The overall prevalence of abdominal striae in the studied population was 49.7% (203/408 women). There were discrepancies in the prevalence of abdominal striae in previous studies with rates of 65.7%, 67.7% among Egyptian women (10, 11) and 80%, and 57.9% among Turkish women (12, 13). This would be rendered to different sample sizes as well as different races among the studied populations.
The subanalysis performed for the study group demonstrated significant differences in the demographic characters (p va2lue 0.001 for almost all variables). In the cohort evaluated in a recent study, there were no differences in the demographic data of the recruited population (10). However, in the cohort evaluated by another researcher, a significant difference was reported between the three groups in age, BMI, weight gain during pregnancy, and fetal weight (11). Such differences would be rendered to different patient grouping (no/mild striae as a group and severe striae as the other one in the former, and no, mild and severe striae in the latter).
Thick intraperitoneal adhesions were noted significantly in women with severe striae [21 (43.75%), p-value <0.001 with mean Davey score of 6.73 ± 0.94). This was following the results reported by Abbas et al.; however, they reported that 90% of women with severe striae had thick adhesions with mean Davey score of 4.25 ± 3.36 (10). Another study reported close results to the current one (50% of patients with severe striae had dense adhesions) (12). This difference would be explained by the different samples included besides; both studies divided patients into two groups only.
In contention with the current study, there was no difference in peritoneal adhesions in women with or without striae (14, 15). However, another study reported higher rates of intraperitoneal adhesions in women with no or mild striae than those with severe striae (67.3%, 65.9%, and 36.3%, respectively) (13). This was explained by the frequent presence of dysfunctional fibroblasts in striae and adhesions. Fibroblasts have an essential role in collagen production in the adhesions; accordingly adhesion formation decreases (13). Besides, the different tools for evaluation of the striae would result in variable results, especially when incorporating the striae color, which was not evaluated in the current study.
The current study reported intraperitoneal adhesions occurring in 194/ 408 (47.5%) of the studied population. This was lower than reported by others (59.6% and 54.3%) (11, 13). However, too much higher rates of intraperitoneal adhesions were reported by Abbas et al. and Khalifi et al. (87% and 73.5%, respectively) (10, 16). This disparity in results would be rendered to differences in surgeons, techniques, and suture materials used in the operations.
Women with severe striae and those with intraperitoneal adhesions had more vascularized, hyperpigmented, less pliable and elevated CS scars (1.69 ± 1.01, 1.73 ± 0.57, 2.67 ± 1.23, and 1.35 ± 1.06 respectively with a p-value of <0.001 each). This contradicted the results reported by previous research, which stated that flat unpigmented scars were more prominent in women with striae. They explained this by the overexpression of transforming growth factor- Beta. It leads to deficient elastin production, which is a causative factor in the formation of abdominal striae (14).
To achieve perfect scar remodeling, collagen fibers are organized in a parallel fashion. While, in elevated scars, increased collagen production is noted. This was thought to arise from variability in transforming growth factor-beta, which plays an essential role in the formation of hypertrophic scars as well as intraperitoneal adhesions (13). Scar width and appearance showed significant association with dense intraperitoneal adhesions (p-value 0.001, and 0.002 respectively) (15). Depressed hypopigmented scars were also associated with adhesions, which were assumed to arise from the inward traction from the adhesion bands (17, 18). Besides, in a meta-analysis of numerous studies, they reported that flat scars were indicative of absent adhesions while depressed ones were associated with adhesions (19). Conflicting results exist as elevated scars were found to be associated with more adhesions all over the abdomen than flat or depressed ones (20).
The Davey's and Vancouver scores showed highly significant predictive performance in the prediction of intraperitoneal adhesions (p-value < 0.001). Davey's score of ≥ 2.5 had a sensitivity and specificity of 46.31% and 100.00%, respectively, in the prediction of intraperitoneal adhesions. This was similar to the results reported previously, where Davey score of 2 was considered a significant risk factor in predicting intraperitoneal adhesions. Also, the best cut off was ≥ 3 with reported sensitivity and specificity of 64% and 51.3%, respectively (10). However, Abdelaal et al. reported that abdominal striae were not considered a predictor for abdominal adhesions while the number of previous CS did (11).
Research implications: The role of the scar characters in relation to intraperitoneal adhesions needs to be evaluated deeply.
Strengths and limitations of the study: Strengths included a large sample size of recruited patients; subanalysis of the patients with striae into mild, moderate and severe provided more robust results, evaluation of the striae and CS scar using simple scoring systems, and the recruited population was of the same ethnicity. However, we did not have any previous medical records about the operative notes of the previous deliveries since most of them delivered in private sittings outside the hospital previously. We did not consider the inter-pregnancy interval as a risk factor for adhesion formation. Also, we did not evaluate the color of the striae.