tissues to mechanical effects [20]. Previous studies reported          study by Wang et al, investigating changes in collagen fibrils,
that women with SG have problems such as adhesion and                  reported increased prominence of dermal blood vessels in
prolapsus [21,22]. However, the effects of these problems              the early period of SG [20]. This alteration, branching, and
on the vessel wall in these individuals were not investigated.         widening of vessels, involving increased numbers, promote
Surgeons should take into consideration this issue in surgical         clinical erythema and explains how the appearance of striae
approaches such as SC where SFL is in higher amounts.                  can be improved [25]. According to them, type-I collagen



4                                                                          Original Article | Dermatol Pract Concept. 2023;13(3):e2023175
                                                                        loss in individuals with SG in CS operations. As the most
                                                                        important point, the relationship between these losses and
                                                                        the severity of SG was independent of bleeding.
                                                                            Although it is novel research in its field, it had strengths
                                                                        and limitations. First, the main strength is that it is the first
                                                                        research to analyze the association between the severity of
                                                                        SG and SFL in pregnant, with a large sample size. Second,
                                                                        demographics such as the age, BMI, and fetal weight of all
                                                                        pregnant were similar which may lessen the bias when com-
                                                                        paring the SG groups. Because we performed the current
                                                                        analysis as a prospective design, we were able to compare
                                                                        blood data such as Hb concentration, Platelets, and RBC
                                                                        before and immediately after the CS to understand SFL con-
                                                                        tent. However, the study proceeded without any long-term
                                                                        follow-up. Among the participants, a collagen measurement
                                                                        could be made in neither the blood nor the SFL.
                                                                            Severe SG according to Davey score was positively asso-
                                                                        ciated with the SFL and evaluation of SG status is a quick
Figure 1. The ROC analysis for prediction of severe stria gravidarum.
                                                                        method that may be used for the prediction of SFL. The
BMI = body mass index; HB = hemoglobin; SFL = surgical fluid loss.
                                                                        severity of SG and the SFL measured during the operation
                                                                        showed a very strong relationship, which was a very import-
fibril fragmentation, and decreased density of the collage-             ant finding that would affect the approach of the surgeons to
nous extracellular matrix, can induce endothelial structures            the patients with SG in terms of fluid loss in CS. Neverthe-
to form vascular tubes [18]. Although it is unclear which al-           less, multicenter studies with more participants are needed in
terations at the collagen matrix trigger endothelial cell orga-         clinical and surgical applications to follow the classification
nization, there may be a decrease in the density of collagen.           of SG severity and thus predict the possible amount of SFL.
A study by Xu et al reported that damage to type-IV-collagen
reveals cryptic regions that alter interactions with vascular
endothelial cells [26]. Although not addressed in the studies           Reference
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6                                                                                 Original Article | Dermatol Pract Concept. 2023;13(3):e2023175
