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Woon Wong K, Okeahialam N, Thakar R, Sultan AH. Obstetric risk factors for levator ani muscle avulsion: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2024; 296:99-106. [PMID: 38422805 DOI: 10.1016/j.ejogrb.2024.02.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 11/15/2023] [Accepted: 02/22/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVES Women have a 11% lifetime risk of undergoing surgery for vaginal prolapse. Levator ani muscle (LAM) avulsion is one etiological factor associated with primary and recurrent pelvic organ prolapse. Pelvic organ prolapse has been shown to greatly affect the quality of life and well-being of women. Conduct a meta-analysis identifying risk factors associated with LAM avulsion recognised on transperineal ultrasound (TPUS) or magnetic resonance imaging (MRI) in primiparous women after vaginal birth. STUDY DESIGN OVID Medline, Embase and the Cochrane Library from inception to January 2021 were searched. Review Manager 5.3 (The Cochrane Collaboration) was used to analyse data. Odds ratios (OR) with 95% confidence intervals (95% CIs) were calculated. The heterogeneity among studies was calculated using the I2statistic. RESULTS Twenty-five studies were eligible for inclusion (n = 9333 women). Major LAM avulsion was diagnosed in an average of 22 % (range 12.7-39.5 %) of cases. Twenty-two studies used TPUS and three used MRI to diagnose avulsion. Modifiable and non-modifiable risk factors were identified. Significant predictors identified were forceps (OR 6.25 [4.33 - 9.0]), obstetric anal sphincter injuries (OR 3.93 [2.85-5.42]), vacuum (OR 2.41 [1.40-4.16]), and maternal age (OR 1.06 [1.02-1.10]). CONCLUSIONS This is the first meta-analysis of both modifiable and non-modifiable risk factors associated with LAM avulsion. This information could be used to develop a clinically applicable risk prediction model to target postnatal women at risk of LAM avulsion with a view to prevent the onset of pelvic floor organ prolapse.
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Affiliation(s)
| | | | - Ranee Thakar
- Croydon University Hospital, UK; St George's University of London, UK
| | - Abdul H Sultan
- Croydon University Hospital, UK; St George's University of London, UK.
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Cadish LA, Shepherd JP, Bretschneider CE. Projecting future prolapse outcomes with induction of labor at 39 weeks: a decision analysis. Int Urogynecol J 2024; 35:311-317. [PMID: 37646803 DOI: 10.1007/s00192-023-05637-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/17/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION AND HYPOTHESIS In 2018, the ARRIVE trial (A Randomized Trial of Induction Versus Expectant Management) concluded that routine induction of labor (IOL) at 39 weeks gestation decreases cesarean delivery risk, with slightly lighter birthweight infants. We debated whether routine IOL would improve, worsen, or not change POP risk compared with expectant management (EM). METHODS We constructed a decision analysis model with a lifetime horizon where nulliparous women reaching 39 weeks underwent IOL or EM. Subsequent vaginal versus cesarean delivery varied based on prior deliveries for up to four births. Subsequent delivery prior to 39 weeks and distribution of gestational age, birthweight, and delivery mode between 24 and 39 weeks was modeled from national data. We modeled increased POP risk with increasing vaginal parity, forceps delivery, and weight of largest infant delivered vaginally, accounting for differential infant weights in each strategy. RESULTS IOL and EM have similar population-wide POP risk (15.9% and 15.7% respectively). Among women with only spontaneous vaginal deliveries that reached 39 weeks or beyond, the prevalence of POP was 20% after one delivery and 29% after four deliveries, with no difference between groups. The cesarean rate was lower with IOL (27.8% versus 29.8%). Sensitivity analysis revealed no meaningful thresholds among the variables, supporting model robustness. CONCLUSION While routine induction of labor at 39 weeks results in a meaningfully higher vaginal delivery rate, there was no increase in POP, possibly due to the protective effect of lower birthweight.
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Affiliation(s)
- Lauren A Cadish
- Urogynecology, Department of Obstetrics and Gynecology, Providence Saint John's Health Center, 2001 Santa Monica Blvd, Suite 680W, Santa Monica, CA, 90404, USA.
| | - Jonathan P Shepherd
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Connecticut Health Center, Hartford, CT, USA
| | - C Emi Bretschneider
- Division of Urogynecology, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL, USA
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Tsui WL, Deng GH, Hsieh TC, Ding DC. Association between vaginal or cesarean delivery and later development of stress urinary incontinence or pelvic organ prolapse: A retrospective population-based cohort study. Int Urogynecol J 2023; 34:2041-2047. [PMID: 36917258 DOI: 10.1007/s00192-023-05504-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/14/2023] [Indexed: 03/15/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Child delivery mode may be associated with pelvic floor disorders. We explored the association between different delivery modes and later development of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) in Taiwanese women. METHODS This was a retrospective population-based cohort study. Women who delivered babies between January 1, 2000, and December 31, 2018, were selected for this study. The study used Taiwan's National Health Insurance (NHI) Research Database. After propensity score matching, 51,587 women who underwent cesarean section (C/S) and 51,587 women who underwent vaginal delivery (VD) were recruited. Primary outcomes were the presence of SUI and POP after delivery. RESULTS The incidence of SUI (1.6/1000 person-years) and POP (1.5/1000 person-years) was higher in the VD group than in the C/S group (0.8 and 0.6 in 1000 person-years). VD was associated with an increased risk of SUI [hazard ratio (HR): 2.79, 95% confidence interval (CI): 2.45-3.17] and POP (HR: 1.96, 95% CI: 1.75-2.19) compared to C/S. We also found that age (HR: 1.06, 95% CI: 1.05-1.08 in SUI, HR: 1.08, 95% CI: 1.07-1.09 in POP) and Charlson Comorbidity Index (CCI) (HR: 1.28, 95% CI: 1.12-1.46 in SUI, HR: 1.27, 95% CI: 1.13-1.43 in POP) were associated with an increased risk of SUI and POP. The cumulative incidence of SUI and POP was higher in the VD group than in the C/S group (log-rank test, P < 0.05). CONCLUSIONS The current study was the largest retrospective cohort study regarding the influence of delivery mode on SUI and POP so far. VD was found to be associated with an increased risk of SUI and POP compared with C/S. Postpartum care for pelvic physical therapy should be provided particularly to women undergoing VD.
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Affiliation(s)
- Wing Lam Tsui
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, 970, Taiwan
| | - Guang-Hong Deng
- Tzu Chi University Research Center for Big Data Teaching, Research and Statistic Consultation, Tzu Chi University, Hualien, 970, Taiwan
| | - Tsung-Cheng Hsieh
- Tzu Chi University Research Center for Big Data Teaching, Research and Statistic Consultation, Tzu Chi University, Hualien, 970, Taiwan
- Institute of Medical Sciences, Tzu Chi University, Hualien, 970, Taiwan
| | - Dah-Ching Ding
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, 970, Taiwan.
- Institute of Medical Sciences, Tzu Chi University, Hualien, 970, Taiwan.
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Eggebø TM, Benediktsdottir S, Hjartardottir H, Salvesen KÅ, Volløyhaug I. Ultrasound examination of the pelvic floor during active labor: A longitudinal cohort study. Acta Obstet Gynecol Scand 2023; 102:1203-1209. [PMID: 37417688 PMCID: PMC10407019 DOI: 10.1111/aogs.14620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/09/2023] [Accepted: 06/11/2023] [Indexed: 07/08/2023]
Abstract
INTRODUCTION There is limited evidence about changes in the pelvic floor during active labor. We aimed to investigate changes in hiatal dimensions during the active first stage of labor and associations with fetal descent and head position. MATERIAL AND METHODS We conducted a longitudinal, prospective cohort study at the National University Hospital of Iceland, from 2016 to 2018. Nulliparous women with spontaneous onset of labor, a single fetus in cephalic presentation, and gestational age ≥37 weeks were eligible. Fetal position was assessed with transabdominal ultrasound and fetal descent was measured with transperineal ultrasound. Three-dimensional volumes were acquired from transperineal scanning at the start of the active phase of labor and in late first stage or early second stage. The largest transverse hiatal diameter was measured in the plane of minimal hiatal dimensions. The levator urethral gap was measured as the distance between the center of the urethra and the levator insertion using tomographic ultrasound imaging. Measurements of the levator urethral gap were made in the plane of minimal hiatal dimensions and 2.5 and 5 mm cranial to this. RESULTS The final study population comprised 78 women. The mean transverse hiatal diameter increased 12.4% between the two examinations, from 39.4 ± 4.1 mm (±standard deviation) at the first examination to 44.3 ± 5.8 mm at the last examination (p < 0.01). We found a moderate correlation between the transverse hiatal diameter and fetal station at the last examination (r = 0.44, r2 = 0.19; p < 0.01; regression equation y = 2.71 + 0.014x), and a weak correlation between the change in transverse hiatal diameter and change in fetal station (r = 0.29; r2 = 0.08; p = 0.01; regression equation y = 0.24 + 0.012x). Levator urethral gap increased significantly in all three planes on both the left and right sides. Head position was not associated with hiatal measurements after adjusting for fetal station. CONCLUSIONS We found a significant, but only modest, increase of the hiatal dimensions during the first stage of labor. The risk of levator ani trauma will therefore be low during this stage. The change in transverse hiatal diameter was associated with fetal descent but not with head position.
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Affiliation(s)
- Torbjørn M. Eggebø
- National Center for Fetal MedicineTrondheim University Hospital (St. Olavs Hospital)TrondheimNorway
- Institute of Clinical and Molecular MedicineNorwegian University of Science and TechnologyTrondheimNorway
- Department of Obstetrics and GynecologyStavanger University HospitalStavangerNorway
| | | | - Hulda Hjartardottir
- Department of Obstetrics and GynecologyLandspitali University HospitalReykjavikIceland
| | - Kjell Å. Salvesen
- National Center for Fetal MedicineTrondheim University Hospital (St. Olavs Hospital)TrondheimNorway
- Institute of Clinical and Molecular MedicineNorwegian University of Science and TechnologyTrondheimNorway
| | - Ingrid Volløyhaug
- Institute of Clinical and Molecular MedicineNorwegian University of Science and TechnologyTrondheimNorway
- Department of Obstetrics and GynecologyTrondheim University Hospital (St. Olavs Hospital)TrondheimNorway
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Schulten SF, Claas-Quax MJ, Weemhoff M, van Eijndhoven HW, van Leijsen SA, Vergeldt TF, IntHout J, Kluivers KB. Risk factors for primary pelvic organ prolapse and prolapse recurrence: an updated systematic review and meta-analysis. Am J Obstet Gynecol 2022; 227:192-208. [PMID: 35500611 DOI: 10.1016/j.ajog.2022.04.046] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/25/2022] [Accepted: 04/23/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To update a previously published systematic review and perform a meta-analysis on the risk factors for primary pelvic organ prolapse and prolapse recurrence. DATA SOURCES PubMed and Embase were systematically searched. We searched from July 1, 2014 until July 5, 2021. The previous search was from inception until August 4, 2014. STUDY ELIGIBILITY CRITERIA Randomized controlled trials and cross-sectional and cohort studies conducted in the Western developed countries that reported on multivariable analysis of risk factors for primary prolapse or prolapse recurrence were included. The definition of prolapse was based on anatomic references, and prolapse recurrence was defined as anatomic recurrence after native tissue repair. Studies on prolapse recurrence with a median follow-up of ≥1 year after surgery were included. METHODS Quality assessment was performed with the Newcastle-Ottawa Scale. Data from the previous review and this review were combined into forest plots, and meta-analyses were performed where possible. If the data could not be pooled, "confirmed risk factors" were identified if ≥2 studies reported a significant association in multivariable analysis. RESULTS After screening, 14 additional studies were selected-8 on the risk factors for primary prolapse and 6 on prolapse recurrence. Combined with the results from the previous review, 27 studies met the inclusion criteria, representing the data of 47,429 women. Not all studies could be pooled because of heterogeneity. Meta-analyses showed that birthweight (n=3, odds ratio, 1.04; 95% confidence interval, 1.02-1.06), age (n=3, odds ratio, 1.34; 95% confidence interval, 1.23-1.47), body mass index (n=2, odds ratio, 1.75; 95% confidence interval, 1.17-2.62), and levator defect (n=2, odds ratio, 3.99; 95% confidence interval, 2.57-6.18) are statistically significant risk factors, and cesarean delivery (n=2, pooled odds ratio, 0.08; 95% confidence interval, 0.03-0.20) and smoking (n=3, odds ratio, 0.59; 95% confidence interval, 0.46-0.75) are protective factors for primary prolapse. Parity, vaginal delivery, and levator hiatal area are identified as "confirmed risk factors." For prolapse recurrence, preoperative prolapse stage (n=5, odds ratio, 2.68; 95% confidence interval, 1.93-3.73) and age (n=2, odds ratio, 3.48; 95% confidence interval, 1.99-6.08) are statistically significant risk factors. CONCLUSION Vaginal delivery, parity, birthweight, age, body mass index, levator defect, and levator hiatal area are risk factors, and cesarean delivery and smoking are protective factors for primary prolapse. Preoperative prolapse stage and younger age are risk factors for prolapse recurrence after native tissue surgery.
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Dembinsky M, Boodoosingh R, Fulu-Aiolupotea SM, Lima UL, Ekeroma A, Bugge C, Hagen S. Translating the Pelvic Organ Prolapse Score into Samoan using a modified back translation methodology. BMC Womens Health 2022; 22:93. [PMID: 35346163 PMCID: PMC8960078 DOI: 10.1186/s12905-022-01676-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 03/10/2022] [Indexed: 11/10/2022] Open
Abstract
Background Although Samoan women have a high prevalence of obesity and multiple parity which are risk factors of pelvic organ prolapse, there is no prevalence data on this condition.
Aims Translate the Pelvic Organ Prolapse-Symptoms Score (POP-SS) from English into Samoan, Materials and methods Standardised methods for translating questionnaires, individual face to face audio-recorded interviews in which women completed the POP-SS using a Think Aloud method, analysis using a Framework approach. Results The POP-SS was successfully translated in to Samoan, an additional information leaflet was developed to support women’s understanding of what prolapse is, 14 Samoan women were recruited of which 13 were interviewed and completed the POP-SS, results of POP-SS (scores), results of think aloud, results in terms of research experience. Conclusions A Samoan version of the POP-SS is now available for further evaluation of its psychometric properties prior to wider use. The team continue to collaborate on their work on establishing the prevalence of prolapse whilst building local research capacity. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-022-01676-3.
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Affiliation(s)
- Melanie Dembinsky
- Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
| | - Ramona Boodoosingh
- School of Nursing and Health Science, National University of Samoa, Apia, Samoa
| | | | - Uila Laifa Lima
- School of Nursing and Health Science, National University of Samoa, Apia, Samoa
| | - Alec Ekeroma
- School of Nursing and Health Science, National University of Samoa, Apia, Samoa
| | - Carol Bugge
- Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
| | - Suzanne Hagen
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK.
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Ghanbari Z, Peivandi S, Pasikhani MD, Darabi F. Comparison of Pelvic Organ Prolapse Quantification and Simplified Pelvic Organ Prolapse Quantification Systems in Clinical Staging of Iranian Women with Pelvic Organ Prolapse. Ethiop J Health Sci 2021; 30:921-928. [PMID: 33883837 PMCID: PMC8047234 DOI: 10.4314/ejhs.v30i6.10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background Pelvic organ prolapse is a common pelvic disorder among women. A standard staging system is needed to carefully evaluate the extent and severity of the disease, and initiate appropriate treatment. The aim of this study was to compare the two methods of standard and simplified pelvic organ prolapse quantification systems in clinical staging of Iranian women with pelvic organ prolapse. Methods This observational cross-sectional study was conducted on all women with complaints of seeing or feeling a vaginal lump or bulge and/or a dragging sensation who were presented to a pelvic floor disorders clinic of Imam Khomeini Hospital in Tehran, Iran, from October 2018 to June 2019. All patients were evaluated in terms of pelvic organ prolapse severity and staging using both instruments. Also, length of time needed to complete the questionnaires were calculated. After data collection, the results of pelvic organ prolapse staging and degree of agreement between two examiners were evaluated. Results A total of 120 women with mean age of 50.92±13.12 years were evaluated. It was shown that there is an almost perfect agreement (kappa coefficient > 0.8) between standard and simplified pelvic organ prolapse quantification systems in all the 3 compartments. Also, there was almost a twofold increase in the time needed to perform standard pelvic organ prolapse quantification (4.16±1.01 minutes) compared to performing simplified pelvic organ prolapse quantification (2.12±1.14 minutes) (p=0.03). Conclusion According to the results of this study, there is a substantial and almost perfect agreement between standard and simplified pelvic organ prolapse quantification systems in clinical staging of Iranian women with pelvic organ prolapse. It seems that using simplified pelvic organ prolapse quantification system is more applicable in clinical practice for staging of pelvic organ prolapse, with high reliability coefficient.
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Affiliation(s)
- Zinat Ghanbari
- Professor, Department of Obstetrics & Gynecology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Saloumeh Peivandi
- Assistant Professor, Department of Gynecology and Obstetrics, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Maryam Deldar Pasikhani
- Assistant Professor, Department of Obstetrics & Gynecology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Foroohar Darabi
- Resident of Gynecology and Obstetrics, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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Paymova L, Svabik K, Neumann A, Kalis V, Ismail KM, Rusavy Z. Vaginal birth after Cesarean section and levator ani avulsion: a case-control study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:303-308. [PMID: 33724564 DOI: 10.1002/uog.23629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/25/2021] [Accepted: 03/03/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The aim of this study was to explore the risk of levator ani muscle (LAM) avulsion and enlargement of the levator hiatus following vaginal birth after Cesarean section (VBAC) in comparison with vaginal delivery in primiparous women. METHODS In this two-center observational case-control study, we identified all women who had a term VBAC for their second delivery at the Departments of Obstetrics and Gynecology at the Faculty of Medicine in Pilsen and the 1st Faculty of Medicine in Prague, Charles University, Czech Republic, between 2012 and 2016. Women with a repeat VBAC, preterm birth or stillbirth were excluded from the study. As a control group, we enrolled a cohort of primiparous women who delivered vaginally during the study period. To increase our control sample, we also invited all primiparous women who delivered vaginally in both participating units between May and June 2019 to participate. All participants were invited for a four-dimensional pelvic floor ultrasound scan to assess LAM trauma. LAM avulsion and the area of the levator hiatus were assessed offline from the stored pelvic floor volumes obtained at rest, during maximum contraction and during Valsalva maneuver. The laterality of the avulsion was also noted. The cohorts were then compared using the χ2 test and Wilcoxon's two-sample test according to the normality of the distribution. P < 0.05 was considered statistically significant. Multivariate regression analysis, controlling for age and body mass index (BMI), was also performed. RESULTS A total of 356 women had a VBAC for their second delivery during the study period. Of these, 152 (42.7%) attended the ultrasound examination and full data were available for statistical analysis for 141 women. The control group comprised 113 primiparous women. A significant difference was observed between the VBAC group and the control group in age (32.7 vs 30.1 years; P < 0.05), BMI (28.4 vs 27.4 kg/m2 ; P < 0.05) and duration of the first and second stages of labor (293.1 vs 345.9 min; P < 0.05 and 27.6 vs 35.3 min; P < 0.05, respectively) at the time of the index birth. The LAM avulsion rate was significantly higher in the VBAC compared with the control group (32.6% vs 18.6%; P = 0.01). The difference between the groups was observed predominantly in the rate of unilateral avulsion and remained significant after controlling for age and BMI (adjusted odds ratio 2.061 (95% CI, 1.103-3.852)). There was no statistically significant difference in the area of the levator hiatus at rest (12.0 vs 12.6 cm2 ; P = 0.28) or on maximum Valsalva maneuver (18.6 vs 18.7 cm2 ; P = 0.55) between the VBAC and control groups. The incidence of levator hiatal ballooning was comparable between the groups (17.7% and 18.6%; P = 0.86). CONCLUSIONS VBAC is associated with a significantly higher rate of LAM avulsion than is vaginal birth in nulliparous women. The difference was significant even after controlling for age and BMI. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- L Paymova
- Department of Obstetrics and Gynecology, Faculty of Medicine in Plzen, Charles University, Plzen, Czech Republic
| | - K Svabik
- Department of Obstetrics and Gynecology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - A Neumann
- Department of Obstetrics and Gynecology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - V Kalis
- Department of Obstetrics and Gynecology, Faculty of Medicine in Plzen, Charles University, Plzen, Czech Republic
- Biomedical Center, Faculty of Medicine in Plzen, Charles University, Plzen, Czech Republic
| | - K M Ismail
- Department of Obstetrics and Gynecology, Faculty of Medicine in Plzen, Charles University, Plzen, Czech Republic
- Biomedical Center, Faculty of Medicine in Plzen, Charles University, Plzen, Czech Republic
| | - Z Rusavy
- Department of Obstetrics and Gynecology, Faculty of Medicine in Plzen, Charles University, Plzen, Czech Republic
- Biomedical Center, Faculty of Medicine in Plzen, Charles University, Plzen, Czech Republic
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Rusavy Z, Paymova L, Kozerovsky M, Veverkova A, Kalis V, Kamel RA, Ismail KM. Levator ani avulsion: a Systematic evidence review (LASER). BJOG 2021; 129:517-528. [PMID: 34245656 DOI: 10.1111/1471-0528.16837] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is variation in the reported incidence rates of levator avulsion (LA) and paucity of research into its risk factors. OBJECTIVE To explore the incidence rate of LA by mode of birth, imaging modality, timing of diagnosis and laterality of avulsion. SEARCH STRATEGY We searched MEDLINE, EMBASE, CINAHL, AMED and MIDIRS with no language restriction from inception to April 2019. STUDY ELIGIBILITY CRITERIA A study was included if LA was assessed by an imaging modality after the first vaginal birth or caesarean section. Case series and reports were not included. DATA COLLECTION AND ANALYSIS RevMan v5.3 was used for the meta-analyses and SW SAS and STATISTICA packages were used for type and timing of imaging analyses. RESULTS We included 37 primary non-randomised studies from 17 countries and involving 5594 women. Incidence rates of LA were 1, 15, 21, 38.5 and 52% following caesarean, spontaneous, vacuum, spatula and forceps births, respectively, with no differences by imaging modality. Odds ratio of LA following spontaneous birth versus caesarean section was 10.69. The odds ratios for LA following vacuum and forceps compared with spontaneous birth were 1.66 and 6.32, respectively. LA was more likely to occur unilaterally than bilaterally following spontaneous (P < 0.0001) and vacuum-assisted (P = 0.0103) births but not forceps. Incidence was higher if assessment was performed in the first 4 weeks postpartum. CONCLUSIONS LA incidence rates following caesarean, spontaneous, vacuum and forceps deliveries were 1, 15, 21 and 52%, respectively. Ultrasound and magnetic resonance imaging were comparable tools for LA diagnosis. TWEETABLE ABSTRACT Levator avulsion incidence rates after caesarean, spontaneous, vacuum and forceps deliveries were 1, 15, 21 and 52%, respectively.
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Affiliation(s)
- Z Rusavy
- Department of Obstetrics and Gynaecology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Obstetrics and Gynaecology, University Hospital, Pilsen, Czech Republic
| | - L Paymova
- Department of Obstetrics and Gynaecology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Obstetrics and Gynaecology, University Hospital, Pilsen, Czech Republic
| | - M Kozerovsky
- Department of Obstetrics and Gynaecology, University Hospital, Pilsen, Czech Republic
| | - A Veverkova
- Department of Obstetrics and Gynaecology, University Hospital, Pilsen, Czech Republic
| | - V Kalis
- Department of Obstetrics and Gynaecology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Obstetrics and Gynaecology, University Hospital, Pilsen, Czech Republic
| | - R A Kamel
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Cairo University, Cairo, Egypt
| | - K M Ismail
- Department of Obstetrics and Gynaecology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
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10
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Barca JA, Bravo C, Pintado-Recarte MP, Asúnsolo Á, Cueto-Hernández I, Ruiz-Labarta J, Buján J, Ortega MA, De León-Luis JA. Pelvic Floor Morbidity Following Vaginal Delivery versus Cesarean Delivery: Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10081652. [PMID: 33924472 PMCID: PMC8070303 DOI: 10.3390/jcm10081652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/05/2021] [Accepted: 04/07/2021] [Indexed: 11/20/2022] Open
Abstract
Objective: To compare pelvic floor disorders between vaginal delivery (VD) and cesarean delivery (CD). Methods: For this study, a PUBMED database search was used, utilizing a combination of relevant medical subjects’ headings (MeSH) terms, with the following keywords: “Pelvic floor disorders” or “Pelvic floor morbidity” and “Delivery”. Search limits were articles in English or Spanish, about women, published from December 2009 to December 2019. The STATA 16 package was used for meta-analysis and data heterogeneity assessment. Results: Thirteen studies meeting eligibility criteria were identified comprising 1,597,303 participants. Abstract: Pelvic floor morbidity prevalence was Urinary Incontinence (UI) 27.9% (5411 patients in 7 studies with reported cases), Pelvic Organ Prolapse (POP) 14.2% (6019 patients in 8 studies with reported cases), and Anal Incontinence (AI) 0.4% (1,589,740 patients in 5 studies with reported cases). Our meta-analyses revealed significantly higher rates of all three morbidities and overall morbidity in the VD versus CD group: UI OR = 2.17, 95% CI 1.64–2.87, p for heterogeneity ≤ 0.0001, I2 = 84%; POP OR = 3.28, 95% CI 1.91–5.63, p for heterogenicity ≤ 0.043, I2 = 63%; AI OR = 1.53, 95% CI 1.32–1.77; p for heterogeneity ≤ 0.291, I2 = 20%; and overall morbidity (OR = 2.17, 95% CI 1.64–2.87; p for heterogeneity ≤ 0.0001, I2 = 84%). Conclusion: Vaginal delivery is directly related to the appearance of pelvic floor disorders, mainly UI, POP, and AI. The risk of POP should be taken into higher consideration after vaginal delivery and postpartum follow-up should be performed, to identify and/or treat it at the earliest stages.
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Affiliation(s)
- Juan A. Barca
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (J.A.B.); (C.B.); (M.P.P.-R.); (I.C.-H.); (J.R.-L.); (J.A.D.L.-L.)
| | - Coral Bravo
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (J.A.B.); (C.B.); (M.P.P.-R.); (I.C.-H.); (J.R.-L.); (J.A.D.L.-L.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
| | - Maria P. Pintado-Recarte
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (J.A.B.); (C.B.); (M.P.P.-R.); (I.C.-H.); (J.R.-L.); (J.A.D.L.-L.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
| | - Ángel Asúnsolo
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain;
- Ramón y Cajal Institute of Healthcare Research (IRYCIS), 28034 Madrid, Spain;
- Department of Epidemiology & Biostatistics, Graduate School of Public Health and Health Policy, University of New York, New York, NY 10027, USA
| | - Ignacio Cueto-Hernández
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (J.A.B.); (C.B.); (M.P.P.-R.); (I.C.-H.); (J.R.-L.); (J.A.D.L.-L.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
| | - Javier Ruiz-Labarta
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (J.A.B.); (C.B.); (M.P.P.-R.); (I.C.-H.); (J.R.-L.); (J.A.D.L.-L.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
| | - Julia Buján
- Ramón y Cajal Institute of Healthcare Research (IRYCIS), 28034 Madrid, Spain;
- Department of Medicine and Medical Specialties, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain
| | - Miguel A. Ortega
- Ramón y Cajal Institute of Healthcare Research (IRYCIS), 28034 Madrid, Spain;
- Department of Medicine and Medical Specialties, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain
- Correspondence: ; Tel.: +34-91-885-45-40; Fax: +34-91-885-48-85
| | - Juan A. De León-Luis
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain; (J.A.B.); (C.B.); (M.P.P.-R.); (I.C.-H.); (J.R.-L.); (J.A.D.L.-L.)
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
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11
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Cattani L, Neefs L, Verbakel JY, Bosteels J, Deprest J. Obstetric risk factors for anorectal dysfunction after delivery: a systematic review and meta-analysis. Int Urogynecol J 2021; 32:2325-2336. [PMID: 33787952 DOI: 10.1007/s00192-021-04723-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 02/04/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Pregnancy and childbirth are considered risk factors for pelvic floor dysfunction, including anorectal dysfunction. We aimed to assess the effect of obstetric events on anal incontinence and constipation after delivery. METHODS We systematically reviewed the literature by searching MEDLINE, Embase and CENTRAL. We included studies in women after childbirth examining the association between obstetric events and anorectal dysfunction assessed through validated questionnaires. We selected eligible studies and clustered the data according to the type of dysfunction, obstetric event and interval from delivery. We assessed risk of bias using the Newcastle Ottawa Scale and we performed a random-effects meta-analysis and reported the results as odds ratios (ORs) with their 95% confidence intervals. Heterogeneity across studies was assessed using I2 statistics. RESULTS Anal sphincter injury (OR: 2.44 [1.92-3.09]) and operative delivery were risk factors for anal incontinence (forceps-OR :1.35 [1.12-1.63]; vacuum-OR: 1.17 [1.04-1.31]). Spontaneous vaginal delivery increased the risk of anal incontinence compared with caesarean section (OR: 1.27 [1.07-1.50]). Maternal obesity (OR:1.48 [1.28-1.72]) and advanced maternal age (OR: 1.56 [1.30-1.88]) were risk factors for anal incontinence. The evidence on incontinence is of low certainty owing to the observational nature of the studies. No evidence was retrieved regarding constipation after delivery because of a lack of standardised validated assessment tools. CONCLUSIONS Besides anal sphincter injury, forceps delivery, maternal obesity and advanced age were associated with higher odds of anal incontinence, whereas caesarean section is protective. We could not identify obstetric risk factors for postpartum constipation, as few prospective studies addressed this question and none used a standardised validated questionnaire.
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Affiliation(s)
- Laura Cattani
- Department Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Gynaecology and Obstetrics, UZ Leuven, Leuven, Belgium
| | - Liesbeth Neefs
- Department Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Gynaecology and Obstetrics, UZ Leuven, Leuven, Belgium
| | - Jan Y Verbakel
- EPI-Centre, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jan Bosteels
- Department Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.,Obstetrics and Gynaecology Unit, Imelda Hospital, Bonheiden, Belgium.,CEBAM, The Centre for Evidence-based Medicine, Cochrane Belgium, Academic Centre for General Practice, Leuven, Belgium
| | - Jan Deprest
- Department Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Department of Gynaecology and Obstetrics, UZ Leuven, Leuven, Belgium. .,Research Department of Maternal Fetal Medicine, Institute for Women's Health, University College London, London, UK.
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12
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Mathew S, Guzman Rojas RA, Nyhus MØ, Salvesen KÅ, Volløyhaug II. Prevalence of anal sphincter defects and association with anal incontinence in women scheduled for pelvic organ prolapse surgery. Neurourol Urodyn 2020; 39:2409-2416. [PMID: 32894645 DOI: 10.1002/nau.24504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/03/2020] [Accepted: 08/24/2020] [Indexed: 11/12/2022]
Abstract
AIMS Some women with pelvic organ prolapse (POP) have concomitant symptoms of anal incontinence. Our aim was to assess the prevalence of anal sphincter defects and the association with incontinence in women undergoing POP surgery. METHODS Cross-sectional study of 200 women scheduled for POP surgery. They answered yes/no and graded any symptoms of fecal and flatal incontinence on a visual analog scale (0-100). 3D/4D transperineal ultrasound was used to assess internal (IAS) and external anal sphincter (EAS) defects. A defect of ≥30° in ≥4 of 6 slices on tomographic imaging was regarded significant. The association between incontinence and sphincter defects was tested with multivariable logistic regression analysis. RESULTS The prevalence of any sphincter defect was 50/200 (25%). Combined IAS/EAS defect was found in 19/200 (9.5%) women, 8/200 (4.0%) had isolated IAS, and 23/200 (11.5%) had isolated EAS defects. In women with defect and intact IAS, 37% and 11% reported fecal incontinence, respectively, adjusted odds ratio (aOR) 2.3 (95% confidence interval [CI], 0.7-7.0), p = .147 and in women with defect versus intact EAS, 36% and 9% had fecal incontinence, aOR 4.0 (95% CI, 1.5-10.8), p = .005. In women with defect and intact IAS, 85% versus 43% reported flatal incontinence, aOR 5.2 (95% CI, 1.6-17.2), p = .007 and in women with defect versus intact EAS, 71% versus 43% had flatal incontinence, aOR 1.9 (95% CI, 0.8-4.5), p = .131. CONCLUSIONS One of four women scheduled for POP surgery had an anal sphincter defect. EAS defects were associated with fecal incontinence and IAS defects were strongly associated with flatal incontinence.
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Affiliation(s)
- Seema Mathew
- Department of Obstetrics and Gynecology, St. Olavs Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Rodrigo A Guzman Rojas
- Departamento de Ginecología y Obstetricia, Facultad de Medicina, Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Maria Ø Nyhus
- Department of Obstetrics and Gynecology, St. Olavs Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kjell Å Salvesen
- Department of Obstetrics and Gynecology, St. Olavs Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ingrid I Volløyhaug
- Department of Obstetrics and Gynecology, St. Olavs Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
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13
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The effect of replacing vacuum with forceps in operative vaginal delivery: an observational study. Int Urogynecol J 2020; 31:1771-1776. [PMID: 32535687 DOI: 10.1007/s00192-020-04352-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/20/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS An increase in vaginal delivery with forceps may increase rates of pelvic floor trauma. This study was designed to predict trauma rates resulting from policies preferencing forceps. METHODS This is an observational cohort study utilizing data from 660 primiparae enrolled in an RCT in two tertiary obstetric units in Sydney, Australia. Participants were assessed clinically and with 4D translabial ultrasound in the late third trimester and again at 3-6 months postpartum. Incidence of trauma associated with mode of delivery was adjusted to reflect change associated with a conversion of vacuum to forceps delivery. Primary outcome measures were third-/fourth-degree tear, levator avulsion (LA) and external anal sphincter (EAS) trauma diagnosed sonographically. RESULTS Five hundred four women were seen at a mean of 5.1 (2.3-24.3) months postpartum. After exclusion of 21 because of missing data, 483 women were analysed: 112 (23%) had a CS, 268 (55%) a normal vaginal delivery (NVD), 69 (14%) a vacuum (VD) and 34 (7%) a forceps (FD). One hundred fifty-two women had EAS trauma and/or LA; 17 sustained both. After VD, 32/69 (46%) women suffered LA and/or EAS trauma; after FD, it was 33/34 (97%). Converting VD to FD was estimated to result in an increase in trauma from 152/483 (31%) to 187/483 (39%). A formula can be generated based on local obstetric and ultrasound data to estimate trauma incidence. CONCLUSIONS A change in obstetric practice resulting in the conversion of primary VD to primary FD would be expected to substantially increase the likelihood of pelvic floor trauma.
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14
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Daly JO, de Leeuw JW, Harvey MA, Freeman R, Sultan A. Regarding SOGC Guideline No. 381-Assisted Vaginal Birth. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 42:405-406. [PMID: 32303293 DOI: 10.1016/j.jogc.2019.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 12/20/2019] [Indexed: 10/24/2022]
Affiliation(s)
- J Oliver Daly
- Department of Obstetrics and Gynaecology, Western Health, Melbourne, Australia.
| | - Jan Willem de Leeuw
- Department of Obstetrics and Gynaecology, Ikazia Hospital, Rotterdam, the Netherlands
| | | | - Robert Freeman
- Department of Obstetrics and Gynaecology, Derriford Hospital, Plymouth, United Kingdom
| | - Abdul Sultan
- Department of Obstetrics and Gynaecology, Croydon University Hospital, London, United Kingdom
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15
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Author Response: No. 381-Assisted Vaginal Birth. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 42:407-408.e1. [PMID: 32303294 DOI: 10.1016/j.jogc.2020.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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16
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García-Mejido JA, Martín-Martínez A, González-Diaz E, Fernández-Fernández C, Ortega I, Medina M, Fernández-Corona A, Fernández-Palacín A, Sainz JA. Malmström vacuum or Kielland forceps: which causes more damage to pelvic floor? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:257-263. [PMID: 31332857 DOI: 10.1002/uog.20404] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 07/01/2019] [Accepted: 07/03/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To determine whether differences exist in the rate of levator ani muscle (LAM) avulsion between women who had undergone either Malmström vacuum delivery (MVD) or Kielland forceps delivery (KFD), allowing for potential confounding factors. METHODS This was a prospective observational study of nulliparous women undergoing instrumental delivery using Malmström vacuum extractor or Kielland forceps, at two hospital centers in Spain. Fetal head position (anterior, posterior or transverse) and fetal head station (low or mid) were assessed by ultrasound and digital examination, respectively. Avulsion was defined on tomographic ultrasound imaging as an abnormal insertion of the LAM in the three central slices from the plane of minimal hiatal dimensions. RESULTS In total, 414 patients were included in the study (212 MVD and 202 KFD). We observed a higher rate of LAM avulsion in the KFD group (KFD 49.5% vs MVD 32.5%; P = 0.001). When the results were evaluated according to fetal head position and station, we observed no differences in LAM avulsion. The crude odds ratio (OR) for the difference in avulsion between women in the KFD and MVD groups was 2.03 (95% CI, 1.36-3.03). However, when adjusted for duration of second stage of labor, fetal head circumference and fetal head station, the OR was no longer statistically significant (OR, 2.14 (95% CI, 0.95-4.85); P = 0.068). CONCLUSION When potential confounding factors are taken into account, the rate of LAM avulsion does not differ between women according to whether they have undergone KFD or MVD. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- J A García-Mejido
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
- Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
| | - A Martín-Martínez
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Gran Canarias, Gran Canarias, Spain
| | - E González-Diaz
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Leon (CAULE), Leon, Spain
| | - C Fernández-Fernández
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Leon (CAULE), Leon, Spain
| | - I Ortega
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Gran Canarias, Gran Canarias, Spain
| | - M Medina
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Gran Canarias, Gran Canarias, Spain
| | - A Fernández-Corona
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Leon (CAULE), Leon, Spain
| | - A Fernández-Palacín
- Biostatistics Unit, Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain
| | - J A Sainz
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
- Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
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17
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Nyhus MØ, Oversand SH, Salvesen Ø, Salvesen KÅ, Mathew S, Volløyhaug I. Ultrasound assessment of pelvic floor muscle contraction: reliability and development of an ultrasound-based contraction scale. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:125-131. [PMID: 31237722 DOI: 10.1002/uog.20382] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 06/04/2019] [Accepted: 06/11/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To determine intra- and interrater reliability and agreement for ultrasound measurements of pelvic floor muscle contraction and to assess the correlation between ultrasound and vaginal palpation. We also aimed to develop an ultrasound scale for assessment of pelvic floor muscle contraction. METHODS This was a cross-sectional study of 195 women scheduled for stress urinary incontinence (n = 65) or prolapse (n = 65) surgery or who were primigravid (n = 65). Pelvic floor muscle contraction was assessed by vaginal palpation using the Modified Oxford Scale (MOS) and by two- and three-dimensional (2D/3D) transperineal ultrasound. Proportional change in 2D and 3D levator hiatal anteroposterior (AP) diameter and 3D levator hiatal area between rest and contraction were used as measures of pelvic floor muscle contraction. One rater repeated all ultrasound measurements on stored volumes, which were used for intrarater reliability and agreement analysis, and three independent raters analyzed 60 ultrasound volumes for interrater reliability and agreement analysis. Reliability was assessed using the intraclass correlation coefficient (ICC) and agreement using Bland-Altman analysis. Tomographic ultrasound was used to identify women with major levator injury. Spearman's rank correlation coefficient (rS ) was used to assess the correlation between ultrasound measurements of pelvic floor muscle contraction and MOS score. The proportion of women allocated to each category of muscle contraction (absent, weak, moderate or strong) by palpation was used to determine the cut-offs for the ultrasound scale. RESULTS Intrarater ICC was 0.81 (95% CI, 0.74-0.85) for proportional change in 2D levator hiatal AP diameter. Interrater ICC was 0.82 (95% CI, 0.72-0.89) for proportional change in 2D AP diameter, 0.80 (95% CI, 0.69-0.88) for proportional change in 3D AP diameter and 0.72 (95% CI, 0.56-0.83) for proportional change in hiatal area. The prevalence of major levator injury was 22.6%. The strength of correlation (rS ) between ultrasound measurements and MOS score was 0.52 for 2D AP diameter, 0.62 for 3D AP diameter and 0.47 for hiatal area (P < 0.001 for all). On the ultrasound contraction scale, proportional change in 2D levator hiatal AP diameter of < 1% corresponds to absent, 2-14% to weak, 15-29% to normal and > 30% to strong contraction. CONCLUSIONS Ultrasound seems to be an objective and reliable method for evaluation of pelvic floor muscle contraction. Proportional change in 2D levator hiatal AP diameter had the highest ICC and moderate correlation with MOS score assessed by vaginal palpation, and we constructed an ultrasound scale for assessment of pelvic floor muscle contraction based on this measure. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M Ø Nyhus
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Obstetrics and Gynaecology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - S H Oversand
- Department of Gynaecology, Oslo University Hospital, Ullevaal, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ø Salvesen
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - K Å Salvesen
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Obstetrics and Gynaecology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - S Mathew
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - I Volløyhaug
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Obstetrics and Gynaecology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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18
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García Mejido JA, Aquise Pino A, Fernández Palacín A, de la Fuente Vaquero P, Ramos Vega Z, Sainz Bueno JA. The correlation between the type of forceps application and the rate of levator ani muscle avulsion: A prospective cohort study. Neurourol Urodyn 2019; 37:1731-1736. [PMID: 30133851 DOI: 10.1002/nau.23500] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 12/25/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The association between the use of forceps and levator ani muscle (LAM) avulsion seems to be clear-cut. However, whether the lesion is due to the mechanical trauma yielded by the instrument or to the intrinsic complexity of this type of delivery, is yet to be determined. This study aims at determining the difference in LAM avulsion rate between Kielland rotational forceps and non-rotational forceps. STUDY DESIGN Prospective observational study with 94 nulliparous women with forceps-assisted deliveries (FD) between July 2015 and January 2016. 3D-TpUS was performed 6 months after every patient's delivery, during which LAM avulsion, and levator hiatus area and anteroposterior and transverse diameters were assessed. RESULTS A total of 89 nulliparous were studied, comprising 27 rotational-FD, and 62 non-rotational-FD. No differences in obstetric, intrapartum, or neonatal characteristics were observed between study groups. There were no statistically significant differences in the presence of avulsion between cases of rotational forceps (44.4% vs 35.5%, OR: 1.5 [0.6-3.6]), correction of asinclitism of the fetal head (34.4% vs. 40.4% OR: 0.8 [0.3-1.9]) or station (midforceps: 32.8% vs low forceps: 50.0% OR: 2.0 [0.8-5.1]). CONCLUSIONS We have not observed differences in the LAM-avulsion rate between rotational forceps and non-rotational forceps performed by highly experienced personnel in instrumental deliveries.
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Affiliation(s)
| | - Adriana Aquise Pino
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
| | - Ana Fernández Palacín
- Biostatistics Unit, Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain
| | | | - Zenaida Ramos Vega
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
| | - José Antonio Sainz Bueno
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain.,Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
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19
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Sainz JA, Martín-Martínez A, González-Diaz E, Fernández-Fernández C, Ortega I, Medina M, Fernández-Corona A, Fernández-Palacín A, García-Mejido JA. Influence of the disengagement of the forceps on levator ani muscle injuries in instrumental delivery: A multicenter study. Acta Obstet Gynecol Scand 2019; 98:1413-1419. [PMID: 31243757 DOI: 10.1111/aogs.13682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/12/2019] [Accepted: 06/18/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Forceps use is the main risk factor for levator ani muscle (LAM) injuries. We believe that the disengagement of the forceps branches before delivery of the fetal head could influence LAM injuries, so we aimed to determine the influence of the disengagement of the forceps on the occurrence of LAM avulsion during forceps delivery. MATERIAL AND METHODS A prospective, observational, multicenter study was conducted with 261 women who underwent forceps delivery. The women were classified according to whether the branches of the forceps had been disengaged before delivery of the fetal head. LAM avulsion was defined using a multislice mode (3 central slices). RESULTS In all, 255 women completed the study (160 without disengagement and 95 with disengagement). LAM avulsions were observed in 37.9% of women in the group with disengagement and in 41.9% of women in the group without disengagement. The crude OR (without disengagement vs with disengagement) for avulsion was 0.90 (95% CI 0.49-1.67, P = 0.757) and an adjusted OR of 0.82 (95% CI 0.40-1.69, P = 0.603). CONCLUSIONS We did not observe a statistically significant reduction in the LAM avulsion rate with disengagement of the forceps branches before delivery of the fetal head.
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Affiliation(s)
- José Antonio Sainz
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain.,Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
| | - Alicia Martín-Martínez
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Gran Canarias, Gran Canarias, Spain
| | - Enrique González-Diaz
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Leon (CAULE), Leon, Spain
| | - Camino Fernández-Fernández
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Leon (CAULE), Leon, Spain
| | - Ismael Ortega
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Gran Canarias, Gran Canarias, Spain
| | - Margarita Medina
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Gran Canarias, Gran Canarias, Spain
| | - Alfonso Fernández-Corona
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Leon (CAULE), Leon, Spain
| | - Ana Fernández-Palacín
- Biostatistics Unit, Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain
| | - José Antonio García-Mejido
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain.,Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
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Association between delivery mode and pelvic organ prolapse: A meta-analysis of observational studies. Eur J Obstet Gynecol Reprod Biol 2019; 235:19-25. [DOI: 10.1016/j.ejogrb.2019.01.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 12/23/2018] [Accepted: 01/23/2019] [Indexed: 11/23/2022]
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21
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Forceps delivery for non-rotational and rotational operative vaginal delivery. Best Pract Res Clin Obstet Gynaecol 2019; 56:55-68. [DOI: 10.1016/j.bpobgyn.2019.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 02/05/2019] [Indexed: 11/30/2022]
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22
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Volløyhaug I, Taithongchai A, Van Gruting I, Sultan A, Thakar R. Levator ani muscle morphology and function in women with obstetric anal sphincter injury. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:410-416. [PMID: 30207014 DOI: 10.1002/uog.20115] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/19/2018] [Accepted: 08/28/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To estimate the prevalence of, and explore the risk factors for, levator ani muscle (LAM) injury in women with clinically diagnosed obstetric anal sphincter injury (OASI). The secondary aim was to assess the association between LAM injury and pelvic floor muscle contraction, anal incontinence (AI) and urinary incontinence (UI) in women with OASI. METHODS This was a cross-sectional study of 250 women with OASI, recruited between 2013 and 2015 from a tertiary referral center at Croydon University Hospital, UK. AI symptoms were assessed using the modified St Mark's incontinence score and UI was assessed using the International Consultation on Incontinence modular Questionnaire for Urinary Incontinence - Short Form. All participants underwent three/four-dimensional transperineal ultrasound at rest and on maximum pelvic floor muscle contraction. Major LAM injury was defined as a unilateral or bilateral defect in all three central slices on tomographic ultrasound imaging. Muscle contraction was assessed using the modified Oxford scale (MOS) and measured on ultrasound as the proportional change in the anteroposterior (AP) levator hiatal diameter between rest and contraction. Multivariable logistic regression analysis was used to study risk factors for LAM injury. Differences in contraction and AI and UI symptoms between women with intact and those with injured LAM were studied using multivariable ANCOVA and the Mann-Whitney U-test. RESULTS Of the 248 women with OASI for whom ultrasound volumes of adequate quality were available, 29.4% were found to have major LAM injury. The prevalence of LAM injury was 23.6% after normal vaginal delivery and 40.2% after operative vaginal delivery (adjusted odds ratio, 4.1 (95% CI, 1.4-11.9); P = 0.01). LAM injury was associated with weaker pelvic floor muscle contraction, with an adjusted mean difference for proportional change in AP diameter of 5.0 (95% CI, 3.0-6.9) and MOS of 0.6 (95% CI, 0.3-0.9) (P < 0.001 for both). AI and UI symptom scores were similar between women with intact and those with injured LAM. CONCLUSIONS Operative vaginal delivery was a risk factor for LAM injury in women with OASI. LAM injury was associated with weaker pelvic floor muscle contraction. Special attention is recommended for women with OASI and LAM injury, as they are at high risk for future pelvic floor disorders. The benefits of implementation of an intensive, focused and structured pelvic floor rehabilitation program need to be evaluated in these women. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- I Volløyhaug
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Obstetrics and Gynaecology, Trondheim University Hospital, Trondheim, Norway
| | - A Taithongchai
- Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
| | - I Van Gruting
- Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
| | - A Sultan
- Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
| | - R Thakar
- Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
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García-Mejido JA, Fernández-Palacín A, Bonomi Barby MJ, Castro L, Aquise A, Sainz JA. A comparable rate of levator ani muscle injury in operative vaginal delivery (forceps and vacuum) according to the characteristics of the instrumentation. Acta Obstet Gynecol Scand 2019; 98:729-736. [PMID: 30681721 DOI: 10.1111/aogs.13544] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 01/17/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Forceps delivery is associated with a high rate of levator ani muscle (LAM) trauma (avulsion) at 35%-65% whereas data on avulsion rates after vacuum delivery vary greatly. Nevertheless, a common characteristic of all previous studies carried out to evaluate the association between instrumental deliveries (forceps and vacuum) and LAM avulsion, is the fact that characteristics of the instrumentation have not been described or evaluated. The objective of this study is to compare the rate of LAM avulsion between forceps and vacuum deliveries according to the characteristics of the instrumentation. MATERIAL AND METHODS Prospective, observational study, including 263 nulliparous women, who underwent an instrumental delivery with either Malmström vacuum or Kielland forceps. The characteristics of the instrumentation, position (anterior position and other position) and height of the fetal head at the moment of instrumentation (low instrumentation [vertex at +2 station] and mid-instrumentation [head is involved but leading part above +2 station]) were assessed. Evaluation of LAM avulsion was performed at 6 months postpartum by three-/four-dimensional transperineal ultrasound. Using the multi-view mode, a complete avulsion was diagnosed when the abnormal muscle insertion was identified in all three central slices, that is, in the plane of minimal hiatal dimensions and the 2.5-mm and 5.0-mm slices cranial to this one. To detect a 30% or 15% difference in the LAM injury rate, with 80% power and 5% α-error, we needed, respectively 42 and 99 women per study group. RESULTS In all, 263 nulliparous individuals have been evaluated (162 vacuum deliveries, 101 forceps deliveries). Instrumentation in an occipito-anterior position was more frequent in vacuum deliveries (75.3% vs 56.4%, P = .002), whereas other positions were more frequent in the forceps deliveries group (24.7% vs 43.6%). No statistically significant differences were noted regarding the height of the fetal head at the moment of instrumentation. No statistically significant differences were found in the presence of LAM avulsion (41.4% vs 38.6%) between vacuum and forceps deliveries. The univariate analysis of the crude odds ratio was 1.17, 95% CI 0.67-1.98, P = .70 for the avulsion of the LAM and the multivariate of the adjusted OR 0.90, 95% CI; 0.53-1.55, P = .71. CONCLUSIONS We consider that, in our population, LAM avulsion rate should not be a factor taken into account when choosing the type of instrumentation (Malmström vacuum or Kielland forceps) in an operative delivery.
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Affiliation(s)
- José A García-Mejido
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain.,Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
| | - Ana Fernández-Palacín
- Biostatistics Unit, Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain
| | - María J Bonomi Barby
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
| | - Laura Castro
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
| | - Adriana Aquise
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain.,Harris Birthright Research Center for Fetal Medicine, King's College Hospital, London, UK
| | - José A Sainz
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain.,Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
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Lin S, Atan IK, Dietz HP, Herbison P, Wilson PD. Delivery mode, levator avulsion and obstetric anal sphincter injury: A cross-sectional study 20 years after childbirth. Aust N Z J Obstet Gynaecol 2019; 59:590-596. [PMID: 30793279 DOI: 10.1111/ajo.12948] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 12/02/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Levator ani muscle (LAM) and anal sphincter injuries are common after vaginal birth and are associated with pelvic organ prolapse and anal incontinence. AIMS Our objective was to investigate long-term association between delivery mode, LAM avulsion and obstetric anal sphincter injuries (OASIS) in women at least 20 years after their first birth. METHODS All women recruited at 'index birth' of the Dunedin (New Zealand) arm of ProLong (PROlapse and incontinence LONG-term research) Study, were invited to have translabial and transperineal ultrasound assessment of LAM and anal sphincters. Post-processing analysis of imaging data was performed blinded against delivery data. Statistical analysis was performed using the χ2 test and results are expressed as odds ratios (OR). RESULTS Of the initial 1250 participants, 196 women returned for examination. Mean age was 50.8 years with a mean body mass index of 27.6 and median parity was three. They were seen on average 23 years after their first delivery. Four data sets were unavailable and one declined ultrasound assessment, leaving 191 for analysis. LAM avulsion was diagnosed in 29 (15.2%), and 24 women (12.6%) had significant anal sphincter defect. LAM avulsion was associated with forceps delivery (OR 2.45, 95% CI 1.04-5.80, P = 0.041). Forceps conveyed a greater risk of OASIS (21%) compared to a spontaneous vaginal delivery (11%) but did not reach statistical significance. CONCLUSIONS Forceps delivery is associated with long-term injurious effect on pelvic floor structures. Discussions of the long-term negative impact of pelvic floor structures and their functions are necessary to achieve an informed consent toward an operative vaginal delivery.
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Affiliation(s)
- Sylvia Lin
- Women's Health Waikato DHB, Hamilton, New Zealand.,Department of Obstetrics & Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Ixora Kamisan Atan
- Department of Obstetrics, Gynaecology & Neonatology, Sydney Medical School Nepean, The University of Sydney, Sydney, New South Wales, Australia.,Department of Obstetrics & Gynaecology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Hans Peter Dietz
- Department of Obstetrics, Gynaecology & Neonatology, Sydney Medical School Nepean, The University of Sydney, Sydney, New South Wales, Australia
| | - Peter Herbison
- Department of Preventive and Social Medicine Dunedin School of Medicine University of Otago, Dunedin, New Zealand
| | - Peter Donald Wilson
- Department of Women's and Children's Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Nyhus MØ, Salvesen KÅ, Volløyhaug I. Association between pelvic floor muscle trauma and contraction in parous women from a general population. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:262-268. [PMID: 30084230 DOI: 10.1002/uog.19195] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 07/13/2018] [Accepted: 07/16/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To study possible associations between pelvic floor muscle contraction, levator ani muscle (LAM) trauma and/or pelvic organ prolapse (POP) ≥ Stage 2 in parous women recruited from a general population. METHODS This was a secondary analysis of data from a cross-sectional study of 608 parous women from a general population examined using the POP quantification system (POP-Q) and three-dimensional/four-dimensional transperineal ultrasound for identification of LAM macrotrauma (avulsion) and microtrauma (distension of levator hiatal area > 75th percentile on Valsalva maneuver). Muscle contraction was assessed using the modified Oxford scale (MOS), perineometry and ultrasound measurement of proportional change of anteroposterior hiatal diameter and levator hiatal area at rest and on pelvic floor muscle contraction. The Mann-Whitney U-test was used to study associations between pelvic floor muscle contraction, LAM trauma and POP. RESULTS Women with macrotrauma (n = 113) had significantly weaker median pelvic floor muscle contraction, as measured using MOS and perineometry, than did women with an intact LAM (n = 493) (contraction strength was 1.5 (range, 0.0-5.0) vs 3.5 (range, 0.0-5.0) on MOS, and vaginal squeeze pressure was 15.0 (range, 0.0-78.0) cmH2 O vs 28.0 (range, 0.0-129.0) cmH2 O on perineometry; P < 0.001). This was also demonstrated by ultrasound measurement, with a proportional change in hiatal area of 19.9% (range, 4.1-48.0%) vs 34.0% (range, 0.0-64.0%) (P < 0.001) and proportional change in anteroposterior diameter of 16.2% (range, -5.7 to 42.6%) vs 26.0% (range, -3.4 to 49.4%) (P < 0.001). No statistically significant difference between women with (n = 65), and those without (n = 378), microtrauma was found after excluding women with macrotrauma. Women with POP had weaker muscle contraction than those without; in those with POP-Q ≥ 2 (n = 275) compared with those with POP-Q < 2 (n = 333), muscle contraction strength was 3.0 (range, 0.0-5.0) vs 3.5 (range, 0.0-5.0) on MOS, vaginal squeeze pressure was 21.0 (range, 0.0-98.0) cmH2 O vs 28.0 (range, 3.0-129.0) cmH2 O on perineometry, proportional change in hiatal area was 29.6% (range, 0.0-60.9%) vs 33.8% (range, 0.0-64.4%) and proportional change in anteroposterior diameter was 22.8% (range, -5.7 to 49.4%) vs 25.7% (range, -3.4 to 49.4%) (P < 0.001 for all). CONCLUSIONS LAM macrotrauma was associated with weaker pelvic floor muscle contraction measured using palpation, perineometry and ultrasound. Women with POP had weaker contraction than did women without POP. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M Ø Nyhus
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Obstetrics and Gynecology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - K Å Salvesen
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Obstetrics and Gynecology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - I Volløyhaug
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Obstetrics and Gynecology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Usman S, Kahrs B, Barton H, Salvesen K, Moe Eggebo T, Lees C. Time to delivery based on sonographic assessment prior to forceps and vacuum. Australas J Ultrasound Med 2019; 22:111-117. [PMID: 34760547 DOI: 10.1002/ajum.12121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Introduction To compare the duration of vacuum and forceps delivery in relation to ultrasound assessment of fetal head position and station. Methods A prospective single-centre cohort study in nulliparous women at term with prolonged second stage of labour. Fetal head position was determined using transabdominal ultrasound and station as head-perineum distance (HPD) from transperineal ultrasound prior to an instrument. The primary outcome was duration of vacuum and forceps to vaginal delivery and was analysed as survival expressed by hazard ratio (HR). Secondary outcomes were delivery mode and immediate neonatal outcome. Results In the study population of 54 women, the primary instrument was vacuum for 36 and forceps for 18. Four women were delivered by Caesarean section. Estimated median duration for forceps deliveries was 5 min (95% CI 4.0-6.0) vs. 9 min (95% CI 7.3-10.6) for vacuum deliveries (P = 0.17; Log-rank test). The HR for vaginal delivery was 2.02 (95% CI 1.04-3.91, P = 0.038) after adjusting for HPD, maternal age and BMI. OP position had minor influence on the primary outcome (HR changed from 2.02 to 2.08). The first instrument failed in 11/31 (35.5%) where HPD > 35 mm vs. 2/21 (9.5%) where HPD ≤ 35 mm (P < 0.05). There were no cases of Apgar score <7 at 5 min or umbilical artery pH < 7.1. Conclusion In prolonged second stage, delivery with forceps was achieved more quickly than by vacuum when matched for ultrasound determined head station. Irrespective of which was the primary instrument, the failure rate was greater at higher head stations.
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Affiliation(s)
- Sana Usman
- Department of Cancer and Surgery Institute of Reproductive Developmental Biology Hammersmith Campus Du Cane Road London W12 ONN UK.,Centre for Fetal Care Imperial College Healthcare NHS Trust Du Cane Road London W12 0HS UK
| | - Birgitte Kahrs
- National Center for Fetal Medicine St Olavs Hospital Trondheim University Hospital Prinsesse Kristinas Gate 3, 7030 Trondheim Norway.,Department of Clinical and Molecular Medicine Norwegian University of Science and Technology NO-7491 Trondheim Norway
| | - Helen Barton
- Department of Cancer and Surgery Institute of Reproductive Developmental Biology Hammersmith Campus Du Cane Road London W12 ONN UK
| | - Kjell Salvesen
- National Center for Fetal Medicine St Olavs Hospital Trondheim University Hospital Prinsesse Kristinas Gate 3, 7030 Trondheim Norway.,Department of Clinical and Molecular Medicine Norwegian University of Science and Technology NO-7491 Trondheim Norway
| | - Torbjorn Moe Eggebo
- National Center for Fetal Medicine St Olavs Hospital Trondheim University Hospital Prinsesse Kristinas Gate 3, 7030 Trondheim Norway.,Department of Clinical and Molecular Medicine Norwegian University of Science and Technology NO-7491 Trondheim Norway
| | - Christoph Lees
- Department of Cancer and Surgery Institute of Reproductive Developmental Biology Hammersmith Campus Du Cane Road London W12 ONN UK.,Centre for Fetal Care Imperial College Healthcare NHS Trust Du Cane Road London W12 0HS UK.,KU Leuven Oude Markt 13 3000 Leuven Belgium
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27
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Contributing factors in forceps associated pelvic floor trauma. Int Urogynecol J 2019; 31:167-171. [PMID: 30666429 DOI: 10.1007/s00192-019-03869-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/02/2019] [Indexed: 12/28/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Levator avulsion occurs in 10-35% of women after a first vaginal delivery, with forceps being the main risk factor. Three mechanisms have been proposed to account for the high risk of trauma: the additional space requirement, increased speed of distension, and/ or greater force. This study examines the additional space requirements associated with forceps to determine any associated increase in avulsion risk. METHODS This was an in vitro simulation study of spatial requirements for delivery of a fetal head by forceps, with mathematical modelling of spatial requirements using data from a local observational study. A balloon device was used to model head circumferences through the range of expected measurements at term, with measurements taken after application of three different types of forceps. Each measurement was performed in triplicate. RESULTS On average, forceps increased the circumference of the fetal head by 1.01 cm for Wrigley's, 1.04 cm for Kielland's, and 1.64 cm for Neville-Barnes forceps, resulting in an estimated increase in the diameter of the fetal head by 0.32 cm, 0.33 cm, and 0.52 cm, respectively. This increase was linear throughout the tested range. In 534 singleton pregnancies at term, we determined an odds ratio (OR) of 1.11 per centimeter head circumference for avulsion. Hence, the additional space requirement due to forceps explains ORs of 1.11, 1.12, and 1.19 for avulsion, depending on forceps type. CONCLUSIONS The effect of forceps on avulsion risk is not fully explained by the increase in space requirement alone. Other factors, such as shortened time to maximum distension and/or increased peak force applied may contribute to the excess risk.
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Delivery mode and the risk of levator muscle avulsion: a meta-analysis. Int Urogynecol J 2019; 30:901-907. [PMID: 30649566 DOI: 10.1007/s00192-018-3827-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 11/13/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Female pelvic organ prolapse (POP) is a common condition, with a lifetime risk for surgery of 10-20%. Pregnancy and childbirth are the commonest modifiable risk factors for POP, and avulsion of the levator ani muscle is likely to be an etiological factor. Avulsion is more common in instrumental delivery. However, we were unable to identify a meta-analysis on this issue. Our aim was to perform a systemic review and quantitative meta-analysis of the prevalence of avulsion relative to delivery mode. METHODS Four electronic databases (MEDLINE, PubMed, Embase, and Google Scholar) were searched for studies published between 1991 and 1 October 2018 without language restrictions. RESULTS Twenty studies met inclusion criteria, and 14 were prospective. Seventeen used sonographic techniques; three were magnetic resonance (MR) studies. For this review, three comparisons were performed: forceps vs. vacuum (9 studies), forceps vs. normal vaginal delivery (NVD) (12 studies), and vacuum vs. NVD (12 studies). The first meta-analysis showed an increased risk for avulsion following forceps compared with vacuum, with an odds ratio (OR) of 4.57 and confidence interval (CI) 3.21-6.51, p < 0.001. The second showed an increased risk for avulsion following forceps compared with NVD, with an OR of 6.94 (4.93-9.78), p < 0.001. The third showed no significant increased risk for avulsion following vacuum compared with NVD, with an OR of 1.31 (1.00-1.72), p = 0.051. CONCLUSIONS Forceps is a strong risk factor for avulsion, with an OR of 6.94 (4.93-9.78) compared with NVD and an OR of 4.57 (3.21-6.51) compared with vacuum birth.
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Turel F, Caagbay D, Dietz HP. Prevalence of Maternal Birth Trauma in Nepali Women. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:2803-2809. [PMID: 29676809 DOI: 10.1002/jum.14637] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/28/2018] [Accepted: 02/26/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Pelvic organ prolapse is very common among women in Nepal, especially uterine prolapse. This would suggest a high rate of levator trauma, which is a strong predictor of such prolapse in the Western world. Hence, we decided to study the prevalence of maternal birth trauma in Nepali women. METHODS In November 2016, we offered an interview, clinical examination, and 4-dimensional translabial sonography to women attending a gynecology clinic. Of 129 women seen, 5 were excluded due to previous pelvic surgery. Translabial sonography volume data sets were obtained and analyzed by tomographic imaging for levator ani and anal sphincter trauma at a later date, blinded against all clinical data. RESULTS Mean age was 39 (21-74) years, median vaginal parity was 2 (0-9), mean age at first delivery 21 (14-40). Seventeen (14%) had not given birth vaginally; of these, 14 (11%) delivered by cesarean only, and 3 (2%) were nulliparous. Tomographic assessment for levator avulsion and anal sphincter trauma was possible in 124 women and performed as previously described. We found 2 (2%) unilateral avulsions and significant external anal sphincter defects in another 2 women. CONCLUSIONS Levator and anal sphincter trauma are significantly less prevalent in Nepali women in comparison to Western populations. This is intriguing, especially in view of the high prevalence of prolapse in Nepali women.
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Affiliation(s)
- Friyan Turel
- Department of Obstetrics, Gynaecology & Neonatology, Sydney Medical School Nepean, Australia
| | - Delena Caagbay
- Department of Physiotherapy, University of Sydney, Australia
| | - Hans Peter Dietz
- Department of Obstetrics, Gynaecology & Neonatology, Sydney Medical School Nepean, Australia
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Riethmuller D, Ramanah R, Mottet N. [Fetal expulsion: Which interventions for perineal prevention? CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]. ACTA ACUST UNITED AC 2018; 46:937-947. [PMID: 30377094 DOI: 10.1016/j.gofs.2018.10.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The objective for all obstetricians and midwifes who intervene during the release of the fetal presentation is to prevent at best the perineal lesions. This work consisted in analyzing the literature, researching and evaluating interventions that reduce this perineal risk during the release. METHODS A keyword search for each medical intervention during the expulsion phase was conducted by selecting studies assessing perineal risk. Interventions during pregnancy and during delivery before the expulsion phase were specifically addressed in other sections of the recommendations. RESULTS Firstly, the degree of perineal stretching during the second stage of labour does not appear to be a risk factor for OASIS, postpartum incontinence, or sexual disorders (LE3) and that a substantial stretching of the perineum is not an indication of episiotomy (Professional consensus). Then, manual control of the expulsion of the fetus at the end of the second stage of labour and support of the posterior perineum during this time appear to reduce the rate of OASIS (LE3). The crowning of the baby's head should be manually controlled and the posterior perineum manually supported manually to reduce the risk of OASIS (GradeC). There is no recognised benefit to episiotomy in normal deliveries (LE1); the liberal practice of episiotomy results in fewer intact perineums than its restrictive practice, and the latter does not result in increasing the number of cases of OASIS. No evidence indicates that an episiotomy for women with a breech presentation, twin pregnancy, or posterior position prevents OASIS (LE3). Indication for episiotomy during delivery depends on individual risk factors and obstetric conditions (Professional consensus). It is recommended that the indication for episiotomy be explained and the woman's consent received before its performance. The performance of an episiotomy during normal deliveries is not recommended to reduce the risk of OASIS (Grade A). The liberal practice of episiotomy to prevent OASIS is not recommended for women with a breech presentation, twin pregnancy, or posterior position (GradeC). Episiotomy during an instrumental delivery appears to be associated with a reduction of the risk of OASIS (LE3). The vacuum extractor appears to induce fewer cases of OASIS than other instruments (LE3). Episiotomy may be indicated in instrumental deliveries to avoid OASIS (GradeC). Training in perineal protection in obstetrics is recommended (Grade B). In operative vaginal deliveries when several instruments can be used, a vacuum extractor is preferentially recommended to reduce the risk of OASIS (GradeC). When forceps or spatulas are used, it is preferable that they be withdrawn just before cephalic deflexion so that the fetal head is not "capped" with these instruments at birth (Professional consensus). Couder's maneuver, which consists of lowering the forearm during the release of the fetal shoulders, appears to decrease the rate of second-degree perineal tears and increase the rate of intact perineum (LE3). CONCLUSION Manual control of the expulsion and perineal support reduce the risk of perineal injury. There is no benefit to episiotomy in normal delivery, nor in special cases such the breech presentation for example. On the other hand, in case of instrumental delivery, an episiotomy may be indicated to avoid OASIS (GradeC), and it is recommended if it is possible to use the ventouse preferentially. The Couder's maneuver seems to reduce the rate of 2nd degree perineal lesions (LE3). Finally, training in perineal obstetric protection is recommended (Grade B).
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Affiliation(s)
- D Riethmuller
- Pôle Mère-Femme, CHRU Besançon, 3, boulevard Fleming, 25000 Besançon, France.
| | - R Ramanah
- Pôle Mère-Femme, CHRU Besançon, 3, boulevard Fleming, 25000 Besançon, France
| | - N Mottet
- Pôle Mère-Femme, CHRU Besançon, 3, boulevard Fleming, 25000 Besançon, France
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Volløyhaug I, Rojas RG, Mørkved S, Salvesen KÅ. Comparison of transperineal ultrasound with POP-Q for assessing symptoms of prolapse. Int Urogynecol J 2018; 30:595-602. [PMID: 30069728 DOI: 10.1007/s00192-018-3722-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 07/12/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Our aim was to study any correlation between pelvic organ prolapse quantification (POP-Q) and ultrasound measurement of prolapse in women from a normal population and to identify the method with a stronger association with prolapse symptoms. METHODS A cross-sectional study of 590 parous women responding to the Pelvic Floor Distress Inventory was carried out. They were examined using POP-Q and transperineal ultrasound, and correlation was tested using Spearman's rank test. Numerical measurements and significant prolapse (POP-Q ≥ 2 in any compartment or bladder ≥10 mm, cervix ≥0 mm or rectal ampulla ≥15 mm below the symphysis on ultrasound) were compared in symptomatic and asymptomatic women (Mann-Whitney U and Chi-squared tests). RESULTS A total of 256 women had POP-Q ≥ 2 and 209 had significant prolapse on ultrasound. The correlation (rs) between POP-Q and ultrasound was 0.69 (anterior compartment), 0.53 (middle), and 0.39 (posterior), p < 0.01. Women with a "vaginal bulge" (n = 68) had greater descent on POP-Q and ultrasound in the anterior and middle compartments than asymptomatic women, p < 0.01. For women with a symptomatic bulge, the odds ratio was 3.8 (95% CI 2.2-6.7) for POP-Q ≥ grade 2 and 2.4 (95% CI 1.4-3.9) for prolapse on ultrasound. A sensation of heaviness (n = 90) and incomplete bladder emptying (n = 4) were more weakly associated with ultrasound (p = 0.03 and 0.04), and splinting (n = 137) was associated with POP-Q Bp, p = 0.02. CONCLUSION POP-Q and ultrasound measurement of prolapse had moderate to strong correlation in the anterior and middle compartments and weak correlation in the posterior compartment. Both methods were strongly associated with the symptom "vaginal bulge," but POP-Q had a stronger association than ultrasound.
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Affiliation(s)
- Ingrid Volløyhaug
- Department of Obstetrics and Gynecology, Trondheim University Hospital, Trondheim, Norway. .,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, PO Box 8905, Medisinsk teknisk forskningssenter, 7491, Trondheim, Norway.
| | - Rodrigo Guzmán Rojas
- Departamento de Ginecología y Obstetricia, Facultad de Medicina, Clínica Alemana-Universidad del Desarrollo, Santiago, Chile.,Departamento de Ginecología y Obstetricia, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Siv Mørkved
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.,Research Department, Trondheim University Hospital, Trondheim, Norway
| | - Kjell Åsmund Salvesen
- Department of Obstetrics and Gynecology, Trondheim University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, PO Box 8905, Medisinsk teknisk forskningssenter, 7491, Trondheim, Norway
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Kahrs BH, Usman S, Ghi T, Youssef A, Torkildsen EA, Lindtjørn E, Østborg TB, Benediktsdottir S, Brooks L, Harmsen L, Salvesen KÅ, Lees CC, Eggebø TM. Fetal rotation during vacuum extractions for prolonged labor: a prospective cohort study. Acta Obstet Gynecol Scand 2018; 97:998-1005. [PMID: 29770435 DOI: 10.1111/aogs.13372] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 04/30/2018] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The aim of the study was to investigate fetal head rotation during vacuum extraction. MATERIAL AND METHODS We conducted a prospective cohort study from November 2013 to July 2016 in seven European hospitals. Fetal head position was determined with transabdominal or transperineal ultrasound and categorized as occiput anterior (OA), occiput transverse (OT) or occiput posterior (OP) position. Main outcome was the proportion of fetuses rotating during vacuum extraction. Secondary outcomes were conversion of delivery method, duration of vacuum extraction, umbilical artery pH <7.10 and agreement between clinical and ultrasound assessments. RESULTS The study population comprised 165 women. During vacuum extraction 117/119 (98%) remained in OA and two fetuses rotated to OP position. Rotation from OT to OA position occurred in 14/19 (74%) and to OP position in 5/19 (26%). Rotation from OP to OA position occurred in 15/25 (60%), and 10/25 (40%) fetuses remained in OP position. Delivery information was missing in two cases. The conversion rate from vacuum extraction to cesarean section or forceps was 10% in the OA group vs. 23% in the non-OA group; p < 0.05. The estimated duration of vacuum extraction was significantly shorter in OA fetuses, 7 min vs. 10 min (log rank test p < 0.01). There was no significant difference in umbilical artery pH < 7.10 between OA and non-OA position. Cohens Kappa of agreement between clinical and ultrasound assessments was 0.42 (95% CI 0.26-0.57). CONCLUSION Most fetuses in OP or OT positions rotated to OA position during vacuum extraction, but the proportion of failed vacuum extractions remained high.
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Affiliation(s)
- Birgitte H Kahrs
- National Center for Fetal Medicine, Trondheim University Hospital (St Olavs Hospital), Trondheim, Norway.,Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sana Usman
- Center for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | - Aly Youssef
- St Orsola Malpighi University Hospital, Bologna, Italy
| | - Erik A Torkildsen
- Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger, Norway
| | - Elsa Lindtjørn
- Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger, Norway
| | - Tilde B Østborg
- Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger, Norway
| | | | - Lis Brooks
- Hvidovre University Hospital, Copenhagen, Denmark
| | | | - Kjell Å Salvesen
- National Center for Fetal Medicine, Trondheim University Hospital (St Olavs Hospital), Trondheim, Norway.,Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Cristoph C Lees
- Center for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Torbjørn M Eggebø
- National Center for Fetal Medicine, Trondheim University Hospital (St Olavs Hospital), Trondheim, Norway.,Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger, Norway
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Guzmán Rojas RA, Salvesen KÅ, Volløyhaug I. Anal sphincter defects and fecal incontinence 15-24 years after first delivery: a cross-sectional study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:677-683. [PMID: 28782264 DOI: 10.1002/uog.18827] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 07/22/2017] [Accepted: 07/28/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To establish the prevalence of external (EAS) and internal (IAS) anal sphincter defects present 15-24 years after childbirth according to mode of delivery, and their association with development of fecal incontinence (FI). The study additionally aimed to compare the proportion of women with obstetric anal sphincter injuries (OASIS) reported at delivery with the proportion of women with sphincter defect detected on ultrasound 15-24 years later. METHODS This was a cross-sectional study including 563 women who delivered their first child between 1990 and 1997. Women responded to a validated questionnaire (Pelvic Floor Distress Inventory) in 2013-2014, from which the proportion of women with FI was recorded. Information about OASIS was obtained from the National Birth Registry. Study participants underwent four-dimensional transperineal ultrasound examination. Defect of EAS or IAS of ≥ 30° in at least four of six slices on tomographic ultrasound was considered a significant defect and was recorded. Four study groups were defined based on mode of delivery of the first child. Women who had delivered only by Cesarean section (CS) constituted the CS group. Women in the normal vaginal delivery (NVD) group had NVD of their first child and subsequent deliveries could be NVD or CS. The forceps delivery (FD) group included women who had FD, NVD or CS after FD of their first born. The vacuum delivery (VD) group included women who had VD, NVD or CS after VD of their first born. Multiple logistic regression was used to calculate adjusted odds ratios (aORs) for comparison of prevalence of an EAS defect following different modes of delivery and to test its association with FI. Fisher's exact test was used to calculate crude odds ratios (ORs) for IAS defects. RESULTS Defects of EAS and IAS were found after NVD (n = 201) in 10% and 1% of cases, respectively, after FD (n = 144) in 32% and 7% of cases and after VD (n = 120) in 15% and 4% of cases. No defects were found after CS (n = 98). FD was associated with increased risk of EAS defect compared with NVD (aOR = 3.6; 95% CI, 2.0-6.6) and VD (aOR = 3.0; 95% CI, 1.6-5.6) and with increased risk of IAS defect compared with NVD (OR = 7.4; 95% CI, 1.5-70.5). The difference between VD and NVD was not significant for EAS or IAS. FI was reported in 18% of women with an EAS defect, in 29% with an IAS defect and in 8% without a sphincter defect. EAS and IAS defects were associated with increased risk of FI (aOR = 2.5 (95% CI, 1.3-4.9) and OR = 4.2 (95% CI, 1.1-13.5), respectively). Of the ultrasonographic sphincter defects, 80% were not reported as OASIS at first or subsequent deliveries. CONCLUSIONS Anal sphincter defects visualized on transperineal ultrasound 15-24 years after first delivery were associated with FD and development of FI. Ultrasound revealed a high proportion of sphincter defects that were not recorded as OASIS at delivery. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R A Guzmán Rojas
- Departamento de Ginecología y Obstetricia, Facultad de Medicina, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
- Departamento de Ginecología y Obstetricia, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - K Å Salvesen
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Obstetrics and Gynaecology, Trondheim University Hospital, Trondheim, Norway
| | - I Volløyhaug
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Obstetrics and Gynaecology, Trondheim University Hospital, Trondheim, Norway
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Abstract
PURPOSE OF REVIEW There is increasing awareness of the importance of intrapartum events for future pelvic floor morbidity in women. In this review, we summarize recent evidence and potential consequences for clinical practice. RECENT FINDINGS Both epidemiological evidence and data from perinatal imaging studies have greatly improved our understanding of the link between childbirth and later morbidity. The main consequences of traumatic childbirth are pelvic organ prolapse (POP) and anal incontinence. In both instances the primary etiological pathways have been identified: levator trauma in the case of POP and anal sphincter tears in the case of anal incontinence. As most such trauma is occult, imaging is required for diagnosis. SUMMARY Childbirth-related major maternal trauma is much more common than generally assumed, and it is the primary etiological factor in POP and anal incontinence. Both sphincter and levator trauma can now be identified on imaging. This is crucial not only for clinical care and audit, but also for research. Postnatally diagnosed trauma can serve as intermediate outcome measure in intervention trials, opening up multiple opportunities for clinical research aimed at primary and secondary prevention.
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Kruger JA, Budgett SC, Wong V, Nielsen PM, Nash MP, Smalldridge J, Hayward LM, Tian TY, Taberner AJ. Characterizing levator-ani muscle stiffness pre- and post-childbirth in European and Polynesian women in New Zealand: a pilot study. Acta Obstet Gynecol Scand 2017; 96:1234-1242. [DOI: 10.1111/aogs.13186] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 06/18/2017] [Indexed: 01/17/2023]
Affiliation(s)
- Jennifer A. Kruger
- Auckland Bioengineering Institute; University of Auckland; Auckland New Zealand
| | | | - Vivien Wong
- Sydney Medical School Nepean; University of Sydney; Sydney Australia
| | - Poul M.F. Nielsen
- Auckland Bioengineering Institute; University of Auckland; Auckland New Zealand
- Department of Engineering Science; University of Auckland; Auckland New Zealand
| | - Martyn P. Nash
- Auckland Bioengineering Institute; University of Auckland; Auckland New Zealand
- Department of Engineering Science; University of Auckland; Auckland New Zealand
| | - Jackie Smalldridge
- Auckland Bioengineering Institute; University of Auckland; Auckland New Zealand
| | - Lynsey M. Hayward
- Auckland Bioengineering Institute; University of Auckland; Auckland New Zealand
| | - Tania Y. Tian
- Auckland Bioengineering Institute; University of Auckland; Auckland New Zealand
| | - Andrew J. Taberner
- Auckland Bioengineering Institute; University of Auckland; Auckland New Zealand
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36
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Bø K, Artal R, Barakat R, Brown WJ, Davies GAL, Dooley M, Evenson KR, Haakstad LAH, Kayser B, Kinnunen TI, Larsén K, Mottola MF, Nygaard I, van Poppel M, Stuge B, Khan KM. Exercise and pregnancy in recreational and elite athletes: 2016/17 evidence summary from the IOC Expert Group Meeting, Lausanne. Part 3-exercise in the postpartum period. Br J Sports Med 2017. [PMID: 28642221 DOI: 10.1136/bjsports-2017-097964] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Kari Bø
- Department of Sport Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Raul Artal
- Department of Obstetrics, Gynecology and Women's Health, Saint Louis University, St Louis, Missouri, USA
| | - Ruben Barakat
- Facultad de Ciencias de la Actividad Física y del Deporte - INEF, Universidad Politécnica de Madrid, Madrid, Spain
| | - Wendy J Brown
- Centre for Research on Exercise Physical Activity and Health, School of Human Movement and Nutrition Sciences, University of Queensland, St Lucia, Australia
| | - Gregory A L Davies
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Queen's University, Kingston, Canada
| | - Michael Dooley
- Department of Sport Gynaecology, Poundbury Clinic, Dorchester, UK.,Poundbury Clinic, King Edward VII Hospital, London, UK
| | - Kelly R Evenson
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lene A H Haakstad
- Department of Sport Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Bengt Kayser
- Faculty of Biology and Medicine, Institute of Sport Science, University of Lausanne, Lausanne, Switzerland
| | - Tarja I Kinnunen
- School of Health Sciences, University of Tampere, Tampere, Finland
| | - Karin Larsén
- The Swedish School of Sport and Health Sciences, Stockholm, Sweden
| | - Michelle F Mottola
- R Samuel McLaughlin Foundation-Exercise and Pregnancy Lab, The University of Western Ontario, London, Canada
| | - Ingrid Nygaard
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
| | | | - Britt Stuge
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Karim M Khan
- Department of Family Practice and School of Kinesiology, Centre for Hip Health and Mobility, University of British Columbia, Vancouver, Canada
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Saunders K. Recent Advances in Understanding Pelvic-Floor Tissue of Women With and Without Pelvic Organ Prolapse: Considerations for Physical Therapists. Phys Ther 2017; 97:455-463. [PMID: 28339839 DOI: 10.1093/ptj/pzx019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 11/13/2016] [Indexed: 11/12/2022]
Abstract
Pelvic organ prolapse is a fairly common condition that imposes significant symptoms, diminished quality of life, social burden, financial expense, and surgical risk on women. As evidence supporting the benefit of pelvic-floor muscle training in nonsurgical management of pelvic organ prolapse grows, physical therapists are becoming a provider of choice interacting with women affected by pelvic organ prolapse. This perspective article will review recent research on tissue characteristics of 3 key components of pelvic organ support: skeletal muscle, ligament, and vaginal wall. This information will be summarized as implications for physical therapists. An improved understanding of pelvic-floor tissue in women with and without pelvic organ prolapse will provide a more comprehensive appreciation of the interaction of multiple systems in the disorder.
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39
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Garcia-Mejido JA, Gutierrez L, Fernandez-Palacín A, Aquise A, Sainz JA. Levator ani muscle injuries associated with vaginal vacuum assisted delivery determined by 3/4D transperineal ultrasound. J Matern Fetal Neonatal Med 2016; 30:1891-1896. [DOI: 10.1080/14767058.2016.1228104] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- J. A. Garcia-Mejido
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain,
| | - L. Gutierrez
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain,
| | - A. Fernandez-Palacín
- Biostatistics Unit, Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain, and
| | - A. Aquise
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain,
| | - J. A. Sainz
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain,
- Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
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Volløyhaug I, Mørkved S, Salvesen Ø, Salvesen KÅ. Assessment of pelvic floor muscle contraction with palpation, perineometry and transperineal ultrasound: a cross-sectional study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:768-73. [PMID: 26300128 DOI: 10.1002/uog.15731] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 07/24/2015] [Accepted: 08/19/2015] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To study the correlation between palpation, perineometry and transperineal ultrasound for assessment of pelvic floor muscle contraction and to define a contraction scale for ultrasound measurements. METHODS This was a cross-sectional study of 608 women examined with palpation of pelvic floor muscle contraction, using the Modified Oxford Scale, and measurement of the vaginal squeeze pressure with a vaginal balloon connected to a fiber-optic microtip transducer (perineometry). Transperineal ultrasound was used for measurements of levator hiatal area and anteroposterior (AP) diameter in the plane of minimal hiatal dimensions, at rest and on contraction. The pelvic floor muscle contraction was expressed as the percentage difference between values at rest and on contraction. Spearman's rank was used to test for correlation between the different methods of assessment. RESULTS Significant correlations were found between all assessment methods (P < 0.001). Palpation correlated with perineometry (rs = 0.74) and with proportional change in hiatal area (rs = 0.67) and AP diameter (rs = 0.69) on ultrasound. Perineometry correlated with proportional change in hiatal area (rs = 0.60) and AP diameter (rs = 0.66) on ultrasound. We defined a contraction scale based on the proportional change in AP diameter. In this population, a change in AP diameter of < 7% corresponded to absence of contractions, 7-18% corresponded to weak contractions, 18-35% corresponded to normal contractions and > 35% corresponded to strong contractions. CONCLUSIONS We found moderate to strong correlation between ultrasound measurements, palpation and perineometry for assessing pelvic floor muscle contraction. The proportional change in levator hiatal AP diameter was the ultrasound measurement with strongest correlation to palpation and perineometry and formed the basis for the contraction scale for ultrasound measurements. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- I Volløyhaug
- Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Obstetrics and Gynecology, Trondheim University Hospital, Trondheim, Norway
| | - S Mørkved
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
- Clinical Service, Trondheim University Hospital, Trondheim, Norway
| | - Ø Salvesen
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
| | - K Å Salvesen
- Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway
- National Center for Fetal Medicine, Trondheim University Hospital, Trondheim, Norway
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Bazi T, Takahashi S, Ismail S, Bø K, Ruiz-Zapata AM, Duckett J, Kammerer-Doak D. Prevention of pelvic floor disorders: international urogynecological association research and development committee opinion. Int Urogynecol J 2016; 27:1785-1795. [PMID: 26971276 DOI: 10.1007/s00192-016-2993-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 02/18/2016] [Indexed: 12/19/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Pelvic floor disorders (PFD), including urinary incontinence, anal incontinence, and pelvic organ prolapse, are common and have a negative effect on the quality of life of women. Treatment is associated with morbidity and may not be totally satisfactory. Prevention of PFDs, when possible, should be a primary goal. The purpose of this paper is to summarise the current literature and give an evidence-based review of the prevention of PFDs METHODS: A working subcommittee from the International Urogynecological Association (IUGA) Research and Development (R&D) Committee was formed. An initial document addressing the prevention of PFDs was drafted, based on a review of the English-language literature. After evaluation by the entire IUGA R&D Committee, revisions were made. The final document represents the IUGA R&D Committee Opinion on the prevention of PFDs. RESULTS This R&D Committee Opinion reviews the literature on the prevention of PFDs and summarises the findings with evidence-based recommendations. CONCLUSIONS Pelvic floor disorders have a long latency, and may go through periods of remission, thus making causality difficult to confirm. Nevertheless, prevention strategies targeting modifiable risk factors should be incorporated into clinical practice before the absence of symptomatology.
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Affiliation(s)
- Tony Bazi
- Department of Obstetrics and Gynecology, Faculty of Medicine, American University of Beirut Medical Center, PO Box 11-0236, Riad El-Solh, Beirut, 1107 2020, Lebanon.
| | - Satoru Takahashi
- Department of Urology, Nihon University School of Medicine, Tokyo, Japan
| | - Sharif Ismail
- Brighton and Sussex Medical School, Brighton and Sussex University Hospitals NHS Trust, Brighton, England, UK
| | - Kari Bø
- Norwegian School of Sport Sciences, Oslo, Norway
| | - Alejandra M Ruiz-Zapata
- Department of Obstetrics and Gynecology, Department of Urology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jonathan Duckett
- Directorate of Women's Health, Medway NHS Foundation Trust, Gillingham, UK
| | - Dorothy Kammerer-Doak
- Women's Pelvic Specialty Care of New Mexico, University of New Mexico Hospital, Albuquerque, NM, USA
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Nygaard I. New directions in understanding how the pelvic floor prepares for and recovers from vaginal delivery. Am J Obstet Gynecol 2015. [PMID: 26216178 DOI: 10.1016/j.ajog.2015.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ingrid Nygaard
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT.
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