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Amin Z, El-Naggar AK, Offiah I, Dua A, Freeman R. Systematic Review and Meta-analysis of the Prevalence of Levator Ani Avulsion with Obstetric Anal Sphincter Injury and its Effects on Pelvic Floor Dysfunction. Int Urogynecol J 2024; 35:955-965. [PMID: 38523161 DOI: 10.1007/s00192-024-05756-w] [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: 09/21/2023] [Accepted: 02/08/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to evaluate the prevalence of levator ani avulsion (LAA) among primiparous women with obstetric anal sphincter injury (OASI) and how this association could affect future pelvic floor dysfunction. METHODS Three electronic databases (MEDLINE/PubMed/EMBASE) were searched in December 2018 and again in October 2022. Nine full-text articles were included in the analysis. The exclusion criteria were language other than English, studies not based on primiparous women only, conference abstracts, and evaluation without ultrasound or MRI. RESULTS The overall prevalence of LAA was 24% (95% CI: 18-30%). Those with OASI, were at a higher risk of LAA, OR 3.49 (95% CI: 1.46 to 8.35). In women with LAA + OASI versus OASI alone, Three of Five studies showed worsened AI symptoms. Three of Five studies assessing urinary incontinence (UI) reported no significant difference in UI, whereas two reported increased UI. All studies that looked at pelvic organ prolapse reported a higher incidence of symptomatic prolapse and reduced pelvic floor muscle strength in women with LAA + OASI compared with those without LAA. CONCLUSION Levator ani avulsion is prevalent following vaginal birth and is strongly associated with OASI. Incidence of AI does not increase in women with LAA and OASI, but they had greater symptom bother. OASI with LAA appears to increase the incidence of pelvic floor weakness and pelvic organ prolapse. There is no consensus agreement on the effect of LAA + OASI on UI.
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Affiliation(s)
- Zohra Amin
- The Royal Oldham Hospital NHS Trust, Oldham, UK.
| | | | | | - Anupreet Dua
- University Hospitals Plymouth NHS Trust, Plymouth, UK
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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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Lin W, Lin L, Dong B, Chen L, Lei H, Gao Y, Chen Y, Sun P. The Role of Obstetric Factors, miRNA-30d and miRNA-181a in Postpartum Women with Pelvic Organ Prolapse. Risk Manag Healthc Policy 2020; 13:2309-2316. [PMID: 33149711 PMCID: PMC7604264 DOI: 10.2147/rmhp.s268235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/15/2020] [Indexed: 01/06/2023] Open
Abstract
Background The diagnosis of postpartum pelvic organ prolapse (POP) relies on symptoms combined with pelvic organ prolapse-quantification (POP-Q) and lacks serological indicators. The objective of this study was to assess serum elastin, type I collagen, miRNA-30d, and miRNA-181a in the early postpartum period to identify hematologic predictors of POP. Material and Methods The study included 1013 42- to 60-day-postpartum women who had delivered at Quanzhou Women's and Children's Hospital from October 1, 2016, to October 31, 2017. This study was performed in accordance with the Declaration of Helsinki. The pregnancy and childbirth characteristics and pelvic floor function were evaluated. Forty cases with and without POP were matched, and serum elastin and type I collagen were determined by enzyme-linked immunosorbent assay (ELISA). Reverse-transcription polymerase chain reaction (RT-PCR) was used to detect miRNA-30d and miRNA-181a in 15 pairs. Results Of the 1013 women recruited, 699 (69.00%) were diagnosed with POP. The mean age was 29.00 years old, and the mean body mass index (BMI) was 22.6 kg/m2. In the univariate analysis, age ≥35 years (OR, 1.449; 95% CI, 0.965, 2.298), postpartum BMI ≥ 24 (OR, 4.402; 95% CI, 2.657, 6.148), neonatal weight ≥4 kg (OR, 4.832; 95% CI, 1.373, 17.290) and vaginal delivery (OR, 2.751; 95% CI, 1.855, 4.081) were risk factors for postpartum POP. There were no significant differences in the concentrations of serum elastin and type I collagen between the groups (P=0.52; P=0.26). There were significant differences in the concentrations of miRNA-30d and miRNA-181a between the groups (P=0.004; P=0.003). Conclusion miRNA-30d and miRNA-181a tended to be increased in women with POP and could be potential clinical predictors.
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Affiliation(s)
- Wenyu Lin
- Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Liqing Lin
- Department of Women's Health Care, Quanzhou Women's and Children's Hospital, Quanzhou, 362000, People's Republic of China
| | - Binhua Dong
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China.,Laboratory of Gynecologic Oncology, Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Lihua Chen
- Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China
| | - Huifang Lei
- Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Yuqin Gao
- Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Yaojia Chen
- Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Pengming Sun
- Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China.,Laboratory of Gynecologic Oncology, Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China
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Lima CTS, Brito GA, Karbage SAL, Bilhar APM, Grande AJ, Carvalho FHC, Bezerra LRPS, Nascimento SL. Pelvic floor ultrasound finds after episiotomy and severe perineal tear: systematic review and meta-analysis. J Matern Fetal Neonatal Med 2020; 35:2375-2386. [PMID: 32660290 DOI: 10.1080/14767058.2020.1786049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AIM Vaginal delivery is a well-known risk factor for pelvic floor muscle (PFM) injuries, mainly when associated to prolonged labor, instrumental birth and perineal trauma such as episiotomy and perineal tears. The purpose of this meta-analysis was to test the hypothesis that episiotomy and severe perineal tear may increase the risk of pelvic floor damage. METHODS We performed a systematic literature search through electronic databases including MEDLINE via PubMed, LILACS via BVS, Embase via Elsevier and Cochrane Library up to January 2019. We included articles that reported as outcome one or more morphological aspects of the PFM evaluated by ultrasonography in primiparous women three to 24 months postpartum. This review is registered in the PROSPERO database (registration number: CRD42017075750). RESULTS the final selection was composed of 18 articles for the systematic review, and 10 for the meta-analysis. Women with levator ani muscle (LAM) avulsion were 1.77 times more likely to have undergone episiotomy (OR = 1.77, CI 95% 1.25-2.51, five trials), 4.31 times more likely to have severe perineal tear (OR = 4.31, CI 95% 2.34-7.91, two trials). Women with defects in the anal sphincters were 2.82 times more likely to have suffered severe perineal tear (OR = 2.82, 95% CI 1.71-4.67, three trials). CONCLUSIONS Both episiotomy and severe perineal tear are risk factors for LAM avulsion and anal sphincter injury, and this can be useful for identifying women who are at greater risk of developing PFM dysfunctions.
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Affiliation(s)
- Clara Taína Silva Lima
- Department of Women's, Child and Adolescent Health, Federal University of Ceara, Fortaleza, Brazil
| | | | | | - Andreisa Paiva Monteiro Bilhar
- Department of Women's, Child and Adolescent Health, Federal University of Ceara, Fortaleza, Brazil.,Maternity School Assis Chateaubriand, Fortaleza, Brazil
| | - Antônio José Grande
- Medicine and Sciences Department, State University of Mato Grosso do Sul, Brazil
| | - Francisco Herlânio Costa Carvalho
- Department of Women's, Child and Adolescent Health, Federal University of Ceara, Fortaleza, Brazil.,Maternity School Assis Chateaubriand, Fortaleza, Brazil
| | | | - Simony Lira Nascimento
- Department of Women's, Child and Adolescent Health, Federal University of Ceara, Fortaleza, Brazil.,Department of Physical Therapy, Federal University of Ceara, Fortaleza, Brazil.,Maternity School Assis Chateaubriand, Fortaleza, Brazil
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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: 21] [Impact Index Per Article: 4.2] [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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Martínez Franco E, López Negre JL, Parés D, Ros Cerro C, Amat Tardiu L, Cuadras D, Espuña Pons M. Anatomic and functional evaluation of the levator ani muscle after an obstetric anal sphincter injury. Arch Gynecol Obstet 2019; 299:1001-1006. [PMID: 30729292 DOI: 10.1007/s00404-019-05070-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/25/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE To study the relationship between symptoms of anal incontinence (AI) and the anatomy and functionality of the levator ani muscle in women with a history of obstetric anal sphincter injury (OASI). METHODS This is a cohort study including patients with OASI from 2013 to 2016. Patients were assessed by a physical examination, endoanal ultrasound using Starck Scale, perineometry and 4D transperineal ultrasound. AI in all patients was measured with the Wexner scale. Correlation between variables has been analyzed in these patients. RESULTS 72 patients were analyzed: 28 with a IIIA degree tear, 26 with a IIIB, 13 with a IIIC and 5 with a IV. 38 patients showed a residual anal sphincter (AS) defect on endoanal ultrasound with an average Starck score of 6.5 ± 3.7. 21 patients expressed AI, with an average Wexner score of 4.1 ± 2.4. In 27 (37.5%) patients, a levator ani avulsion was observed: 17 unilateral and 10 bilateral. Patients with a levator ani defect had weaker pelvic floor muscle (PFM) function. These differences were statistically significant with perineometry (p = 0.01 and p = 0.03) but not for the Oxford test (p = 0.08). Patients with a residual AS defect as well as an injury to the levator ani muscle expressed greater AI symptomatology than patients with residual sphincter injury who maintain the integrity of the levator ani: Wexner 4.9 0.9 vs 3.3 1 (p = 0.02). CONCLUSIONS The PFM has correlation with AI symptom development in patients with a history of OASI. Therefore, we suggest a key role of anatomical and functional assessments of the levator ani muscle in these patients.
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Affiliation(s)
- Eva Martínez Franco
- Obstetrics and Gynecology Department, Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Camí Vell de la Colonia num 25, 08830, Sant Boi de Llobregat, Spain.
| | - José Luís López Negre
- General and Digestive Surgery Department, Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Sant Boi de Llobregat, Spain
| | - David Parés
- Colorectal Surgery Unit, General and Digestive Surgery Department, Hospital Germans Trias I Pujol, Universitat Autónoma de Barcelona, Badalona, Spain
| | - Cristina Ros Cerro
- Obstetrics and Gynecology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Lluís Amat Tardiu
- Obstetrics and Gynecology Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Spain
| | - Daniel Cuadras
- Statistical and Methodological Department, Sant Joan de Déu Research Foundation, Esplugues de Llobregat, Spain
| | - Montserrat Espuña Pons
- Obstetrics and Gynecology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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