Effect of childbirth on pelvic organ support and quality of life: a longitudinal cohort study

Potential role of physical labor and cultural views of menstruation in high incidence of pelvic organ prolapse in Nepalese women: a comparative study across the menstrual cycle

Introduction

Pelvic organ prolapse (POP) is a significant health concern for young Nepali women, with potential risk factors including pelvic floor trauma from vaginal delivery and heavy lifting. The prevalence of symptomatic POP (SPOP) among nulliparous women in Nepal is 6%, while the general population of Nepali women aged 15-49 years reports a prevalence of 7%. Surprisingly, the average age of SPOP onset in Nepal is 27 years, challenging the assumption that postmenopausal age and vaginal delivery are the sole risk factors. This study aims to investigate the influence of increased intra-abdominal pressure (IAP) during lifting tasks on pelvic organ descent in Nepali women across different menstrual cycle stages.

Methods

The study included 22 asymptomatic Nepali women aged 18-30 years who regularly engage in heavy lifting. Intra-abdominal pressure was measured intra-vaginally during typical and simulated lifting tasks, which encompassed various scenarios such as ballistic lifting, ramped lifting, and pre-contraction of pelvic floor muscles, as well as coughing, Valsalva maneuver, and pelvic floor contractions. Pelvic floor displacement was recorded using transperineal ultrasound during menstruation, ovulation, and the mid-luteal phase.

Results

Results indicated that pelvic floor displacement was greater during menstruation than ovulation when performing a simulated ballistic lifting task (6.0 ± 1.6 mm vs. 5.1 ± 1.5 mm, p = 0.03, d = 0.6). However, there was no significant difference in pelvic floor displacement during lifting when the pelvic muscles were pre-contracted.

Conclusion

These findings suggest that lifting heavy loads during menstruation may increase the risk of stretching and injuring pelvic floor supportive tissues, potentially contributing to SPOP in young Nepali women. Pre-contracting pelvic floor muscles during lifting tasks may offer a protective effect. Understanding these factors could aid in developing targeted preventive measures and raising awareness about the impact of heavy lifting on pelvic floor health among Nepali women.

Total Pelvic Floor Lifting: A New Approach for the Anatomic Repair of Pelvic Floor Hypermobility and Vaginal Laxity in Parous Women

Recent years have seen a steady increase in the information available regarding pelvic floor changes after childbirth. Obstetric trauma, to which all structures of the urogenital sphere are subjected, can affect different anatomical areas, including the vagina, perineum, deep pelvic floor muscles, and sphincter. Main complaints of parous women with regard to their pelvic floor are vaginal laxity, a wide introitus, and increased mobility of the uterus. Unilateral pectineal suspension is a novel method for surgical correction of the sequelae of vaginal birth-giving such as uterine hypermobility and perception of loose tissue, restoring a natural anatomy when conservative therapy has failed. Since the method is not ablative and does not interfere with anatomical structures, subsequent pregnancies and deliveries remain possible. Furthermore, there is no mesh application, adding to the safety aspects of this unique approach. The surgical technique is straightforward and can be adopted by laparoscopically trained surgeons without problems. The procedure consists of five clearly defined steps, which makes it easily reproducible. Unilateral pectineal suspension restores the pelvic floor and the vagina, with a single suture lifting the sagging structures back to their original position. If needed and according to the patient's choice, a short perineum associated with a wide introitus can be corrected in the same session by perineoplasty, resulting in a total aesthetic reconstruction of the female genital anatomy.

Vaginal delivery effects on 3D morphology of the bladder, urethra, and vagina: a pilot study comparing women with different numbers of deliveries

PURPOSE

To explore 3D morphological changes of the bladder, urethra, and vagina following different numbers of vaginal deliveries.

METHODS

Sampled patients had undergone magnetic resonance imaging for gynecological diseases in Nanfang Hospital. A total of 167 patients who met the study inclusion and exclusion criteria were enrolled and divided into four groups. Mimics and UG software packages were used for reconstructions and measurements, and data were compared with one-way analyses of variance.

RESULTS

A total of 167 3D models were constructed, and eight parameters related to the bladder and urethra were measured (5 angles, 2 lengths, and 1 thickness). No statistically significant differences were found between subgroups, although mean plot figures of urethra pubic and α angles showed trends to increase with more deliveries, and the opposite trend was seen for the urethra tilt angle. There were no obvious trends between other parameters and delivery number. There were seven vaginal parameters (6 lengths and 1 shape). Mid-urethral and vaginal gap measurements tended to become wider as delivery number increased, and the opposite was seen for the distal gap. Mid-vaginal 2D cross-sectional shape and the proportion of shallow concave types also tended to significantly increase with more deliveries, especially after the third birth.

CONCLUSION

As the number of deliveries through the vagina increases, the lateral support function of this organ and the urethra become relatively weaker. These fine anatomical changes are related to delivery numbers and become most obvious after the third birth.

An International Continence Society (ICS)/ International Urogynecological Association (IUGA) joint report on the terminology for the assessment and management of obstetric pelvic floor disorders

AIMS

The terminology of obstetric pelvic floor disorders should be defined and reported as part of a wider clinically oriented consensus.

METHODS

This Report combines the input of members of two International Organizations, the International Continence Society (ICS) and the International Urogynecological Association (IUGA). The process was supported by external referees. Appropriate clinical categories and a sub-classification were developed to give coding to definitions. An extensive process of 12 main rounds of internal and 2 rounds of external review was involved to exhaustively examine each definition, with decision-making by consensus.

RESULTS

A terminology report for obstetric pelvic floor disorders, encompassing 357 separate definitions, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it usable by different specialty groups and disciplines involved in the study and management of pregnancy, childbirth and female pelvic floor disorders. Clinical assessment, investigations, diagnosis, conservative and surgical treatments are major components. Illustrations have been included to supplement and clarify the text. Emerging concepts, in use in the literature and offering further research potential but requiring further validation, have been included as an Appendix. As with similar reports, interval (5-10 year) review is anticipated to maintain relevance of the document and ensure it remains as widely applicable as possible.

CONCLUSION

A consensus-based Terminology Report for obstetric pelvic floor disorders has been produced to support clinical practice and research.

Reliability of the Polish Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and Assessment of Sexual Function before and after Pelvic Organ Prolapse Reconstructive Surgery-A Prospective Study

It is estimated that 31–44% of all patients with symptomatic POP and/or UI suffer from sexual dysfunction. We aimed to validate the PISQ-12 in pre-and postmenopausal women and to assess the sexual function before and after POP reconstructive surgery. One hundred and forty sexually active patients were hospitalized due to symptomatic POP and 50 healthy controls were enrolled into the study. The patients were asked to complete PISQ-12, the FSFI and Beck’s depression scale questionnaires twice. The Cronbach’s alpha (α) was used to estimate the internal consistency. The scores were compared using the Intraclass Correlation Coefficient (ICC). Improvement in the QoSL (quality of sexual life) was observed in each age group of women. Pre-menopausal patients’ QoSL was much better, both before and after surgery (29.62 and 34.64 points, respectively). The correlation between questionnaires before surgery was 0.63, and after was −0.76. The α value for the PISQ-12 was 0.83 before the procedure and 0.80 afterwards. In all the groups, the test–retest reliability was good—ICC = 0.72. Vaginal reconstructive surgeries improve the QoSL. The only demographic factor influencing the QoSL was the menopausal status. The Polish version of the PISQ-12 is a reliable and responsive instrument for assessing the sexual function in patients with diagnosed POP and/or UI.

Habitus and Pelvic Floor Symptoms and Support 1 Year Postpartum

OBJECTIVE

To estimate the association between habitus measures and pelvic floor support and symptoms in primiparous women 1 year after term vaginal delivery.

METHODS

In this cross-sectional study including women enrolled at seven academic and community sites, we assessed pelvic floor support, weight, height, waist circumference, and percent fat using air displacement plethysmography and participants completed questionnaires, all at one year postpartum. We tested the association of quintiles of habitus measure, including body mass index (BMI), waist circumference, percent body fat, and waist/height ratio, with the primary outcomes: anatomic support, dichotomized as maximal vaginal descent less than 0 cm (better support) compared with 0 cm or more (worse support) per the pelvic organ prolapse quantification examination and symptom burden (positive with bothersome symptoms in two or more of six symptom domains), and on five secondary outcomes. The sample size provides 90% power to detect odds ratios (ORs) of 1.78 or greater between women at mean compared with mean+1 SD of habitus measure.

RESULTS

Of 592 participants, 55 (9.3%) demonstrated worse support and 321 (54.2%) symptom burden. In multivariable analyses, habitus measures were not significantly associated with anatomic support or, except for the highest waist/height ratio quintile, with symptom burden. Compared with women in the first quintile of each habitus measure, those in most higher quintiles demonstrated elevated odds of moderate to severe urinary incontinence (UI); increased odds for stress urinary incontinence (SUI) were mainly limited to the highest quintile. After adjusting for percent body fat, the increased odds for BMI on SUI (OR 2.47, 95% CI 1.43-4.28) were no longer significant (OR 1.38, 95% CI 0.54, 3.51).

CONCLUSION

Habitus in primiparous patients at 1 year postpartum was not associated with anatomic support or symptom burden. Habitus was more associated with moderate to severe UI than mild UI. The association of higher BMI with SUI was attenuated by fitness, reflected by fat percentage.

Trajectories of Pelvic Floor Symptoms and Support After Vaginal Delivery in Primiparous Women Between Third Trimester and 1 Year Postpartum

OBJECTIVES

The objectives of this study were to describe trajectories of pelvic floor symptoms and support from the third trimester to 1 year postpartum in primiparous women after vaginal delivery and to explore factors associated with their resolution between 8 weeks postpartum and 1 year postpartum.

METHODS

Five hundred ninety-seven nulliparous women 18 years or older who gave birth vaginally at term completed the Epidemiology of Prolapse and Incontinence Questionnaire and the Pelvic Organ Prolapse Quantification examination at the third trimester, 8 weeks postpartum, and 1 year postpartum.

RESULTS

At 1 year postpartum, 41%, 32%, and 23% of participants reported stress urinary incontinence, nocturia, and flatus incontinence, respectively, and 9% demonstrated maximal vaginal descent (MVD) ≥ 0 cm. For more common symptoms, incidence rates between the third trimester and 8 weeks postpartum ranged from 6% for urinary frequency to 22% for difficult bowel movements, and resolution rates between 8 weeks postpartum and 1 year postpartum ranged from 23% for stress urinary incontinence to 73% for pain. Between the third trimester and 8 weeks postpartum, 13% demonstrated de novo MVD ≥ 0 cm. For most symptoms, the presence of the same symptom before delivery decreased the probability of resolution between 8 weeks postpartum and 1 year. However, the sensitivities of predelivery vaginal bulge and MVD of 0 cm or greater for those outcomes at 1 year postpartum was overall low (10-12%).

CONCLUSIONS

One year postpartum, urinary and bowel symptoms are common in primiparous women who gave birth vaginally. A substantial portion of this burden is represented by symptoms present before delivery, while most of the prevalence of worse anatomic support is accounted for by de novo changes after delivery.

Ultrasound analysis of the effect of second delivery on pelvic floor function in Chinese women

In our study, patients who had a second delivery were categorised into the following 4 groups. Pelvic floor ultrasound data were compared during the 6th week after the second delivery. The incidence of cystoceles was highest in group A and lowest in group D. In addition, groups A and B had a higher rate of rectoceles or perineum descent. Similarly, the areas of the levator hiatus were higher in Groups A and B during Valsalva manoeuvres. The area of the levator hiatus from the resting state to the Valsalva manoeuvre effect had the greatest change in Group A. A comparison of the PR thickening rates among the four groups did not reveal significant differences. All second delivery methods can cause varying degrees of pelvic organ prolapse and decreased pelvic floor function; however, vaginal delivery as the second delivery mode may have a more significant effect in Chinese women.Impact StatementWhat is already known on this subject? Different modes of delivery have significantly different effects on female pelvic floor function. Pregnancy beyond 35 weeks of gestation has an effect on female pelvic floor function, irrespective of the mode of delivery.What do the results of this study add? This study analysed the impact of different delivery modes on Chinese female pelvic floor function. Parous women who underwent different modes of second delivery all demonstrated different degrees of pelvic organ prolapse, as well as pelvic floor function decline.What are the implications of these findings for clinical practice and/or further research? Our study will provide basic research of Chinese female pelvic floor function after a second delivery, which will be of clinical significance around the world, as well as in China. China will keep promoting further delivery as the aging population is increasing. If the developing countries want to promote the second delivery around the women, they have basic research and data to instruct the females.

COL3A1 rs1800255 polymorphism is associated with pelvic organ prolapse susceptibility in Caucasian individuals: Evidence from a meta-analysis

Background

The collagen 3 alpha 1 (COL3A1) rs1800255 polymorphism has been reported to be associated with women pelvic organ prolapse (POP) susceptibility, but the results of these previous studies have been contradictory. The objective of current study is to explore whether COL3A1 rs1800255 polymorphism confers risk to POP.

Methods

Relevant literatures were searched by searching databases including Pubmed, Embase, Google academic, the Cochrane library, China National Knowledge Infrastructure (CNKI). Search time is from database foundation to March 2021.

Results

A total of seven literatures were enrolled in the present meta-analysis, including 1642 participants. Overall, no significant association was found by any genetic models. In subgroup analysis based on ethnicity, significant associations were demonstrated in Caucasians by allele contrast (A vs. G: OR = 1.34, 95%CI = 1.03–1.74,), homozygote comparison (AA vs. GG: OR = 3.25, 95%CI = 1.39–7.59), and recessive genetic model (AA vs. GG/GA: OR = 3.22, 95%CI = 1.40–7.42).

Conclusions

The present meta-analysis suggests that the COL3A1 is a candidate gene for POP susceptibility. Caucasian individuals with A allele and AA genotype have a higher risk of POP. The COL3A1 rs1800255 polymorphism may be risk factor for POP in Caucasian population.

Urogynecology in obstetrics: impact of pregnancy and delivery on pelvic floor disorders, a prospective longitudinal observational pilot study

Purpose

To assess changes in the pelvic floor anatomy that cause pelvic floor disorders (PFDs) in primigravidae during and after pregnancy and to evaluate their impact on women’s quality of life (QoL).

Methods

POP-Q and translabial ultrasound examination was performed in the third trimester and 3 months after delivery in a cohort of primigravidae with singleton pregnancy delivering in a tertiary center. Results were analyzed regarding mode of delivery and other pre- and peripartal factors. Two individualized detailed questionnaires were distributed at 3 months and at 12 months after childbirth to determinate QoL.

Results

We recruited 45 women, of whom 17 delivered vaginally (VD), 11 received a vacuum extraction delivery (VE) and 17 a Cesarean section in labor (CS). When comparing third-trimester sonography to 3 months after delivery, bladder neck mobility increased significantly in each delivery group and hiatal area increased significantly in the VD group. A LAM avulsion was found in two women after VE. Connective tissue weakness (p = 0.0483) and fetal weight at birth (p = 0.0384) were identified as significant risk factors for the occurrence of PFDs in a multivariant regression analysis. Urinary incontinence was most common with 15% and 11% of cases at 3, respectively, 12 months after delivery. 42% of women reported discomfort during sexual intercourse, 3 months after delivery and 24% 12 months postpartum. Although 93% of women engage a midwife after delivery, only 56% participated in pelvic floor muscle training.

Conclusion

Connective tissue weakness and high fetal weight at birth are important risk factors for the occurrence of PFDs. Nevertheless, more parturients should participate in postpartal care services to prevent future PFDs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00404-021-06022-w.

Early postpartum physical activity and pelvic floor support and symptoms 1 year postpartum

BACKGROUND

Risks of pelvic organ prolapse and urinary incontinence increase after the first vaginal delivery. During the early postpartum period, a time of active regeneration and healing of the pelvic floor, women may be particularly vulnerable to greater pelvic floor loading.

OBJECTIVE

This prospective cohort study aimed to determine whether objectively measured moderate to vigorous physical activity in the early postpartum period predicts pelvic floor support and symptoms 1 year after the first vaginal birth.

STUDY DESIGN

We enrolled nulliparous women in the third trimester, later excluding those who had a cesarean or preterm delivery. Participants wore triaxial wrist accelerometers at 2 to 3 weeks and 5 to 6 weeks postpartum for ≥4 days. Primary outcomes, assessed 1 year postpartum, included (1) pelvic floor support on Pelvic Organ Prolapse Quantification examination, dichotomized as maximal vaginal descent of <0 cm (better support) vs ≥0 cm (worse support); and (2) pelvic floor symptom burden, considered positive with report of ≥1 bothersome symptom in ≥2 of 6 domains, assessed using the Epidemiology of Prolapse and Incontinence Questionnaire. The primary predictor was average daily moderate to vigorous physical activity. Because we could not eliminate women with pelvic floor changes before pregnancy, we modeled prevalence, rather than risk, ratios for each outcome using modified Poisson regression.

RESULTS

Of 825 participants eligible after delivery, 611 completed accelerometry and 1-year follow-up; 562 completed in-person visits, and 609 completed questionnaires. The mean age was 28.9 years (standard deviation, 5.01). The mean for moderate to vigorous physical activity measured in minutes per day was 57.3 (standard deviation, 25.4) and 68.1 (standard deviation, 28.9) at 2 to 3 weeks and 5 to 6 weeks, respectively. One year postpartum, 53 of 562 participants (9.4%) demonstrated worse vaginal support and 330 of 609 participants (54.2%) met criteria for pelvic floor symptom burden. In addition, 324 (53.1%), 284 (46.6%), 144 (23.6%), and 25 (4.1%) reported secondary outcomes of stress urinary incontinence, overactive bladder, anal incontinence, and constipation, respectively, and 264 (43.4%), 250 (41.0%), and 89 (14.6%) reported no, mild, or moderate to severe urinary incontinence, respectively. The relationship between moderate to vigorous physical activity and outcomes was not linear. On the basis of plots, we grouped quintiles of moderate to vigorous physical activity into 3 categories: first and second quintiles combined, third and fourth quintiles combined, and fifth quintile. In final multivariable models, compared with women in moderate to vigorous physical activity quintiles 3 and 4, those in the lower 2 (prevalence ratio, 0.55; 95% confidence interval, 0.31-1.00) and upper quintile (prevalence ratio, 0.70; 95% confidence interval, 0.35-1.38)) trended toward lower prevalence of worse support. However, we observed the reverse for symptom burden: compared with women in quintiles 3 and 4, those in the lower 2 (prevalence ratio, 1.20; 95% confidence interval, 1.02-1.41) and upper quintile prevalence ratio 1.34 (95% confidence interval, 1.11-1.61) demonstrated higher prevalence of symptom burden. Moderate to vigorous physical activity did not predict any of the secondary outcomes. The presence of a delivery factor with potential to increase risk for levator ani muscle injury did not modify the effect of moderate to vigorous physical activity on outcomes.

CONCLUSION

Except for support, which was worse in women with moderately high levels of activity, early postpartum moderate to vigorous physical activity was either protective or had no effect on other parameters of pelvic floor health. Few women performed substantial vigorous activity, and thus, these results do not apply to women performing strenuous exercise shortly after delivery.

Association Between Measures of Trunk Recovery 5 to 10 Weeks Postpartum and Pelvic Floor Support and Symptoms 1 Year Postpartum in Primiparas Delivered Vaginally

OBJECTIVE

To determine whether 2 aspects of trunk recovery after childbirth, intraabdominal pressure (IAP) generation and trunk flexor endurance (TFE), predict measures of pelvic floor health 1 year postpartum.

METHODS

In this prospective cohort study, we enrolled nulliparas in their third trimester and followed up those delivered vaginally for 1 year. We measured IAP while lifting a weighted car seat (IAPLIFT), IAP during TFE testing (IAPTFE), and TFE duration 5 to 10 weeks postpartum and assessed pelvic floor support and symptoms 1 year postpartum.

RESULTS

Mean age of the 624 participants was 28.7 years. At 5 to 10 weeks postpartum, mean (SD) maximal IAPLIFT and IAPTFE were 47.67 (11.13) and 51.57 (12.34) cm H2O, respectively. Median TFE duration was 126 seconds (Interquartile range, 74-211). At 1 year postpartum, 9.3% demonstrated worse support (maximal vaginal descent at or below hymen) and 54% met criteria for symptom burden (bothersome symptoms in ≥2 domains of Epidemiology of Prolapse and Incontinence Questionnaire). In multivariable models, neither IAPLIFT nor IAPTFE were associated with worse support or symptom burden (P = 0.54-1.00). Trunk flexor endurance duration increased prevalence of worse support (prevalence ratio, 1.05; 95% confidence interval, 1.01-1.08) per 60-second increase, P = 0.005) but not symptom burden (prevalence ratio, 1.00; 95% confidence interval, 0.98-1.03; P = 0.92).

CONCLUSIONS

These results provide some reassurance to early postpartum women, who are unlikely to perform routine activities that generate IAP far outside the range tested. Further research is needed to understand why women with long TFE durations have increased prevalence of worse support.

The meaning of postpartum sexual health for women living in Spain: a phenomenological inquiry

BACKGROUND

Sexual health is a multidimensional phenomenon constructed by personal, social, and cultural factors but continues to be studied with a biomedical approach. During the postpartum period, a woman transitions to mother, as well as partner-to-parent and couple-to-family. There are new realities in life in the postpartum period, including household changes and new responsibilities that can impact the quality of sexual health. This phenomenon is understudied especially in the context of Spain. The purpose of this study was to describe the lived experience of postpartum sexual health among primiparous women giving birth in Catalonia (Spain).

METHODS

This was a phenomenological study with a purposive sample of primiparous women. Data was collected through semi-structured interviews until saturation. Analysis followed Colaizzi's seven-step process with an eighth translation step added to limit cross-cultural threats to validity. Also, the four dimensions of trustworthiness were established through strategies and techniques during data collection and analysis.

RESULTS

Ten women were interviewed from which five themes emerged, including: Not feeling ready, inhibiting factors, new reality at home, socio-cultural factors, and the clinician within the health system. Returning to sexual health led women to engage in experiential learning through trial and error. Most participants reported reduced libido, experienced altered body image, and recounted resumption of sexual activity before feeling ready. A common finding was fatigue and feeling overloaded by the demands of the newborn. Partner support was described as essential to returning to a meaningful relationship. Discussions about postpartum sexual health with clinicians were described as taboo, and largely absent from the care model.

CONCLUSION

Evidence-based practices should incorporate the best evidence from research, consider the postpartum sexual health experiences and preferences of the woman, and use clinician expertise in discussions that include the topic of postpartum sexual health to make decisions. As such, human caring practices should be incorporated into clinical guidelines to recognize the preferences of women. Clinicians need to be authentically present, engage in active communication, and individualize their care. More qualitative studies are needed to understand postpartum sexual health in different contexts, cultures, and countries and to identify similarities and differences through meta-synthesis.

Pelvic floor changes in the first term pregnancy and postpartum period

OBJECTIVE

To follow a prospective cohort of women during their first term pregnancy to elucidate the nature and timing of changes to the pelvic floor during pregnancy and after vaginal delivery.

METHODS

Enrolled subjects were evaluated at four time points with dynamic MRI, POP-Q examinations, and validated symptom questionnaires. The four assessments occurred during the first trimester (ePG), late third trimester (lPG), within a week after vaginal delivery (ePP), and three months postpartum (lPP). Two-dimensional T1-weighted MRI measurements included bladder descent and area of the levator hiatus at rest and during Valsalva maneuvers. Sample size of ten subjects was calculated for a power of 0.8 to detect a 20% change in bladder position with p < 0.05. Comparative statistical tests were used for parametric and non-parametric data, respectively.

RESULTS

Twelve subjects completed the study. At lPP, the bladder descent was increased (p = 0.03) at rest and with Valsalva compared to ePG. Levator hiatus area did not differ (p = 0.63) between time points at rest or with Valsalva. Median POP stage increased (p = 0.001) to 1.5 at lPP. Mean genital hiatus increased (p = 0.0003) at each time point. Higher scores were recorded on the UDI-6 (p < 0.001) and the PFDI-20 (p = 0.003) questionnaires at lPG and ePP, but returned to ePG levels by lPP.

CONCLUSION

Anatomic changes measured by dynamic MRI and POP-Q examinations demonstrate significant descent at 3 months postpartum. However, these anatomic changes did not significantly correlate with changes in symptoms.

Symptomatic pelvic organ prolapse in middle-aged women: a national matched cohort study on the influence of childbirth

BACKGROUND

The relative impact of age, pregnancy, and vaginal delivery on symptomatic pelvic organ prolapse is still an unresolved issue that involves the controversial question about the protective effect of cesarean section.

OBJECTIVE

The purpose of this study was to compare the age-related prevalence of symptomatic genital prolapse in nulliparous, vaginal- and cesarean-delivered women aged 40-64 years.

STUDY DESIGN

This Swedish, nationwide matched cohort study involved 14,335 women. Three restricted, randomly selected source cohorts of women (nulliparous women unexposed to childbirth [n = 9136], 1-para cesarean delivered women, exposed to 1 pregnancy [n = 1412], and 1-para women exposed to 1 pregnancy followed by vaginal delivery [n = 3787]) were retrieved from the Swedish Medical Birth Register and Statistics Sweden and surveyed in 2008 and 2014. The surveys used a postal and Internet-based questionnaire containing validated questions for pelvic floor disorders. Symptomatic prolapse was defined by the question, "Do you have a sensation of tissue protrusion (a vaginal bulge) from your vagina?" In this study the symptom frequencies, sometimes and often, were defined as a positive response. Parous women were all assessed 20 years postnatally. One-to-one matching with an age interval for pairing of 3 years and 3 units of body mass index (kilograms per square meter) was used in women aged 40-64 years. The procedure succeeded in 2635 of 2640 women (99.8%), resulting in an adequate distribution of age and body mass index (kilograms per square meter) between matched groups. For comparison between groups, a Fisher exact test was used for categorical variables and the Mann-Whitney U test for continuous variables. Trend between matched groups was analyzed with Mantel-Haenszel statistics. Estimated, age-related values of symptomatic prolapse were obtained by logistic regression analysis.

RESULTS

In nulliparous and cesarean-delivered women, the prevalence of symptomatic prolapse was relatively similar and below 5% across ages 40-64 years. In contrast, in women after vaginal delivery, there was an accelerating increase in the prevalence of symptomatic genital prolapse up to 65 years of age. Estimated probability from the regression model increased 4-fold, from 3.8% at 40 years to 13.4% at 64 years of age. The observed induction period associated with 1 vaginal delivery seemed to be at least 20 years among women giving birth in their early 20s. At age 64 years, the estimated probability of symptomatic prolapse was 12 times higher after vaginal delivery compared with cesarean deliery (13.4% [95% confidence interval, 9.4-18.9] vs 1.1% [95% confidence interval, 0.4-2.5], P < .0001). The calculated reduction of symptomatic prolapse by cesarean delivery at 64 years of age was thus 92%.

CONCLUSION

In this national matched cohort study, the interaction between vaginal delivery and aging was the most important factor for the occurrence of symptomatic prolapse. Because the effect of aging can be modified only to a small extent, preventive strategies for genital prolapse should focus on how to avoid the adverse events related to a vaginal delivery.

Pelvic floor disorders following different delivery modes-a population-based cohort analysis

INTRODUCTION AND HYPOTHESIS

Identifying protective factors against pelvic floor disorders (PFDs) is important. We investigated whether cesarean delivery (CD) at the indication of abnormal second stage of labor (ASSL) has the same protective effect against future PFDs.

METHODS

This population-based cohort study included deliveries occurring from 1991-2017 in a tertiary medical center. Women were grouped by their delivery mode: patients with vaginal deliveries (VD) only; those with CD only, excluding second-stage indications; and those with CD due to ASSL. The outcome measure, PFDs and related repair diagnoses, included any recorded hospitalization involving a pre-defined set of ICD-9 codes. A Kaplan-Meier survival curve compared cumulative PFD morbidity in the different groups, and a Cox proportional hazards model controlled for confounders.

RESULTS

A total of 106,003 patients met the inclusion criteria; 86.7% (n = 91,856) experienced VD only, 11.7% (n = 12,359) underwent CD only and 1.7% (n = 1788) had at least one CD due to ASSL. PFD-related hospitalization incidence was 0.7% (n = 719) for the entire cohort. While a significantly higher PFD-related hospitalization rate was recorded in the VD group (0.7%) compared with the ASSL CD group (0.3%) and the non-ASSL CD group (0.5%, p < 0.001), after controlling for potential confounders, an independent and protective association was noted between CD and later PFDs only in parturients who did not experience ASSL (aHR 0.679, 95% CI 0.51-0.90, p = 0.006).

CONCLUSIONS

CDs may be protective against later PFD development only if performed prior to the second stage of labor.

Postnatal pelvic floor muscle stiffness measured by vaginal elastometry in women with obstetric anal sphincter injury: a pilot study

Introduction and hypothesis

Vaginal childbirth is associated with pelvic floor muscle (PFM) damage in a third of women. The biomechanics prediction, detection and management of PFM damage remain poorly understood. We sought in this pilot study to determine whether quantifying PFM stiffness postnatally by vaginal elastometry, in women attending a perineal trauma clinic (PTC) within 6 months of obstetric anal sphincter injury, correlates with their antecedent labour characteristics, pelvic floor muscle damage, or urinary/bowel/sexual symptoms, to inform future definitive prospective studies.

Methods

In this pilot study, we measured postnatal PFM stiffness by vaginal elastometry in 54 women. A subset of participants (n = 14) underwent magnetic resonance imaging (MRI) to define any levator ani (LA) muscle defects from vaginal childbirth. We investigated the association of PFM stiffness with demographics, labour and delivery characteristics, clinical features and MRI evidence of LA damage.

Results

Raised maternal BMI was associated with reduced pelvic floor stiffness (r = −0.4; p < 0.01). Higher stiffness values were associated with forceps delivery for delayed second stage of labour (n = 14) vs non-forceps vaginal delivery (n = 40; 630 ± 40 N/m vs 500 ± 30 N/m; p < 0.05), and a non-significant trend towards longer duration of the second stage of labour. Women with urinary, bowel or sexual symptoms (n = 37) demonstrated higher pelvic floor stiffness values than those without (570 ± 30 N/m vs 450 ± 40 N/m; p < 0.05).

Conclusions

A history of delayed second stage of labour and forceps delivery was associated with higher PFM stiffness values in the postnatal period. Whether high pelvic muscle stiffness antenatally is a risk factor for instrumental vaginal delivery and LA avulsion is unknown.

Defining "normal recovery" of pelvic floor function and appearance in a high-risk vaginal delivery cohort

INTRODUCTION AND HYPOTHESIS

Childbirth pelvic floor trauma leads to pelvic floor disorders. Identification of significant injuries would facilitate intervention for recovery. Our objectives were to identify differences in pelvic floor appearance and function following delivery and patterns of normal recovery in women sustaining high-risk labor events.

METHODS

We completed a prospective cohort study comparing women undergoing vaginal births involving risk factors for pelvic floor injury with women undergoing cesareans. Data were collected on multidimensional factors including levator ani muscle (LA) tears. Descriptive and bivariate statistics were used to compare the groups. We identified potential markers of pelvic floor injury based on effect size.

RESULTS

Eighty-two women post-vaginal delivery and 30 women post-cesarean enrolled. The vaginal group had decreased perineal body length between early postpartum, 6 weeks (p < 0.001), and 6 months (p = 0.001). POP-Q points did not change between any time point (all p > 0.05). Measures of strength improved between each time point (all p < 0.002). When compared with cesarean delivery, women post-vaginal birth had longer genital hiatus and lower anterior and posterior vaginal walls (all p < 0.05). Based on theoretical considerations and effect sizes, those with Bp ≥0 cm, Kegel force ≤1.50 N, and/or an LA tear on imaging were considered to have significant pelvic floor injury. Using this definition, at 6 weeks, 27 (46.4%) women were classified as injured. At 6 months, 13 (29.6%) remained injured.

CONCLUSIONS

We propose that pelvic floor muscle strength, posterior vaginal wall support, and imaging consistent with LA tear are potential indicators of abnormal or prolonged recovery in this cohort with high-risk labor events.

Evaluation of the effect of a new method on the pelvic organ prolapse symptoms

OBJECTIVE

Previous studies of treatment for prolapse, patients have undergone pelvic floor muscle training (PFMT), but no exercises were performed for the hip muscles. Accordingly, this study investigated a new conservative treatment approach that was hypothesized to improve prolapse symptoms more than PFMT.

METHODS

Forty women with Stage 2 or 3 prolapse were randomly assigned to either the control or intervention group (n = 20 in each). In this study, patients are treated for 12 sessions (4 weeks and 3 sessions each week). In the control group, the pelvic floor muscle training is applied in for treatment. In the intervention group, in addition to pelvic floor muscle training, postural or positional inversion exercises are included in training.

RESULTS

There was a significant difference between the control and intervention groups in only three domains of the Prolapse Quality of Life questionnaire, namely general health (P = 0.010), physical limitation (P = 0.038), and social limitation (P = 0.010). Furthermore, International Consultation of Incontinence (ICIQ) scores for filling symptoms and bother scale differed significantly between the two groups (P = 0.035 and P = 0.045, respectively). There was also a significant difference in the stage of prolapse and pelvic floor muscle strength in both groups compared with baseline, although only pelvic floor. muscle strength differed significantly between the two groups (P = 0.041).

CONCLUSION

This new method of postural or positional inversion leads to a greater improvement in symptoms of pelvic organ prolapse.

Questionnaires to evaluate pelvic floor dysfunction in the postpartum period: a systematic review

Background

Pelvic floor dysfunctions (PFDs) affect the female population, and the postpartum period can be related to the onset or aggravation of the disease. Early identification of the symptoms and the impact on quality of life can be achieved through assessment instruments.

Objective

The purpose of this systematic review is to evaluate questionnaires used to assess PFD in the postpartum period.

Methods

A systematic review study was conducted, following Preferred Reporting Items for the Systematic Reviews and Meta-Analyses (PRISMA) criteria, using the databases: PubMed, Biblioteca Virtual de Saúde (BVS), Web of Science, and Scopus, and the keywords PFD or pelvic floor disorders, postpartum or puerperium, and questionnaire. Articles published up till May 2018 were included, searching for articles using validated questionnaires for the evaluation of PFDs in postpartum women. The articles included were evaluated according to a checklist, and the validation studies and translated versions of the questionnaires were identified.

Results

The search of the databases resulted in 359 papers, and 33 were selected to compose this systematic review, using nine validated questionnaires to assess PFDs in the postpartum period: International Consultation on Incontinence Questionnaire – Vaginal Symptoms (ICIQ-VS), Pelvic Floor Distress Inventory 20 (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), PFDI-46, Pelvic Floor Impact Questionnaire (PFIQ-31), Pelvic Floor Bother Questionnaire (PFBQ), Female Pelvic Floor Questionnaire, electronic Personal Assessment Questionnaire – Pelvic Floor, and PFD questionnaire specific for pregnancy and postpartum. The most frequently reported questionnaires included PFDI-20, PFIQ-7, and ICIQ-VS and are recommended by ICI. In addition, the review identified a specific questionnaire, recently developed, to access PFD during pregnancy and postpartum.

Conclusion

The questionnaires used to evaluate PFD during postpartum period are developed for general population or urology/gynecology patients with incontinence and reinforce the paucity of highly recommended questionnaires designed for postpartum, in order to improve early and specific approach for this period of life.

Pelvic floor dysfunction after vaginal and cesarean delivery among singleton primiparas

OBJECTIVE

To compare the prevalence of pelvic floor dysfunction symptoms, including pelvic organ prolapse (POP), urinary incontinence (UI), and fecal incontinence (FI) among primiparous women after vaginal and cesarean delivery.

METHODS

In a prospective cohort study at a University hospital in the Czech Republic, singleton primiparas with cephalic presentation who delivered at term were enrolled between 2002 and 2007. In 2013, 5-10 years after delivery, women who had not delivered again completed an internet-based survey about current symptoms of POP, UI, and FI, which were evaluated using validated questionnaires. The relative risk (RR) of POP, UI, and FI symptoms was calculated.

RESULTS

Complete questionnaire data were obtained from 641 women who delivered vaginally and 224 who delivered by cesarean. The mean UI score (ICIQ-SF) was 2.3 ± 3.6 in the vaginal group and 1.0 ± 2.7 in the cesarean group (P=0.005). The mean POP scores (POPDI-6) were 2.2 ± 2.3 and 2.1 ± 2.0, respectively (P=0.944). The mean Wexner scores to evaluate FI were 1.3 ± 1.7 and 1.0 ± 1.5, respectively (P=0.220). The RR of pelvic floor dysfunction after vaginal delivery was highest for women with UI symptoms (RR 1.15, 95% confidence interval 0.92-1.42).

CONCLUSION

Significant differences in the occurrence of symptoms of UI were observed after vaginal delivery as compared with cesarean delivery. ClinicalTrials.gov: NCT02661867.

Physical and cultural determinants of postpartum pelvic floor support and symptoms following vaginal delivery: a protocol for a mixed-methods prospective cohort study

INTRODUCTION

Pelvic floor disorders (PFDs), including pelvic organ prolapse (POP), stress and urgency urinary incontinence, and faecal incontinence, are common and arise from loss of pelvic support. Although severe disease often does not occur until women become older, pregnancy and childbirth are major risk factors for PFDs, especially POP. We understand little about modifiable factors that impact pelvic floor function recovery after vaginal birth. This National Institutes of Health (NIH)-funded Program Project, 'Bridging physical and cultural determinants of postpartum pelvic floor support and symptoms following vaginal delivery', uses mixed-methods research to study the influences of intra-abdominal pressure, physical activity, body habitus and muscle fitness on pelvic floor support and symptoms as well as the cultural context in which women experience those changes.

METHODS AND ANALYSIS

Using quantitative methods, we will evaluate whether pelvic floor support and symptoms 1 year after the first vaginal delivery are affected by biologically plausible factors that may impact muscle, nerve and connective tissue healing during recovery (first 8 weeks postpartum) and strengthening (remainder of the first postpartum year). Using qualitative methods, we will examine cultural aspects of perceptions, explanations of changes in pelvic floor support, and actions taken by Mexican-American and Euro-American primipara, emphasising early changes after childbirth. We will summarise project results in a resource toolkit that will enhance opportunities for dialogue between women, their families and providers, and across lay and medical discourses. We anticipate enrolling up to 1530 nulliparous women into the prospective cohort study during the third trimester, following those who deliver vaginally 1 year postpartum. Participants will be drawn from this cohort to meet the project's aims.

ETHICS AND DISSEMINATION

The University of Utah and Intermountain Healthcare Institutional Review Boards approved this study. Data are stored in a secure password-protected database. Papers summarising the primary results and ancillary analyses will be published in peer-reviewed journals.

Impact of vaginal parity and aging on the architectural design of pelvic floor muscles

BACKGROUND

Vaginal delivery and aging are key risk factors for pelvic floor muscle dysfunction, which is a critical component of pelvic floor disorders. However, alterations in the pelvic floor muscle intrinsic structure that lead to muscle dysfunction because of childbirth and aging remain elusive.

OBJECTIVES

The purpose of this study was to determine the impact of vaginal deliveries and aging on human cadaveric pelvic floor muscle architecture, which is the strongest predictor of active muscle function.

STUDY DESIGN

Coccygeus, iliococcygeus, and pubovisceralis were obtained from younger donors who were ≤51 years old, vaginally nulliparous (n = 5) and vaginally parous (n = 6) and older donors who were >51 years old, vaginally nulliparous (n = 6) and vaginally parous (n = 6), all of whom had no history of pelvic floor disorders. Architectural parameters, which are predictive of muscle's excursion and force-generating capacity, were determined with the use of validated methods. Intramuscular collagen content was quantified by hydroxyproline assay. Main effects of parity and aging and the interactions were determined with the use of 2-way analysis of variance, with Tukey's post-hoc testing and a significance level of .05.

RESULTS

The mean age of younger and older donors differed by approximately 40 years (P = .001) but was similar between nulliparous and parous donors within each age group (P > .9). The median parity was 2 (range, 1-3) in younger and older vaginally parous groups (P = .7). The main impact of parity was increased fiber length in the more proximal coccygeus (P = .03) and iliococcygeus (P = .04). Aging changes manifested as decreased physiologic cross-sectional area across all pelvic floor muscles (P < .05), which substantially exceeded the age-related decline in muscle mass. The physiologic cross-sectional area was lower in younger vaginally parous, compared with younger vaginally nulliparous, pelvic floor muscles; however, the differences did not reach statistical significance. Pelvic floor muscle collagen content was not altered by parity but increased dramatically with aging (P < .05).

CONCLUSIONS

Increased fiber length in more proximal pelvic floor muscles likely represents an adaptive response to the chronically increased load placed on these muscles by the displaced apical structures, presumably as a consequence of vaginal delivery. In younger specimens, a consistent trend towards decrease in force-generating capacity of all pelvic floor muscles in the parous group suggests a potential mechanism for clinically identified pelvic floor muscle weakness in vaginally parous women. The substantial decrease in predicted muscle force production and fibrosis with aging represent likely mechanisms for the pelvic floor muscle dysfunction in older women.

Pelvic floor dysfunction and sensory impairment: Current evidence

AIMS

To explore the role of sensory nerve impairment in women with pelvic organ prolapse, painful bladder syndrome, urinary and fecal incontinence, and sexual dysfunction.

METHODS

Medline and Embase were searched for articles in which sensory testing, either quantitative sensory testing or current perception thresholds, had been used to evaluate women with pelvic organ prolapse, stress and urge urinary incontinence, fecal incontinence and female sexual dysfunction. All search terms were expanded within each database prior to searching.

RESULTS

Research to date has included small numbers of participants, used poorly matched controls, lacked a systemic sensory examination and applied non-standardized sensory testing techniques. However, the evidence suggests women with pelvic organ prolapse demonstrate sensory dysfunction. The role of sensory impairment in stress urinary incontinence is inconclusive. In women with urge urinary incontinence there is some evidence to suggest it may be urethrally mediated. Women with painful bladder syndrome may have more sensitive nerve endings which are unable to ignore repeated stimuli. Sensory impairment is common in women with sexual dysfunction, typically involving larger nerve fibres. There were no studies evaluating sensory function in women with fecal incontinence.

CONCLUSION

Current evidence suggests women with pelvic floor dysfunction demonstrate sensory impairment though the causes remain unclear. Further studies are needed to investigate the different conditions of pelvic floor dysfunction using standardized sensory testing techniques, as well as evaluate the timing and mechanism by which any sensory impairment develops. Neurourol. Urodynam. 36:550-556, 2017. © 2016 Wiley Periodicals, Inc.

Postpartum pelvic floor muscle training and pelvic organ prolapse--a randomized trial of primiparous women

OBJECTIVE

Pelvic organ prolapse (POP) is a common and distressing condition. The aim of the present study was to evaluate the effect of pelvic floor muscle training (PFMT) on prevention and treatment of symptoms and signs of POP in primiparous postpartum women.

STUDY DESIGN

This was a parallel group assessor blind randomized controlled trial. One hundred seventy-five primiparous postpartum women, mean age 29.8 years (standard deviation 4.1), stratified on major levator ani defects or no defect diagnosed by 3-/4-dimensional ultrasound, participated in a 4-month PFMT starting at 6-8 weeks' postpartum or control. All participants had thorough individual instruction and assessment of ability to perform correct pelvic floor muscle contractions. The PFMT group followed a supervised, weekly group training program and performed 3 sets of 8-12 daily maximal contractions at home. Main outcome was POP stage II or greater assessed by POP quantification and bladder neck position assessed by 3-/4- dimensional transperineal ultrasonography. Secondary outcome was symptoms of vaginal bulge using International Consultation on Incontinence Vaginal Symptoms questionnaire.

RESULTS

Ninety-six percent of the intervention group adhered to ≥80% of both group and home training sessions. At postintervention, there was no significant risk difference in POP (rational ratio, 1.62; 95% confidence interval, 0.55-4.75), bladder neck position or symptoms of vaginal bulging.

CONCLUSION

No effect was found of postpartum PFMT on POP in primiparous women. More randomized controlled trials are needed before strong conclusions can be drawn on the effect of PFMT on POP in the particular population.

Prevalence, etiology and risk factors of pelvic organ prolapse in premenopausal primiparous women

INTRODUCTION

The natural history of pelvic organ prolapse (POP) is poorly understood. We investigated the prevalence and risk factors of postnatal POP in premenopausal primiparous women and the associated effect of mode of delivery.

METHODS

We conducted a prospective cohort study in a tertiary teaching hospital attending 9,000 deliveries annually. Collagen-diseases history and clinical assessment was performed in 202 primiparae at ≥ 1 year postnatally. Assessment included Pelvic Organ Prolapse Quantification (POP-Q) system, Beighton mobility score, 2/3D-transperineal ultrasound (US) and quantification of collagen type III levels. Association with POP was assessed using various statistical tests, including logistic regression, where results with p < 0.1 in univariate analysis were included in multivariate analysis.

RESULTS

POP had a high prevalence: uterine prolapse 89 %, cystocele 90 %, rectocele 70 % and up to 65 % having grade two on POP-Q staging. The majority had multicompartment involvement, and 80 % were asymptomatic. POP was significantly associated with joint hypermobility, vertebral hernia, varicose veins, asthma and high collagen type III levels (p < 0.05). In multivariate logistic regression, only levator ani muscle (LAM) avulsion was significant in selected cases (p < 0.05). Caesarean section (CS) was significantly protective against cystocele and rectocele but not for uterine prolapse.

CONCLUSIONS

Mild to moderate POP has a very high prevalence in premenopausal primiparous women. There is a significant association between POP, collagen levels, history of collagen disease and childbirth-related pelvic floor trauma. These findings support a congenital contribution to POP etiology, especially for uterine prolapse; however, pelvic trauma seems to play paramount role. CS is significantly protective against some types of prolapse only.

Pelvic floor biometry in Chinese primiparous women 1 year after delivery: a prospective observational study

OBJECTIVES

To evaluate pelvic floor biometry in Chinese women 1 year following childbirth and to explore factors that affect it.

METHODS

Translabial ultrasound examination was performed at rest, on Valsalva maneuver (VM) and on pelvic floor muscle contraction (PFMC) in the first, second and third trimesters of pregnancy and at 8 weeks, 6 months and 12 months after delivery in a cohort of women delivering at term their first child. Offline analysis was undertaken to measure the position of the bladder neck, cervix, anorectal junction and hiatal dimensions at each posture and at each visit, and to detect levator ani muscle (LAM) injury on PFMC 8 weeks and 12 months after delivery. Results were analyzed according to mode of delivery.

RESULTS

We recruited 442 women, of whom 328 (74.2%) completed the study; there was LAM injury in 48 women at 8 weeks and in only 38 women at 12 months. When comparing first-trimester biometry to that at 12 months after delivery, the bladder neck was more distal on VM and bladder neck displacement was increased, and the cervix was lower at rest and on VM in the vaginal delivery group. In the Cesarean section group, bladder neck and anorectal junction were more distal on VM, the cervix was lower at rest, on VM and on PFMC, and the hiatal area was increased on VM. There was a greater increase in hiatal area after vaginal delivery. Overall, 34.8% had irreversible hiatal distension (> 20% increase in hiatal area after delivery as compared to first trimester). LAM injury was significantly associated with irreversible hiatal distension (odds ratios, 5.2-9.5 at different postures).

CONCLUSIONS

Pregnancy beyond 35 weeks of gestation has an effect on the pelvic floor of Chinese women, irrespective of mode of delivery. The pelvic organs remain more mobile after delivery when compared to in the first trimester, and there is no clear difference between the findings observed following vaginal delivery or Cesarean section, except in hiatal distension, which is greater after vaginal delivery. LAM injury is the factor most strongly associated with irreversible hiatal distension.

Intra- and interobserver reliability of levator ani muscle biometry and avulsion using three-dimensional endovaginal ultrasonography

OBJECTIVES

To test intra- and interobserver reliability of assessment of levator ani muscle (LAM) biometry and avulsion using antenatal and postnatal three-dimensional (3D) endovaginal ultrasonography (EVUS), and to determine levator-urethra gap (LUG) values on EVUS.

METHODS

Primigravid women were scanned prior to delivery, early postpartum and 3 months postpartum, with EVUS performed at rest using a standardized protocol. During post-processing, measurements were taken in the plane of minimal hiatal dimensions by two independent investigators blinded to the clinical information and each other's results. LAM attachment to the pubic bone was assessed at the pubococcygeus and puborectalis levels using a score system: (1) intact; (2) partial avulsion (< 50%); (3) partial avulsion (≥ 50%); and (4) complete avulsion. Intraclass correlation coefficients (ICCs) and limits of agreement (LOAs) were calculated for each time point, with intraobserver analysis conducted in a random sample of 20 women scanned 3 months following delivery.

RESULTS

One hundred and sixty-nine antenatal scans, 83 early postpartum scans and 75 scans at 3 months postpartum were performed. The intra- and interobserver ICCs, respectively, were 0.95 and 0.86-0.88 for hiatal area, 0.90 and 0.16-0.74 for hiatal transverse diameter, 0.91 and 0.73-0.80 for hiatal anteroposterior diameter, 0.50 and 0.32-0.52 for LAM thickness at the '9 o'clock position' and 0.55 and 0.33-0.45 for LAM thickness at the '3 o'clock position'. Both intra- and interobserver analysis revealed acceptable LOAs for hiatal measurements, but the LOAs were wide for thickness measurements. The correlation of LAM avulsion score was excellent on intra- and interobserver analysis. Antenatal mean ± SD LUGs were 18.8 ± 2.4 mm and 19.2 ± 2.3 mm on right and left sides, respectively; the intraobserver ICC was 0.82-0.91 but LOAs were wide, while interobserver ICC was 0.13-0.68 and also had wide LOAs.

CONCLUSIONS

3D-EVUS is a reliable tool for the assessment of hiatal measurements and LAM avulsion in women during pregnancy and after delivery, but performs less well for measurements of LAM thickness and LUG. EVUS can therefore be used in research studies involving childbirth and recurrent prolapse.