الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
SUMMARY
T
he use of caesarean sections for multiple births is becoming more common all over the world. Nearly 90% of women who have had a previous caesarean section will have a caesarean section during their next pregnancy.
Post-CS adhesions are a significant complication in subsequent surgeries, increasing the risk of bladder and bowel injury (0.1–0.3%), haemorrhage (0.1–1.4%), infection (0.4–1.6%), and even hysterectomy (0.1–1.4%).
Adhesiolysis may cause injury to adjacent viscera, blood loss, and, in the case of emergency CS, a perinatal adverse outcome associated with the neonate’s delayed delivery, in addition to the risks associated with the abdominal surgical procedure itself.
Currently, surgeons do not have a reliable method for predicting intra-abdominal adhesions in repeat caesarean deliveries prior to surgery.
Several approaches have been proposed, including the visual characteristics of skin scars and surgical history. However, these methods are unreliable, and there is often no relevant history prior to the first repeat caesarean delivery.
As a result, it’s unclear whether a particular woman is at risk of serious intra-abdominal adhesions prior to having a repeat caesarean delivery. This is a major healthcare problem because it has a significant impact on both the patient and healthcare costs, thus rising morbidity and mortality.
Women who are suspected of having serious intra-abdominal adhesions may benefit from proper blood product preparation, better surgeon assignment, preoperative surgical assistance from other medical specialties, and possibly a midline skin incision to reach the peritoneal cavity. As a result, it is critical for surgeons to identify patients who are at high risk of developing adhesions.
This information will help a multidisciplinary team of surgeons plan ahead of time and advise the patient about the potentially high risk of complications. The analysis of patient features and the appearance of the scar have both been proposed as ways to predict adhesions prior to surgery.
Prior to laparoscopic surgery, the Sonographic sliding sign has been shown to have a high predictive value for detecting pelvic adhesions in women with endometriosis and chronic pelvic inflammation, as well as infra-umbilical adhesions.
This prospective observational study was conducted at department of obstetrics and gynecology at maternity hospital of Ain Shams University (labour ward and ultrasound unit) between April 2020 and April 2021 to evaluate the value of preoperative sliding sign in prediction of pelvic adhesion related complications.
The study was conducted on 120 women fulfilling the inclusion criteria eligible for elective lower caesarean section at (38-40 week) gestation or more.
All women underwent a transabdominal ultrasound. The probe was placed over the transverse skin scar and perpendicular to it. During the examination, the probe was moved slightly back and forth along the scar and perpendicular to it.
In order to determine a positive sliding sign, the description of sliding of the uterus against the abdominal wall was needed.
When no motion of the above mentioned structure was detected, the sliding sign was considered negative. When a sliding sign was visualized, women were considered to have a low risk for adhesions. When the sliding sign was negative (no movements was observed under the fascia transversalis) women were considered to have a high risk for intra-abdominal adhesions.
When there was only a moderate movement it was considered as low risk for severe adhesions. The adhesion examination took only a few seconds, did not cause any inconvenience to the patient and did not significantly prolong the normal ultrasound examination.
Sonographers were aware of the fact that the women underwent CS, but they didn’t inform the surgeons or the women about their findings. Therefore the surgeons performing the CS were blinded to the results of the ultrasound sliding sign assessment.
Following the CS, the surgeons’ reports were compared to the preliminary ultrasound diagnosis to evaluate correspondence between pre and intra-operative evaluation.
In this study it was found that the mean age of studied group was 29.43 year old (±6.27 SD), the mean BMI was 30.53kg/m2 (±2.05 SD), the mean GA was 39.07 weeks (±0.90 SD), according to previous CS there were 116 patients(representing 38.7%) who had CS once, 136 patients (representing 45.3%) who had 2 previous C.S, 32 patients (representing 10.7%) who has 3 previous C.S and 16 patients (representing 5.3%) who had 4 C.S.
The results of this study showed that among the studied cases 33 patients (11%) had Hb DROP <1gm%, 262 patients (87.3%) had Hb DROP between 1-3 gm% and 5 patients (1.7%) had Hb DROP >3gm%, there were 11 patients (3.7%) with visceral injury, 278 patients (92.7%) with sliding sign and according to adhesion there were 23 patients (7.7%) with mild adhesion and 23 patients (7.7%) with marked adhesion.
In this thesis we found that among the marked adhesion group there were 11 patients (47.8%) with positive sliding sign, among the mild adhesion group there were 20 patients (87%) with positive sliding sign and among the group with no adhesion there were 248 patients (97.6%) with positive sliding sign. In which there was high statistically significant difference between the adhesion subgroups as regard sliding sign.
In this study it was demonstrated that the sensitivity, specificity, Positive predictive value and negative predictive value of sliding sign in predicting marked intraoperative adhesions were 57.1%, 96.1%, 70% and 93.8%, respectively.
This study demonstrated that the median delivery time of the positive sliding group was 8 minutes with interquartile range (7-9), the median delivery time of the negative sliding group was 15 minutes with interquartile range (12-18). There was high statistically significant difference between the sliding sign subgroups as regard delivery time.
In this study it was illustrated that among the cases with Hb DROP <1mg% there were 32 patients (97%) with positive sliding sign, among the cases with Hb DROP 1-3 mg% there were 235 patients (89.7%) with positive sliding sign and among the cases with Hb DROP >3mg% there no cases with positive sliding sign.
In this study it was found that among the cases of visceral injury, there were 9 patients (81.8%) with a positive sliding sign, and among the cases without visceral injury there were 270 patients (93.3%) with a positive sliding sign.
In this study, it was found that among the cases of visceral injury there were 9 patients representing (81.8%) with a positive sliding sign, 7 cases from the urinary bladder and 2 cases from intestinal injury. Two patients representing (18.2%) with negative sliding signs and both had intestinal injury. Among the cases without visceral injury, there were 270 patients (93.3%) with positive sliding sign and 19 patients (6.7%) with negative sliding signs. There was no statistically significant difference between visceral injury and the presence of sliding sign. Bladder injury during cesarean delivery may be related to this organ adhesion high in the lower uterine segment.
In this study it was found that the mean of hospital stay of positive sliding group was (1.35) days and the mean of negative sliding group (4.9) days. There was highly statistically significant difference between the sliding sign and the length of hospital stay, as hospital stay in patients with negative sliding signs is longer than in patients with positive sliding sign, such as the p-value (<0.001).