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Yang Z, Zhou L, Yang L, He H. Restoration of bladder neck activity and levator hiatus dimensions in Asian primipara: a prospective study. J OBSTET GYNAECOL 2023; 43:2173564. [PMID: 36752287 DOI: 10.1080/01443615.2023.2173564] [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: 02/09/2023]
Abstract
Pelvic floor muscle training (PFMT) reduces the symptoms in women with pelvic floor dysfunction (PFD); however, the optimal initial timing for secondary prevention of PFD by PFMT is not clear. To identify the optimal timing in Asian primiparas with vaginal delivery, bladder neck descent (BND), levator hiatus areas, and levator hiatus distensibility and contractility were assessed in 26 nulliparous women at 36 weeks of gestation and at 2, 4, 6, and 12 weeks postpartum. We found that BND increased significantly from 2 weeks onwards until 6 weeks postpartum (p = 0.004); the levator hiatus area at rest and contraction both showed the largest value at 2 weeks postpartum (p = 0.005 and p < 0.005 respectively), followed by a continuous decrease; the hiatus area during Valsalva manoeuvre, and the levator hiatus distensibility and contractility showed the lowest value at 2 weeks postpartum, followed by a continuous increase; the changes in BND showed no correlation with the changes in distensibility or hiatus area during Valsalva manoeuvre (p = 0.073 and 0.590 respectively). In Asian primiparas with vaginal delivery, the recovery of levator hiatus and bladder neck mobility begins at 2 and 6 weeks, respectively. This information could be useful in defining the best time to begin PFMT for secondary prevention of postpartum PFD in Asian primiparous women.IMPACT STATEMENTWhat is already known on this subject? Pelvic floor muscle training (PFMT) helps to reduce symptoms of pelvic floor dysfunction (PFD), however, there are no clear time strategies for the secondary prevention of PFD by PFMT in Asian primiparas with vaginal delivery.What do the results of this study add? This study was the first longitudinal study in Asian primipara to investigate the natural regeneration of pelvic floor functions in the early postpartum period by intensively monitoring the bladder neck mobility and levator hiatus dimensions at multiple time points. We found that bladder neck descent (BND) increased significantly from 2 weeks onwards until 6 weeks postpartum; the levator hiatus area at rest and contraction both showed the largest value at 2 weeks postpartum, followed by a continuous decrease; the hiatus area during Valsalva manoeuvre, and the levator hiatus distensibility and contractility showed the lowest value at 2 weeks postpartum, followed by a continuous increase; the changes in BND showed no correlation with the changes in distensibility or hiatus area during Valsalva manoeuvre.What are the implications of these findings for clinical practice and/or further research? Our study suggested that in Asian primipara, the recovery of bladder neck mobility after vaginal delivery begins at 6 weeks postpartum, while the levator hiatus muscle begins to recover within the first 2 weeks postpartum. Therefore, it could be useful in deciding the best time to start PFMT for secondary prevention of postpartum PFD in Asian primiparous women.
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Affiliation(s)
- Zexuan Yang
- Department of Ultrasound, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, The People's Republic of China (PRC)
| | - Liuying Zhou
- Department of Ultrasound, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, The People's Republic of China (PRC)
| | - Liwen Yang
- Department of Ultrasound, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, The People's Republic of China (PRC)
| | - Hui He
- Department of Ultrasound, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, The People's Republic of China (PRC)
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Kiefner B, Schwab F, Kuppinger M, Nacke A, Kelkenberg U, Schütze S, Berger F, Lindner A, Hellmeyer L, Janni W, Metz M, Deniz M. Evaluating compliance and applicability of postpartum pessary use for preventing and treating pelvic floor dysfunction: a prospective multicenter study. Arch Gynecol Obstet 2023; 308:651-659. [PMID: 37210701 PMCID: PMC10293351 DOI: 10.1007/s00404-023-07075-9] [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: 03/13/2023] [Accepted: 05/04/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE Pelvic floor disorders are common and associated with pregnancy and childbirth. For restitution of pelvic floor connective tissue and thereby therapy of postpartum pelvic organ prolapse and stress urinary incontinence, the Restifem® pessary is approved. It supports the anterior vaginal wall behind the symphysis, the lateral sulci and the sacro-uterine ligaments and stabilises the connective tissue. We evaluated the compliance and applicability of Restifem® use in women postpartum in a preventive and therapeutic approach. METHODS Restifem® pessary was handed out to 857 women. Six weeks after birth, they started the pessary use. After 8 weeks, 3 and 6 months postpartum, women received a questionnaire via online survey for evaluation of pessary applicability and efficacy. RESULTS After 8 weeks, 209 women answered the questionnaire. 119 women used the pessary. Common problems were discomfort, pain and the pessary use was to circuitous. Vaginal infections were rare. After 3 months, 85 women and after 6 months, 38 women still used the pessary. 3 months postpartum, 94% of women with POP, 72% of women with UI and 66% of women with OAB stated to have an improvement of their symptoms using the pessary. 88% women without any disorder felt an improvement of stability. CONCLUSIONS Use of the Restifem® pessary in the postpartum period is feasible and accompanied with less complications. It reduces POP and UI and leads to an increased sense of stability. So, Restifem® pessary can be offered to women postpartum to improve pelvic floor dysfunction.
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Affiliation(s)
| | - Frank Schwab
- Charité Universitätsmedizin Berlin, Institute of Hygiene and Environmental Medicine, Berlin, Germany
| | | | - Anna Nacke
- Vivantes Klinikum Friedrichshain, Department of Obstetrics, Berlin, Germany
| | - Ute Kelkenberg
- Klinikum Bielefeld, Departement of Obstetrics and Gynecology, Bielefeld, Germany
| | | | | | | | - Lars Hellmeyer
- Vivantes Klinikum Friedrichshain, Department of Obstetrics, Berlin, Germany
| | | | - Melanie Metz
- Vivantes Klinikum Friedrichshain, Department of Obstetrics, Berlin, Germany
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Cheng W, English E, Horner W, Swenson CW, Chen L, Pipitone F, Ashton-Miller JA, DeLancey JOL. Hiatal failure: effects of pregnancy, delivery, and pelvic floor disorders on level III factors. Int Urogynecol J 2023; 34:327-343. [PMID: 36129480 PMCID: PMC10171831 DOI: 10.1007/s00192-022-05354-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 08/28/2022] [Indexed: 01/26/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The failure of the levator hiatus (LH) and urogenital hiatus (UGH) to remain closed is not only associated with pelvic floor disorders, but also contributes to recurrence after surgical repair. Pregnancy and vaginal birth are key events affecting this closure. An understanding of normal and failed hiatal closure is necessary to understand, manage, and prevent pelvic floor disorders. METHODS This narrative review was conducted by applying the keywords "levator hiatus" OR "genital hiatus" OR "urogenital hiatus" in PubMed. Articles that reported hiatal size related to pelvic floor disorders and pregnancy were chosen. Weighted averages for hiatal size were calculated for each clinical situation. RESULTS Women with prolapse have a 22% and 30% larger LH area measured by ultrasound at rest and during Valsalva than parous women with normal support. Women with persistently enlarged UGH have 2-3 times higher postoperative failure rates after surgery for prolapse. During pregnancy, the LH area at Valsalva increases by 29% from the first to the third trimester in preparation for childbirth. The enlarged postpartum hiatus recovers over time, but does not return to nulliparous size after vaginal birth. Levator muscle injury during vaginal birth, especially forceps-assisted, is associated with increases in hiatal size; however, it only explains a portion of hiatus variation-the rest can be explained by pelvic muscle function and possibly injury to other level III structures. CONCLUSIONS Failed hiatal closure is strongly related to pelvic floor disorders. Vaginal birth and levator injury are primary factors affecting this important mechanism.
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Affiliation(s)
- Wenjin Cheng
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.
- Beaumont Hospital Dearborn, Department of Obstetrics and Gynecology, 18101 Oakwood Blvd, Dearborn, MI, 48124, USA.
| | - Emily English
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Michigan Medicine, University of Michigan Health-West, Grand Rapids, MI, USA
| | - Whitney Horner
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Carolyn W Swenson
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Division of Urogynecology and Pelvic Reconstructive, University of Utah, Salt Lake City, UT, USA
| | - Luyun Chen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Fernanda Pipitone
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - James A Ashton-Miller
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - John O L DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
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Burkett LS, Canavan TP, Glass Clark SM, Giugale LE, Artsen AM, Moalli PA. Reducing pelvic floor injury by induction of labor. Int Urogynecol J 2022; 33:3355-3364. [PMID: 35976420 PMCID: PMC9383672 DOI: 10.1007/s00192-022-05296-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/27/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We hypothesized that elective induction of labor (eIOL) at 39 weeks is protective of levator ani muscle injury (LAMI) and is associated with decreased pelvic symptoms at 6 weeks postpartum compared to expectant management of labor. METHODS Prospective cohort pilot study of uncomplicated, primiparous women with a singleton, vertex gestation enrolled immediately post-vaginal delivery (VD). Subjects were dichotomized into two groups based on labor management: eIOL without complication defined by the ARRIVE trial versus spontaneous VD between 39 weeks0/7 and 42 weeks5/7 or no indication for IOL prior to 40 weeks5/7. The primary outcome was LAMI at 6 weeks postpartum as evidenced by any of the following ultrasound measures: (1) increased levator hiatal area (LHA) > 2500 mm2, (2) increased elasticity index (EI, > 75th quartile) or (3) levator enthesis avulsion. RESULTS Analysis represents 45/102 consented women from July 2019-October 2020 (eIOL n = 22 and spontaneous VD, n = 23). Neither maternal, clinical, sociodemographic characteristics nor pelvic symptoms differed between groups. Fewer women had LAMI as defined by the primary outcome with eIOL (n = 5, 23.8%) compared to spontaneous VD (n = 15, 65.2%), p = 0.008. Levator enthesis was more deformable (increased EI) with spontaneous VD as compared to the eIOL [10.66 (8.99) vs. 5.68 (2.93), p = 0.046]. On univariate logistic regression women undergoing spontaneous VD had unadjusted OR of 6.0 (1.6-22.5, p = 0.008) of sustaining LAMI compared to those undergoing eIOL. CONCLUSIONS Composite measures of LAMI though not pelvic floor symptoms were markedly increased in women undergoing spontaneous VD compared to those undergoing eIOL at 39 weeks.
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Affiliation(s)
- Linda S Burkett
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA
- Virginia Commonwealth University Health System, 1250 East Marshall Street, Richmond, VA, 23298, USA
| | - Timothy P Canavan
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA
| | - Stephanie M Glass Clark
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA
| | - Lauren E Giugale
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA
| | - Amanda M Artsen
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA
| | - Pamela A Moalli
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA.
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA.
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Liu Y, Liu P, Peng C, Chen C, Lu Y, Li Y, Chen R. Three‐dimensional magnetic resonance imaging assessment of levator ani in women progressing from full‐term pregnancy to 10 months postpartum. J Obstet Gynaecol Res 2022; 48:2552-2562. [PMID: 35869635 DOI: 10.1111/jog.15370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Yunlu Liu
- Department of Obstetrics and Gynecology, Nanfang Hospital Southern Medical University Guangzhou China
| | - Ping Liu
- Department of Obstetrics and Gynecology, Nanfang Hospital Southern Medical University Guangzhou China
| | - Cheng Peng
- Department of Obstetrics and Gynecology, Nanfang Hospital Southern Medical University Guangzhou China
| | - Chunlin Chen
- Department of Obstetrics and Gynecology, Nanfang Hospital Southern Medical University Guangzhou China
| | - Yijia Lu
- Department of Obstetrics and Gynecology, Nanfang Hospital Southern Medical University Guangzhou China
| | - Yige Li
- Department of Obstetrics and Gynecology, Nanfang Hospital Southern Medical University Guangzhou China
| | - Ruiying Chen
- Department of Radiology, Nanfang Hospital Southern Medical University Guangzhou China
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Moossdorff-Steinhauser HFA, Berghmans BCM, Spaanderman MEA, Bols EMJ. Urinary incontinence 6 weeks to 1 year post-partum: prevalence, experience of bother, beliefs, and help-seeking behavior. Int Urogynecol J 2021; 32:1817-1824. [PMID: 33484286 PMCID: PMC8295159 DOI: 10.1007/s00192-020-04644-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 12/09/2020] [Indexed: 01/28/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Post-partum, women often experience urinary incontinence (UI). However, the association between experienced UI bother and UI beliefs and help-seeking behavior is less known. Therefore, we aim to investigate the prevalence of self-reported UI, the level of experienced bother and beliefs, to explain help-seeking behavior for UI in women in the Netherlands from 6 weeks to one year post-partum. METHODS A digital survey among post-partum women, shared on social media, was used for recruitment. The survey consists of: 1. demographic variables, 2. International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF), 3. ICIQ Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTSqol), and 4. questions on beliefs and help-seeking behavior. For analysis, descriptive statistics and the independent samples t-test were used to determine differences between help- and non-help-seekers. RESULTS 415 women filled in the survey. The mean age was 30.6 years (SD 4.0, range 21-40) of which 48.2% was primiparous. The overall prevalence of UI was 57.1% (95% confidence interval (CI) (52.3-61.8)). Primiparous women reported a statistically significantly lower overall prevalence than multiparous women, 52.0% and 61.9% respectively (p = .043). UI was reported as bothersome in 38% of women, 25% of all women sought help. Help-seeking women showed significantly higher scores for bother, measured by the ICIQ-UI SF, than non-help seekers (p = .001). CONCLUSIONS More than half of all post-partum women in the Netherlands from 6 weeks to one year post childbirth experience UI (57.1%), 38% classified their UI as bothersome. In total 25% of UI women sought professional help.
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Affiliation(s)
| | - Bary C M Berghmans
- Pelvic Care Unit Maastricht, CAPHRI, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | | | - Esther M J Bols
- Care and Public Health Research Institute (CAPHRI), Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
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Zhou B, Zhang H, Yuan J, Bu C, Lai W. Pelvic floor assessment using magnetic resonance imaging after vaginal delivery and elective caesarean delivery. Int Urogynecol J 2020; 32:3023-3029. [PMID: 32886174 DOI: 10.1007/s00192-020-04514-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/21/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We aimed to compare quantitative static and dynamic magnetic resonance imaging (MRI) measurements of pelvic floor changes during postpartum recovery from 1 week to 6 months after different modes of delivery. METHODS In this prospective study, 51 primiparous women (vaginal delivery group: 30 women; elective caesarean delivery group: 21 women) underwent static and dynamic MRI at 1 week, 6 weeks, 3 months, and 6 months postpartum to measure pelvic floor MRI values. Between-group differences in pelvic floor values at these time points were determined; subsequently, within-group comparisons according to time were performed. Analysis included independent samples t-tests and paired t-tests. RESULTS The puborectal hiatus line (H line), muscular pelvic floor relaxation line (M line), bladder-pubococcygeal line (B-PCL), and uterus-pubococcygeal line (U-PCL) differed significantly between groups during the Valsalva manoeuvre at 1 week postpartum (p < 0.05). The H line, M line, and B-PCL values differed significantly between groups during the Valsalva manoeuvre at 6 weeks postpartum (p < 0.05). There were few significant between-group differences in pelvic floor values at 3 months and 6 months postpartum. In the vaginal delivery group, the differences in the H line and M line at 1 week, 6 weeks, and 3 months postpartum were significant (p < 0.001). In the elective caesarean delivery group, U-PCL differed significantly at 6 weeks compared to 1 week postpartum during the Valsalva manoeuvre (p < 0.05). CONCLUSIONS Pelvic floor recovery primarily occurred during the early phase after delivery in both groups. Elective caesarean delivery had a non-significant protective effect on postpartum pelvic floor structure and function compared to vaginal delivery.
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Affiliation(s)
- Beibei Zhou
- Department of Radiology, The Seventh Affiliated Hospital, Sun Yat-sen University, 628 Zhenyuan Road, Shenzhen, 518107, People's Republic of China
| | - Hongbo Zhang
- Department of Radiology, The Seventh Affiliated Hospital, Sun Yat-sen University, 628 Zhenyuan Road, Shenzhen, 518107, People's Republic of China.
| | - Jianpeng Yuan
- Department of Radiology, The Seventh Affiliated Hospital, Sun Yat-sen University, 628 Zhenyuan Road, Shenzhen, 518107, People's Republic of China
| | - Chao Bu
- Department of Radiology, The Seventh Affiliated Hospital, Sun Yat-sen University, 628 Zhenyuan Road, Shenzhen, 518107, People's Republic of China
| | - Weijian Lai
- Department of Radiology, The Seventh Affiliated Hospital, Sun Yat-sen University, 628 Zhenyuan Road, Shenzhen, 518107, People's Republic of China
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García-Mejido JA, Sainz JA. Type of levator ani muscle avulsion as predictor for the disappearance of avulsion. Neurourol Urodyn 2020; 39:2293-2300. [PMID: 32827224 DOI: 10.1002/nau.24484] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/07/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The objective of our study was to establish whether the type of levator ani muscle (LAM) avulsion diagnosed 6 months after delivery influences the integrity of the LAM at 1 year after delivery and determine its influence on the levator hiatus area. STUDY DESIGN This observational prospective cohort study included 192 primiparous women with vaginal delivery. Transperineal ultrasound examinations were performed at 6 months and 1 year postpartum. Levator hiatus measurements (anteroposterior diameter, transverse diameter, and area) were performed in the plane of minimal dimensions. Complete avulsion was defined based on maximum contraction in multislice mode. Type I LAM avulsion was present when most lateral fibers of the pubovisceral muscle were observed at its insertion at the pubic level (the arch of the elevator remained intact). Type II LAM avulsion was defined as a complete detachment of the pubovisceral muscle from its insertion at the pubic level. RESULTS In total, 192 patients were recruited after delivery; 48 patients were diagnosed with complete LAM avulsion, and 13 patients with avulsion did not attend the second ultrasound follow-up at 1 year after delivery. Thirty-five patients with complete LAM avulsion were included in the study. At 6 months after delivery, 51 LAM avulsions were observed in 35 patients (including bilateral LAM avulsion in 16 cases), of which 54.9% were right avulsions and 45.1% left avulsions. Furthermore, 11 (five right and six left) were type I LAM avulsions at the 6-month assessment, and all of these had disappeared 1 year after delivery. However, none of the type II LAM avulsions (23 right and 17 left) observed at 6 months had disappeared at the second ultrasound examination. There were no differences between the LAM areas detected at the first and second ultrasound examinations (10.2 ± 3.3 vs 9.3 ± 1.8; P = .404). CONCLUSIONS The type of LAM avulsion observed at 6 months after childbirth predicts LAM persistence at 1 year postpartum.
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Affiliation(s)
- José Antonio García-Mejido
- Department of Obstetrics and Gynecology, University of Seville, Seville, Spain.,Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
| | - José Antonio Sainz
- Department of Obstetrics and Gynecology, University of Seville, Seville, Spain.,Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
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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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Van de Waarsenburg MK, van der Vaart CH, Withagen MIJ. Structural changes in puborectalis muscle after vaginal delivery. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:256-261. [PMID: 29947067 DOI: 10.1002/uog.19170] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/22/2018] [Accepted: 06/18/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To evaluate the structural composition of the puborectalis muscle before and at several timepoints after first vaginal delivery, by the use of echogenicity and area measurements, in order to explore its recovery. METHODS Twenty nulliparous women with a singleton pregnancy underwent 3D/4D transperineal ultrasound assessments at rest, on pelvic floor muscle contraction and on Valsalva maneuver at 12 weeks' gestation and at 1 day and 1, 2, 3, 4, 6, 12, 18 and 24 weeks after vaginal delivery. The puborectalis muscle was delineated for measurements of mean echogenicity (MEP) and area (PMA). To assess changes in MEP and PMA over time, linear mixed model analysis was used. The exact number of days after delivery at each ultrasound examination was used as a covariate. RESULTS For all timepoints after delivery, MEP was significantly decreased compared with that at 12 weeks' gestation. MEP values increased significantly over time from 1 day to 24 weeks after delivery. Although not statistically significant, a decrease in MEP was observed between 3 and 4 weeks after delivery for all maneuvers. PMA at rest and on Valsalva maneuver remained constant after delivery. CONCLUSION When compared with measurements taken during pregnancy, a sharp decrease in MEP was observed soon after vaginal delivery, which was most likely caused by stretch trauma to the puborectalis muscle and subsequent formation of (micro) hematoma and edema. Subsequent increases in MEP may reflect the disappearance of hematoma and edema, and also the formation of connective and scar tissue. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M K Van de Waarsenburg
- Department of Obstetrics and Gynecology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - C H van der Vaart
- Department of Obstetrics and Gynecology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - M I J Withagen
- Department of Obstetrics and Gynecology, University Medical Centre Utrecht, Utrecht, The Netherlands
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