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Kojima M, Miyake T, Tani S, Sakai S, Nishina Y, Kaida S, Takebayashi K, Maehira H, Mori H, Otake R, Matsunaga T, Ishikawa H, Shimizu T, Tani M. Perineoplasty for anal incontinence after obstetric anal sphincter injury repair: a case report. Surg Case Rep 2024; 10:116. [PMID: 38724859 PMCID: PMC11082125 DOI: 10.1186/s40792-024-01917-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/30/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND The rectal and vaginal walls are typically sutured if severe perineal lacerations with rectal mucosal damage occur during vaginal delivery. In case of anal incontinence after the repair, re-suturing of the anal sphincter muscle is standard procedure. However, this procedure may not result in sufficient improvement of function. CASE PRESENTATION A 41-year-old woman underwent suture repair of the vaginal and rectal walls for fourth-degree perineal laceration at delivery. She was referred to our department after complaining of flatus and fecal incontinence. Her Wexner score was 15 points. Examination revealed decreased anal tonus and weak contractions on the ventral side. We diagnosed anal incontinence due to sphincter dysfunction after repair of a perineal laceration at delivery. We subsequently performed sphincter re-suturing with perineoplasty to restructure the perineal body by suturing the fascia located lateral to the perineal body and running in a ventral-dorsal direction, which filled the space between the anus and vagina and increased anal tonus. One month after surgery, the symptoms of anal incontinence disappeared (the Wexner score lowered to 0 points), and the anorectal manometry values increased compared to the preoperative values. According to recent reports on the anatomy of the female perineal region, bulbospongiosus muscle in women does not move toward the midline to attach to the perineal body, as has been previously believed. Instead, it attaches to the ipsilateral surface of the external anal sphincter. We consider the fascia lateral to the perineal body to be the fascia of the bulbospongiosus muscle. CONCLUSIONS In a case of postpartum anal incontinence due to sphincter dysfunction after repair of severe perineal laceration, perineoplasty with re-suturing an anal sphincter muscle resulted in improvement in anal sphincter function. Compared to conventional simple suture repair of the rectal wall only, this surgical technique may improve sphincter function to a greater degree.
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Affiliation(s)
- Masatsugu Kojima
- Department of Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, 520-2192, Japan.
| | - Toru Miyake
- Department of Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, 520-2192, Japan
| | - Soichiro Tani
- Department of Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, 520-2192, Japan
| | - Sachiko Sakai
- Department of Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, 520-2192, Japan
| | - Yusuke Nishina
- Department of Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, 520-2192, Japan
| | - Sachiko Kaida
- Department of Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, 520-2192, Japan
| | - Katsushi Takebayashi
- Department of Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, 520-2192, Japan
| | - Hiromitsu Maehira
- Department of Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, 520-2192, Japan
| | - Haruki Mori
- Department of Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, 520-2192, Japan
| | - Reiko Otake
- Department of Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, 520-2192, Japan
| | - Takashi Matsunaga
- Department of Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, 520-2192, Japan
| | - Hajime Ishikawa
- Department of Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, 520-2192, Japan
| | - Tomoharu Shimizu
- Medical Safety Section, Shiga University of Medical Science Hospital, Tsukinowa-cho, Seta, Otsu, Shiga, 520-2192, Japan
| | - Masaji Tani
- Department of Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, 520-2192, Japan
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Kumar S, Chaudhary RK, Shah SS, Kumar D, Nepal P, Ojili V. Current update on the role of endoanal ultrasound: a primer for radiologists. Abdom Radiol (NY) 2024:10.1007/s00261-024-04300-0. [PMID: 38580791 DOI: 10.1007/s00261-024-04300-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 03/16/2024] [Accepted: 03/20/2024] [Indexed: 04/07/2024]
Abstract
Endoanal ultrasound (EAUS) is a valuable imaging modality for the evaluation of anal and perianal pathologies. It provides detailed information about the anatomy and physiology of the anorectal region and has been used in pre-and post-operative settings of anorectal pathologies. EAUS is not only useful in the evaluation of benign pathologies but also in loco-regional staging of anal and rectal tumors. EAUS has several advantages over MRI, including reduced cost, better patient tolerance, and improved scope of application in patients with contraindications to MRI. Despite its benefits, EAUS is not widely performed in many centers across the globe. This article aims to educate radiologists, trainees, and surgeons about the indications, contraindications, patient preparation, imaging technique, and findings of EAUS. We will also highlight the technical difficulties, diagnostic challenges, and procedural complications encountered during EAUS, along with a comparative analysis of EAUS with other imaging approaches.
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Affiliation(s)
- Shruti Kumar
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W Markham St, Slot 556, Little Rock, AR, 72205, USA.
| | - Ranjit K Chaudhary
- Department of Radiology, St. Vincent's Medical Center, Bridgeport, CT, USA
| | - Samir S Shah
- Department of Radiology, Canpic Medical and Education Foundation, Pune, India
| | - Devendra Kumar
- Department of Clinical Imaging, Hamad Medical Corporation, Doha, Qatar
| | - Pankaj Nepal
- Department of Radiology, Inova Fairfax Hospital, Fairfax, VA, USA
| | - Vijayanadh Ojili
- Department of Radiology, University of Texas Health, San Antonio, TX, USA
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Sarofim M, Slaar A, Dermout S, den Boer F, Engel A. Irritable bowel syndrome worsens faecal incontinence after primary repair of major obstetric anal sphincter injuries. Colorectal Dis 2024; 26:508-514. [PMID: 38229253 DOI: 10.1111/codi.16862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 11/22/2023] [Accepted: 12/11/2023] [Indexed: 01/18/2024]
Abstract
AIM Obstetric anal sphincter injuries (OASIS) occur in approximately 3%-6% of vaginal deliveries and are the leading risk factor for late-onset faecal incontinence, which is an underdiagnosed pathology. The aim of this work was to use a validated scoring system to quantify the effect of irritable bowel syndrome (IBS) on the severity of faecal incontinence symptoms after primary repair of major OASIS (Grade IIIb-IV). METHOD A prospective cohort study was performed on all women who underwent primary repair of major OASIS over a 6-year period. They were assessed with ultrasonography within 12 weeks. Two control groups (who did not have OASIS) were women who underwent elective caesarean section and primigravid women. Questionnaires were sent at least 12 months after delivery, or at first consultation for primigravids, which generated the main outcome measures: Cleveland Clinic faecal incontinence severity scores and the presence of IBS based on Rome III criteria. RESULTS There was a total of 211 patients included in the three groups and the mean follow-up time was 26 months after sphincter repair. Ultrasonographic sphincter defects were detected in 37% but did not affect the faecal incontinence score (p = 0.47), except in patients with IBS. Within each group, patients with IBS had significantly worse faecal incontinence than those without. Women with both OASIS and IBS had the most severe faecal incontinence scores. CONCLUSION OASIS has a limited negative effect on faecal incontinence, independent of whether residual ultrasonographic sphincter defects are present. However, the presence of IBS has a significant compounding effect on faecal incontinence in OASIS patients. The effect of IBS on faecal incontinence is also notable in caesarean section patients and primigravids, suggesting that IBS is an independent risk-factor that should have its place in predelivery assessment and counselling.
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Affiliation(s)
- Mina Sarofim
- Department of Colorectal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- School of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Annelie Slaar
- Department of Radiology Dirksland Ziekenhuis, Hoorn, The Netherlands
| | - Sylvia Dermout
- Department of Gynaecology and Obstetrics, Zaans Medisch Centrum, Zaandam, The Netherlands
| | - Frank den Boer
- Department of Surgery, Zaans Medisch Centrum, Zaandam, The Netherlands
| | - Alexander Engel
- Department of Colorectal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- School of Medicine, University of Sydney, Sydney, New South Wales, Australia
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Okeahialam NA, Sultan AH, Thakar R. The prevention of perineal trauma during vaginal birth. Am J Obstet Gynecol 2024; 230:S991-S1004. [PMID: 37635056 DOI: 10.1016/j.ajog.2022.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/08/2022] [Accepted: 06/12/2022] [Indexed: 08/29/2023]
Abstract
Perineal trauma after vaginal birth is common, with approximately 9 of 10 women being affected. Second-degree perineal tears are twice as likely to occur in primiparous births, with a incidence of 40%. The incidence of obstetrical anal sphincter injury is approximately 3%, with a significantly higher rate in primiparous than in multiparous women (6% vs 2%). Obstetrical anal sphincter injury is a significant risk factor for the development of anal incontinence, with approximately 10% of women developing symptoms within a year following vaginal birth. Obstetrical anal sphincter injuries have significant medicolegal implications and contribute greatly to healthcare costs. For example, in 2013 and 2014, the economic burden of obstetrical anal sphincter injuries in the United Kingdom ranged between £3.7 million (with assisted vaginal birth) and £9.8 million (with spontaneous vaginal birth). In the United States, complications associated with trauma to the perineum incurred costs of approximately $83 million between 2007 and 2011. It is therefore crucial to focus on improvements in clinical care to reduce this risk and minimize the development of perineal trauma, particularly obstetrical anal sphincter injuries. Identification of risk factors allows modification of obstetrical practice with the aim of reducing the rate of perineal trauma and its attendant associated morbidity. Risk factors associated with second-degree perineal trauma include increased fetal birthweight, operative vaginal birth, prolonged second stage of labor, maternal birth position, and advanced maternal age. With obstetrical anal sphincter injury, risk factors include induction of labor, augmentation of labor, epidural, increased fetal birthweight, fetal malposition (occiput posterior), midline episiotomy, operative vaginal birth, Asian ethnicity, and primiparity. Obstetrical practice can be modified both antenatally and intrapartum. The evidence suggests that in the antenatal period, perineal massage can be commenced in the third trimester of pregnancy to increase muscle elasticity and allow stretching of the perineum during birth, thereby reducing the risk of tearing or need for episiotomy. With regard to the intrapartum period, there is a growing body of evidence from the United Kingdom, Norway, and Denmark suggesting that the implementation of quality improvement initiatives including the training of clinicians in manual perineal protection and mediolateral episiotomy can reduce the incidence of obstetrical anal sphincter injury. With episiotomy, the International Federation of Gynecology and Obstetrics recommends restrictive rather than routine use of episiotomy. This is particularly the case with unassisted vaginal births. However, there is a role for episiotomy, specifically mediolateral or lateral, with assisted vaginal births. This is specifically the case with nulliparous vacuum and forceps births, given that the use of mediolateral or lateral episiotomy has been shown to significantly reduce the incidence of obstetrical anal sphincter injury in these groups by 43% and 68%, respectively. However, the complications associated with episiotomy including perineal pain, dyspareunia, and sexual dysfunction should be acknowledged. Despite considerable research, interventions for reducing the risk of perineal trauma remain a subject of controversy. In this review article, we present the available data on the prevention of perineal trauma by describing the risk factors associated with perineal trauma and interventions that can be implemented to prevent perineal trauma, in particular obstetrical anal sphincter injury.
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Affiliation(s)
| | - Abdul H Sultan
- Croydon University Hospital, London, United Kingdom; St George's University of London
| | - Ranee Thakar
- Croydon University Hospital, London, United Kingdom; St George's University of London.
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Shaffer AB, Cigna ST, Pope R, Krapf JM. Pregnancy, parturition and postpartum considerations among patients with vulvar lichen sclerosus: A retrospective cross-sectional online survey. BJOG 2024; 131:327-333. [PMID: 37424180 DOI: 10.1111/1471-0528.17601] [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: 04/19/2023] [Revised: 06/23/2023] [Accepted: 06/25/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVE Characterise VLS and obstetric considerations among women during pregnancy, parturition and postpartum. DESIGN Retrospective cross-sectional online survey, 2022. SETTING International, English-speakers. POPULATION Self-identified individuals aged 18-50 diagnosed with VLS with symptom onset prior to pregnancy. METHODS Participants recruited from social media support groups and accounts, completed a 47-question survey including yes/no, multiple answer, and free-text responses. Data were analysed with frequency, means and the Chi-square test. MAIN OUTCOME MEASURES VLS symptom severity, mode of delivery, perineal laceration, source and sufficiency of information provided about VLS and obstetrics, anxiety about delivery, and postpartum depression. RESULTS Of 204 responses, 134 met inclusion criteria, encompassing 206 pregnancies. Mean respondent age was 35 years (SD 6) and mean age of VLS symptom onset, diagnosis and birth, was 22 (SD 8), 29 (SD 7) and 31 (SD 4) years, respectively. Symptoms decreased in 44% (n = 91) of pregnancies and increased during the postpartum period in 60% (n = 123). In all, 67% (n = 137) of pregnancies resulted in vaginal birth and 33% (n = 69) in caesarean birth. Anxiety for delivery due to VLS symptoms was reported by 50% (n = 103); 31% (n = 63) experienced postpartum depression. Of respondents previously diagnosed with VLS, 60% (n = 69) used topical steroids prior to pregnancy, 40% (n = 45) were treated during pregnancy and 65% (n = 75) postpartum. In all, 94% (n = 116) reported receiving an insufficient amount of information on the topic. CONCLUSION In this online survey, we found reported symptom severity remained unchanged or decreased during pregnancy, but increased postpartum. Use of topical corticosteroids decreased during pregnancy compared with before and after pregnancy. Half of the respondents reported anxiety regarding VLS and delivery.
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Affiliation(s)
- Alyssa B Shaffer
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Sarah T Cigna
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Rachel Pope
- Division of Women's Sexual Health, Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, Ohio, USA
| | - Jill M Krapf
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Center for Vulvovaginal Disorders, Washington, DC, USA
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Maher GM, O'Byrne LJ, McKernan J, Corcoran P, Greene RA, Khashan AS, McCarthy FP. Predicting perineal trauma during childbirth using data from a general obstetric population. HRB Open Res 2023; 5:79. [PMID: 37928404 PMCID: PMC10624951 DOI: 10.12688/hrbopenres.13656.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2023] [Indexed: 11/07/2023] Open
Abstract
Background Perineal trauma is a common complication of childbirth and can have serious impacts on long-term health. Few studies have examined the combined effect of multiple risk factors. We developed and internally validated a risk prediction model to predict third and fourth degree perineal tears using data from a general obstetric population. Methods Risk prediction model using data from all singleton vaginal deliveries at Cork University Maternity Hospital (CUMH), Ireland during 2019 and 2020. Third/fourth degree tears were diagnosed by an obstetrician or midwife at time of birth and defined as tears that extended into the anal sphincter complex or involved both the anal sphincter complex and anorectal mucosa. We used univariable and multivariable logistic regression with backward stepwise selection to develop the models. Candidate predictors included infant sex, maternal age, maternal body mass index, parity, mode of delivery, birthweight, post-term delivery, induction of labour and public/private antenatal care. We used the receiver operating characteristic (ROC) curve C-statistic to assess discrimination, and bootstrapping techniques were used to assess internal validation. Results Of 8,403 singleton vaginal deliveries, 8,367 (99.54%) had complete data on predictors for model development. A total of 128 women (1.53%) had a third/fourth degree tear. Three variables remained in the final model: nulliparity, mode of delivery (specifically forceps delivery or ventouse delivery) and increasing birthweight (per 100 gram increase) (C-statistic: 0.75, 95% CI: 0.71, 0.79). We developed a nomogram to calculate individualised risk of third/fourth degree tears using these predictors. Bootstrapping indicated good internal performance. Conclusions Use of our nomogram can provide an individualised risk assessment of third/fourth degree tears and potentially aid counselling of women on their potential risk.
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Affiliation(s)
- Gillian M. Maher
- INFANT Research Centre, University College Cork, Cork, T12YE02, Ireland
- School of Public Health, University College Cork, Cork, T12XF62, Ireland
| | - Laura J. O'Byrne
- INFANT Research Centre, University College Cork, Cork, T12YE02, Ireland
- Department of Obstetrics and Gynaecology, University College Cork, Cork, T12YE02, Ireland
- National Perinatal Epidemiology Centre, University College Cork, Cork, T12YE02, Ireland
| | - Joye McKernan
- National Perinatal Epidemiology Centre, University College Cork, Cork, T12YE02, Ireland
| | - Paul Corcoran
- National Perinatal Epidemiology Centre, University College Cork, Cork, T12YE02, Ireland
| | - Richard A. Greene
- Department of Obstetrics and Gynaecology, University College Cork, Cork, T12YE02, Ireland
- National Perinatal Epidemiology Centre, University College Cork, Cork, T12YE02, Ireland
| | - Ali S. Khashan
- INFANT Research Centre, University College Cork, Cork, T12YE02, Ireland
- School of Public Health, University College Cork, Cork, T12XF62, Ireland
| | - Fergus P. McCarthy
- INFANT Research Centre, University College Cork, Cork, T12YE02, Ireland
- Department of Obstetrics and Gynaecology, University College Cork, Cork, T12YE02, Ireland
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Dietz HP. Diagnosis of maternal birth trauma by pelvic floor ultrasound. Eur J Obstet Gynecol Reprod Biol 2023; 285:86-96. [PMID: 37087835 DOI: 10.1016/j.ejogrb.2023.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/01/2023] [Accepted: 04/06/2023] [Indexed: 04/25/2023]
Abstract
BRIEF SUMMARY Maternal somatic birth trauma due to vaginal delivery is more common than generally assumed and an important cause of future morbidity. Maternal birth trauma may involve both psychological and somatic morbidity, some of it long-term and permanent. Somatic birth trauma is now understood to encompass not just episiotomy, perineal tears and obstetric anal sphincter injuries (OASI), but also trauma to the levator ani muscle, termed 'avulsion'. This review will focus on recent developments in the imaging diagnosis of maternal birth trauma, discuss the most important risk factors and strategies for primary and secondary prevention. Translabial and exo-anal ultrasound allow the assessment of maternal birth trauma in routine clinical practice and enable the use of levator avulsion and anal sphincter trauma as key performance indicators of maternity services. This is likely to lead to a greater awareness of maternal birth trauma amongst maternity caregivers and improved outcomes for patients, not the least due to an increasing emphasis on patient autonomy and informed consent in antenatal and intrapartum care.
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Fruscalzo A, Novak A, Somma C, Xholli A, Michelerio V, Prefumo F, Londero AP, Cagnacci A. Anthropometric Features and Third-Fourth Degree Perineal Tears. J Pers Med 2023; 13:jpm13030545. [PMID: 36983727 PMCID: PMC10053975 DOI: 10.3390/jpm13030545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/11/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
The main objective of this study was to evaluate the association between maternal and fetal anthropometric characteristics and third- and fourth-degree perineal tears. This retrospective cohort study considered all consecutive pregnancies from 2011 to 2017 at a single Institution. The inclusion criteria were: singletons who delivered vaginally during the study period, the presence of information on maternal pre-pregnancy weight, maternal height, and weight of the newborn. The feto-maternal body-mass index (BMI) was calculated as neonatal weight in kg on maternal height in squared meters (kg/m2). In total, 5397 singleton-term pregnancies were included; the prevalence of third-fourth-degree perineal tears was 0.47%. The most predictive factors were: nulliparity, feto-maternal BMI, neonatal weight, gestational age at delivery, and neonatal head circumference. After adjustment in multivariate analysis, the only independent predictors were nulliparity and fetomaternal BMI. The AUC of the final multivariate model was 73.54% (95% CI 65.65-81.42). Furthermore, feto-maternal BMI and gestational age had a significant direct correlation. Nulliparity and feto-maternal BMI are the two best predictors for third and fourth-degree perineal tears in our setting. Confirming this association in future research and integrating it into a decision algorithm on delivery timing could reduce obstetric damage to the anal sphincter.
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Affiliation(s)
- Arrigo Fruscalzo
- Clinic of Obstetrics and Gynecology, University Hospital of Fribourg, 1752 Fribourg, Switzerland
| | - Alice Novak
- Clinic of Obstetrics and Gynecology, DAME, Academic Hospital of Udine, 33100 Udine, Italy
| | - Camilla Somma
- Clinic of Obstetrics and Gynecology, DAME, Academic Hospital of Udine, 33100 Udine, Italy
| | - Anjeza Xholli
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale San Martino, 16132 Genoa, Italy
| | - Virginia Michelerio
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale San Martino, 16132 Genoa, Italy
| | - Federico Prefumo
- Obstetrics and Gynecology Unit, IRCCS Istituto Giannina Gaslini, 16147 Genova, Italy
| | - Ambrogio P Londero
- Obstetrics and Gynecology Unit, IRCCS Istituto Giannina Gaslini, 16147 Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health, University of Genoa, 16132 Genova, Italy
| | - Angelo Cagnacci
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale San Martino, 16132 Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health, University of Genoa, 16132 Genova, Italy
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Gutzeit O, Justman N, Zvi DB, Siegler Y, Khatib N, Ginsberg Y, Beloosesky R, Weiner Z, Vitner D, Liberman S, Zipori Y. Late preterm delivery has a distinctive second-stage duration and characteristics. Am J Obstet Gynecol MFM 2023; 5:100845. [PMID: 36572106 DOI: 10.1016/j.ajogmf.2022.100845] [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: 09/16/2022] [Revised: 12/06/2022] [Accepted: 12/20/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Late preterm neonates born between 34.0 and 36.6 weeks' gestation are at increased risk for short- and long-term morbidity and mortality when compared with their term counterparts. Currently, no separate labor curve is available for late preterm births, and this group's optimal duration of the second stage of labor has never been defined separately. OBJECTIVE This study aimed to compare the second stage duration between late preterm and term births. STUDY DESIGN This was a retrospective study from May 2014 until May 2021. Eligible were women with a singleton pregnancy, vertex presentation, spontaneous or induced onset of labor, and those who delivered vaginally beyond 34.0 weeks of gestation. The primary outcome of our study was to compare and characterize the second stage of labor duration between late preterm and term births. RESULTS We analyzed 962 late preterm and 9476 term vaginal deliveries. Women who delivered during the late preterm period were more likely to be multiparous (52.4% vs 45.2%; P<.001) and fewer required oxytocin during labor (41.2% vs 54.4%; P<.001) or used epidural analgesia (75.2% vs 83.6%; P<.001). The overall mean duration of the second stage of labor was significantly shorter in the late preterm period than at term (1.08±1.09 hours vs 1.49±1.22 hours; P<.001). This was even more pronounced for nulliparous women (1.05±1.00 hours vs 2.10±1.17 hours; P<.001). Among multiparous women, epidural use significantly affected the duration of the second stage of labor, and the second stage was relatively longer during the late preterm period than at term in this subgroup (1.16 vs 0.5 hours; P<.001). Using a multivariate Cox regression, variables such as maternal age (hazard ratio, 1.02; 95% confidence interval, 1.01-1.04), parity (hazard ratio, 4.11; 95% confidence interval, 3.65-4.63), preterm birth (hazard ratio, 2.08; 95% confidence interval, 1.4-3.10), and birthweight at delivery (hazard ratio, 1.15; 95% confidence interval, 1.01-1.30) shortened the second stage, whereas induction of labor (hazard ratio, 0.75; 95% confidence interval, 0.66-0.86) and epidural use (hazard ratio, 0.68; 95% confidence interval, 0.64-0.86) extended its total duration. Regardless of parity, lower rates of operative vaginal deliveries were observed in the late preterm period than at term (3.7% vs 15.5%; P<.001). This period was also associated with lower rates of third- and fourth-degree perineal lacerations (0.2% vs 2.2%; P<.001) but higher rates of chorioamnionitis (1.7% vs 0.1%; P<.001), Apgar score at 5 minutes <7 (1.0% vs 0.2%; P<.001), and admission to the neonatal intensive care unit (19.3% vs 1.0%; P<.001). CONCLUSION Women who delivered vaginally during the late preterm period had a distinctive second-stage duration. Primarily, it was shown to be significantly shorter for nulliparous and multiparous women. Future studies should further clarify the optimal duration of this stage in relation to neonatal outcomes at such a vulnerable period.
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Affiliation(s)
- Ola Gutzeit
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori)
| | - Naphtali Justman
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori)
| | - Dikla Ben Zvi
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori)
| | - Yoav Siegler
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori)
| | - Nizar Khatib
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori); Ruth & Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel (Drs Khatib, Ginsberg, Beloosesky, Weiner, Vitner, and Zipori)
| | - Yuval Ginsberg
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori); Ruth & Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel (Drs Khatib, Ginsberg, Beloosesky, Weiner, Vitner, and Zipori)
| | - Ron Beloosesky
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori); Ruth & Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel (Drs Khatib, Ginsberg, Beloosesky, Weiner, Vitner, and Zipori)
| | - Zeev Weiner
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori); Ruth & Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel (Drs Khatib, Ginsberg, Beloosesky, Weiner, Vitner, and Zipori)
| | - Dana Vitner
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori); Ruth & Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel (Drs Khatib, Ginsberg, Beloosesky, Weiner, Vitner, and Zipori)
| | - Sapir Liberman
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori)
| | - Yaniv Zipori
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel (Drs Gutzeit, Justman, Ben Zvi, Siegler, Khatib, Ginsberg, Beloosesky, Weiner, Vitner, Liberman, and Zipori); Ruth & Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel (Drs Khatib, Ginsberg, Beloosesky, Weiner, Vitner, and Zipori).
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10
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Polnaszek BE, Danilack VA, Has P, Russo M, Hamel M, Tuuli MG, Savitz DA, Lewkowitz AK. Risk of Spontaneous Obstetric Anal Sphincter Injury Following Non-Operative Vaginal Delivery in a High-Risk Cohort. RHODE ISLAND MEDICAL JOURNAL (2013) 2023; 106:43-44. [PMID: 36848543 PMCID: PMC10408132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Affiliation(s)
- Brock E Polnaszek
- Warren Alpert Medical School of Brown University, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Women & Infants Hospital, Providence, Rhode Island
| | - Valery A Danilack
- ale School of Medicine, Department of Internal Medicine, New Haven, Connecticut
| | - Phinnara Has
- Warren Alpert Medical School of Brown University, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Women & Infants Hospital, Providence, Rhode Island
| | - Melissa Russo
- Warren Alpert Medical School of Brown University, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Women & Infants Hospital, Providence, Rhode Island
| | - Maureen Hamel
- Warren Alpert Medical School of Brown University, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Women & Infants Hospital, Providence, Rhode Island
| | - Methodius G Tuuli
- Warren Alpert Medical School of Brown University, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Women & Infants Hospital, Providence, Rhode Island
| | - David A Savitz
- Warren Alpert Medical School of Brown University, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Women & Infants Hospital, Providence, Rhode Island
| | - Adam K Lewkowitz
- Warren Alpert Medical School of Brown University, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Women & Infants Hospital, Providence, Rhode Island
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11
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Narice BF, Marks K, Jha S. Factors that influence pregnant women's decision on mode of delivery after previous obstetric anal sphincter injury. Eur J Obstet Gynecol Reprod Biol 2023; 281:32-35. [PMID: 36529064 DOI: 10.1016/j.ejogrb.2022.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/09/2022] [Accepted: 11/26/2022] [Indexed: 12/03/2022]
Abstract
PURPOSE Maternal request for caesarean section (CS) is increasing. One common reason is following a previous obstetric anal sphincter injury (OASI). We aim to understand which factors bear the greatest influence in driving this women's decision-making process once they are pregnant after having sustained an OASI. METHODS Pregnant women with a previous OASIS who were attending their first antenatal appointment were deemed eligible and were asked to complete two questionnaires on their preferred mode of delivery (MoD) and ongoing pelvic floor symptomatology. Data were analysed with descriptive and inferential statistics using SPSS, and results were presented both quanti- and qualitatively. RESULTS Data from 63 participants was included in the final analysis. Most women had experienced 3A/3B OASIS (n = 49, 77.78 %), and they were more likely to report bladder pain and difficulties with voiding than those with major tears (p < 0.05). The type of tear did not impact directly on the preferred MoD. However, women still experiencing bladder pain were more likely to request a CS (p < 0.05). Even though all participants who attended a perineal trauma clinic postpartum found it helpful, they reported that ultimately the decision on how to deliver was theirs, and their ideas and concerns played the greatest influence. CONCLUSION Pregnant women with ongoing urinary symptoms rather than sexual or bowel dysfunction seem to favour a planned CS, regardless of the severity of their previous tear. Postpartum follow-up in a perineal trauma clinic is extremely valuable but even more is the need to understand women's motivations to support them make an informed decision.
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Affiliation(s)
- Brenda F Narice
- Academic Unit of Reproductive and Developmental Medicine, the University of Sheffield, Jessop Wing, Tree Root Walk, Sheffield S10 2SF, UK; Department of Obstetrics and Gynaecology, Sheffield Teaching Hospitals NHS Foundation Trust, Jessop Wing, Tree Root Walk, Sheffield S10 2SF, UK
| | - Kylie Marks
- Department of Obstetrics and Gynaecology, Sheffield Teaching Hospitals NHS Foundation Trust, Jessop Wing, Tree Root Walk, Sheffield S10 2SF, UK
| | - Swati Jha
- Department of Obstetrics and Gynaecology, Sheffield Teaching Hospitals NHS Foundation Trust, Jessop Wing, Tree Root Walk, Sheffield S10 2SF, UK; Department of Urogynaecology, Sheffield Teaching Hospitals NHS Foundation Trust, Jessop Wing, Tree Root Walk, Sheffield S10 2SF, UK.
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12
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Brismar Wendel S, Liu C, Stephansson O. The association between episiotomy or OASIS at vacuum extraction in nulliparous women and subsequent prelabor cesarean delivery: A nationwide observational study. Acta Obstet Gynecol Scand 2023; 102:378-388. [PMID: 36691864 PMCID: PMC9951312 DOI: 10.1111/aogs.14513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 12/28/2022] [Accepted: 01/02/2023] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Severe perineal injuries at childbirth affect women's postnatal health, including future childbirths. First births with vacuum extraction carry an increased risk of obstetric anal sphincter injuries (OASIS). Lateral or mediolateral episiotomy at vacuum extraction may decrease the risk of OASIS. Our aim was to assess whether lateral or mediolateral episiotomy, or OASIS, at vacuum extraction in nulliparous women is associated with prelabor cesarean delivery in the subsequent childbirth. MATERIAL AND METHODS This is a nationwide observational study using data from the Swedish Medical Birth Register, including women having a first birth with vacuum extraction and a second birth in 2000-2014. Both births were live, single, cephalic, ≥34 gestational weeks without malformations. The association between episiotomy or OASIS in the first birth and prelabor cesarean delivery in the second birth was examined using univariate and multivariate logistic regression with inverse probability of treatment weighting, and interaction analysis. Main outcome measure was prelabor cesarean delivery in the second birth. RESULTS In total, 44 656 women with vacuum extraction at their first birth were included. The rate of prelabor cesarean delivery in the second birth was 5.9% (824 of 13 950) in women with episiotomy, compared with 6.0% (1830 of 30 706) in women without episiotomy. Thus, women with episiotomy did not have an increased risk of prelabor cesarean delivery (adjusted odds ratio [aOR] 1.00, 95% confidence interval [95% CI] 0.83-1.20) compared with women without episiotomy. For comparison, the rate of prelabor cesarean delivery in the second birth was 20.6% (1275 of 6176) in women with OASIS, compared with 3.6% (1379 of 38 480) in women without OASIS (aOR 6.57, 95% CI 5.97-7.23). There was no interaction between episiotomy and OASIS. CONCLUSIONS Lateral or mediolateral episiotomy at vacuum extraction in nulliparous women did not increase the risk of prelabor cesarean delivery in the subsequent childbirth. OASIS increased the odds of prelabor cesarean delivery more than sixfold.
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Affiliation(s)
- Sophia Brismar Wendel
- Department of Clinical SciencesKarolinska Institutet, Danderyd HospitalStockholmSweden,Department of Women's HealthDanderyd HospitalStockholmSweden,Clinical Epidemiology Division, Department of MedicineKarolinska InstitutetStockholmSweden
| | - Can Liu
- Clinical Epidemiology Division, Department of MedicineKarolinska InstitutetStockholmSweden,Department of Public Health SciencesStockholm UniversityStockholmSweden,Centre for Health Equity Studies (CHESS)Stockholm University/Karolinska InstitutetStockholmSweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of MedicineKarolinska InstitutetStockholmSweden,Department of Women's Health, Division of ObstetricsKarolinska University HospitalStockholmSweden
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13
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Maher GM, O'Byrne L, McKernan J, Corcoran P, Greene RA, Khashan AS, McCarthy FP. Predicting perineal trauma during childbirth using data from a general obstetric population. HRB Open Res 2022. [DOI: 10.12688/hrbopenres.13656.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Perineal trauma is a common complication of childbirth and can have serious impacts on long-term health. Few studies have examined the combined effect of multiple risk factors. We developed and internally validated a risk prediction model to predict third and fourth degree perineal tears using data from a general obstetric population. Methods: Risk prediction model using data from all singleton vaginal deliveries at Cork University Maternity Hospital (CUMH), Ireland during 2019 and 2020. Third/fourth degree tears were diagnosed by an obstetrician or midwife at time of birth and defined as tears that extended into the anal sphincter complex or involved both the anal sphincter complex and anorectal mucosa. We used univariable and multivariable logistic regression with backward stepwise selection to develop the models. Candidate predictors included infant sex, maternal age, maternal body mass index, parity, mode of delivery, birthweight, post-term delivery, induction of labour and public/private antenatal care. We used the receiver operating characteristic (ROC) curve C-statistic to assess discrimination, and bootstrapping techniques were used to assess internal validation. Results: Of 8,403 singleton vaginal deliveries, 8,367 (99.54%) had complete data on predictors for model development. A total of 128 women (1.53%) had a third/fourth degree tear. Three variables remained in the final model: nulliparity, mode of delivery (specifically forceps delivery or ventouse delivery) and increasing birthweight (per 100 gram increase) (C-statistic: 0.75, 95% CI: 0.71, 0.79). We developed a nomogram to calculate individualised risk of third/fourth degree tears using these predictors. Bootstrapping indicated good internal performance. Conclusions: Use of our nomogram can provide an individualised risk assessment of third/fourth degree tears and potentially aid counselling of women on their potential risk.
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14
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Baruch Y, Gold R, Eisenberg H, Amir H, Yogev Y, Groutz A. Substantial Obstetric Anal Sphincter Injury during Vacuum Assisted Delivery: An Obstetrical Issue or Device Related? J Clin Med 2022; 11:jcm11236990. [PMID: 36498565 PMCID: PMC9736983 DOI: 10.3390/jcm11236990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/17/2022] [Accepted: 11/25/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Obstetric anal sphincter injuries (OASIS) might be associated with long-term urinary and anorectal morbidities. The aim of the study was to investigate the risk factors and clinical implications of OASIS associated with vacuum-assisted deliveries versus normal vaginal deliveries. METHODS A series of 413 consecutive OASIS cases were retrospectively analyzed. A comparison was made between OASIS cases diagnosed following vacuum-assisted deliveries versus OASIS cases diagnosed following normal vaginal deliveries. Multivariable analysis was used to study the association between vacuum-assisted deliveries and superficial (3A and 3B) versus deep (3C and 4) perineal tears. RESULTS The study population comprised 88,123 singleton vaginal deliveries. Diagnosis of OASIS was made in 413 women (0.47% of the total cohort), 379 (91.8%) of whom had third-degree tears and 34 (8.2%) of whom had fourth-degree tears. Among the 7410 vacuum-assisted deliveries, 102 (1.37%) had OASIS, whereas, among the 80,713 normal vaginal deliveries, only 311 (0.39%) had OASIS. In a multivariate analysis, only vacuum-assisted delivery was found to be associated with a significant risk of deeper (3C or 4) perineal tears (OR = 1.72; 95% CI 1.02-2.91; p = 0.043). CONCLUSIONS Vacuum-assisted instrumental intervention is a significant risk factor for OASIS and especially for deeper tears, independent of other maternal and obstetric risk factors.
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Affiliation(s)
- Yoav Baruch
- Urogynecology and Pelvic Floor Unit, Department of Obstetrics and Gynecology, Tel Aviv Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Correspondence: ; Tel.: +972-36925603
| | - Ronen Gold
- Urogynecology and Pelvic Floor Unit, Department of Obstetrics and Gynecology, Tel Aviv Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Hagit Eisenberg
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Hadar Amir
- Lis Maternity Hospital, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Yariv Yogev
- Lis Maternity Hospital, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Asnat Groutz
- Urogynecology and Pelvic Floor Unit, Department of Obstetrics and Gynecology, Tel Aviv Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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15
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Barba M, Bernasconi DP, Manodoro S, Frigerio M. Risk factors for obstetric anal sphincter injury recurrence: A systematic review and meta-analysis. Int J Gynaecol Obstet 2022; 158:27-34. [PMID: 34559892 PMCID: PMC9298380 DOI: 10.1002/ijgo.13950] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 09/13/2021] [Accepted: 09/23/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Women with previous obstetric anal sphincter injuries (OASIs) are at a higher risk of recurrence in the subsequent pregnancy, which may lead to the development or worsening of anal incontinence. Due to a lack of evidence, few recommendations can be made about the factors that may affect the risk of OASI recurrence. OBJECTIVE We sought to conduct a systematic review and meta-analysis to investigate potential risk factors for recurrent OASIs. SEARCH STRATEGY Studies up to May 2019 were identified from PubMed, Scopus, Cochrane Library, and ISI Web of Science. SELECTION CRITERIA Studies assessing the impact of risk factors on OASI recurrence in subsequent pregnancies were included. Reviews, letters to the editor, conference abstracts, book chapters, guidelines, Cochrane reviews, and expert opinions were excluded. DATA COLLECTION AND ANALYSIS Data were extracted by two independent reviewers. Odds ratio and standardized mean difference were chosen as effect measures. Pooled estimates were calculated using the random-effects model. MAIN RESULTS The meta-analysis showed that maternal age, gestational age, occiput posterior presentation, oxytocin augmentation, operative delivery, and shoulder dystocia were associated with the risk of recurrent OASIs in the subsequent delivery. CONCLUSION Prenatal and intrapartum risk factors are associated with recurrence of OASI. PROSPERO registration no. CRD42020178125.
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Affiliation(s)
- Marta Barba
- Department of Obstetrics and GynecologyUniversity Milano‐BicoccaMonzaItaly
| | | | - Stefano Manodoro
- Department of Obstetrics and GynecologyASST Santi Paolo e Carlo, San Paolo HospitalMilanoItaly
| | - Matteo Frigerio
- Department of Obstetrics and GynecologyASST Monza, San Gerardo HospitalMonzaItaly
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16
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Akıncı O, Keklikkıran ZZ, Tosun Y. Comparison of the outcomes of overlapping and direct apposition sphincteroplasty techniques in anal sphincter repair. Turk J Surg 2022; 38:134-139. [PMID: 36483173 PMCID: PMC9714655 DOI: 10.47717/turkjsurg.2022.5648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 05/17/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Sphincteroplasty is of great importance in the repair of anal sphincter damage. In the present study, we compared the results of overlapping sphincteroplasty and direct apposition techniques used in anal sphincter repair. MATERIAL AND METHODS Between 2011 and 2021, 36 patients underwent sphincteroplasty for anal sphincter injury and were analysed retrospectively. Sex, age, etiologic factors, repair technique, degree of laceration, postoperative complications, length of hospital stay, time between injury and repair, follow-up time and postoperative Cleveland Clinic Incontinence Score (CCIS) were recorded for analysis, and the two techniques were compared statistically using SPSS statistics, Version 17.0. RESULTS Of the sample, 31 were females and five were males, with a mean age of 31.50 ± 6.7 years. The etiologic factors were obstetric trauma in 25 patients, perianal interventions in seven patients and other traumas in four patients. The overlapping technique was applied to 14 patients and the direct apposition technique was applied to 22 patients. Mean postoperative CCIS of all cases was 5.53 ± 2.59, and was significantly lower in those who underwent overlapping sphincteroplasty technique than those who underwent apposition repair (p= 0.006). It was observed that postoperative CCIS decreased as the time between sphincter injury and repair decreased (p <0.001; r= 0.625). CONCLUSION It is vital to repair anal sphincter damage as early as possible. The overlapping sphincteroplasty and direct apposition methods can both be considered safe for anal sphincter repair although in terms of faecal incontinence, the outcomes of overlapping sphincteroplasty are better than those of the direct apposition technique.
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Affiliation(s)
- Ozan Akıncı
- Clinic of General Surgery, Kartal Dr. Lütfi Kırdar City Hospital, İstanbul, Türkiye
| | | | - Yasin Tosun
- Clinic of General Surgery, Kartal Dr. Lütfi Kırdar City Hospital, İstanbul, Türkiye
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17
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Markaryan DR, Lukyanov AM, Garmanova TN, Agapov MA, Kubyshkin VA. [Postpartum fecal incontinence. State of the problem]. Khirurgiia (Mosk) 2022:127-132. [PMID: 35658144 DOI: 10.17116/hirurgia2022061127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A review of the current national and foreign literature is devoted to epidemiology, risk factors, causes, diagnosis and modern treatment approaches for fecal incontinence (FI). Incidence of FI in early and delayed period after childbirth is 30% or more. At the same time, up to 87% of postpartum injuries of anal sphincter remain undiagnosed. Importantly, routine caesarean section does not reduce the risk of incontinence. In addition to typical complaints of spontaneous gas and stool, diagnosis of FI after childbirth includes transrectal ultrasound, MRI, anorectal manometry and pudendal nerve terminal motor latency testing. Survey of proctologists from different regions of Russia revealed a high demand from medical community for educational programs devoted to diagnosis, treatment and rehabilitation of patients with postpartum perineal injuries.
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Affiliation(s)
| | - A M Lukyanov
- Lomonosov Moscow State University, Moscow, Russia
| | | | - M A Agapov
- Lomonosov Moscow State University, Moscow, Russia
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18
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Schwertner-Tiepelmann N, Lorenz K, Schwab F, Beilecke K, Marschke J, Tunn R. Berlin survey on obstetric anal sphincter injury (OASI). Arch Gynecol Obstet 2022; 306:1117-1125. [DOI: 10.1007/s00404-022-06627-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 05/11/2022] [Indexed: 12/01/2022]
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Luchristt D, Meekins AR, Zhao C, Grotegut C, Siddiqui NY, Alhanti B, Jelovsek JE. Risk of obstetric anal sphincter injuries at the time of admission for delivery: A clinical prediction model. BJOG 2022; 129:2062-2069. [PMID: 35621030 DOI: 10.1111/1471-0528.17239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/18/2022] [Accepted: 05/19/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To develop and validate a model to predict obstetric anal sphincter injuries (OASIS) using only information available at the time of admission for labour. DESIGN A clinical predictive model using a retrospective cohort. SETTING A US health system containing one community and one tertiary hospital. SAMPLE A total of 22 873 pregnancy episodes with in-hospital delivery at or beyond 21 weeks of gestation. METHODS Thirty antepartum risk factors were identified as candidate variables, and a prediction model was built using logistic regression predicting OASIS versus no OASIS. Models were fit using the overall study population and separately using hospital-specific cohorts. Bootstrapping was used for internal validation and external cross-validation was performed between the two hospital cohorts. MAIN OUTCOME MEASURES Model performance was estimated using the bias-corrected concordance index (c-index), calibration plots and decision curves. RESULTS Fifteen risk factors were retained in the final model. Decreasing parity, previous caesarean birth and cardiovascular disease increased risk of OASIS, whereas tobacco use and black race decreased risk. The final model from the total study population had good discrimination (c-index 0.77, 95% confidence interval [CI] 0.75-0.78) and was able to accurately predict risks between 0 and 35%, where average risk for OASIS was 3%. The site-specific model fit using patients only from the tertiary hospital had c-stat 0.74 (95% CI 0.72-0.77) on community hospital patients, and the community hospital model was 0.77 (95%CI 0.76-0.80) on the tertiary hospital patients. CONCLUSIONS OASIS can be accurately predicted based on variables known at the time of admission for labour. These predictions could be useful for selectively implementing OASIS prevention strategies.
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Affiliation(s)
- Douglas Luchristt
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA
| | - Ana Rebecca Meekins
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA.,Department of Biostatistics & Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Congwen Zhao
- Department of Biostatistics & Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Chad Grotegut
- Department of Obstetrics and Gynecology Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Nazema Y Siddiqui
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA.,Department of Biostatistics & Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Brooke Alhanti
- Department of Biostatistics & Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - John Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA
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Brown O, Luchristt D, Miller ES, Pidaparti M, Geynisman-Tan J, Kenton K, Lewicky-Gaupp C. Is there an Association between Vaginal Birth after Cesarean Prediction and Obstetric Anal Sphincter Injury? Am J Perinatol 2022; 39:750-758. [PMID: 32992349 DOI: 10.1055/s-0040-1717099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE This study aimed to estimate whether there is an association between the predicted probability of vaginal birth after cesarean delivery (VBAC) and the occurrence of obstetric anal sphincter injuries (OASIS). STUDY DESIGN This was a single-site retrospective cohort study of all women with a singleton vaginal birth after a previous cesarean section between January 2011 and December 2016. Women were divided into four ordinal groupings by the predicted probability of achieving vaginal birth after cesarean using the Maternal-Fetal Medicine Units Network VBAC calculator (less than 41%, 40.1-60%, 60.1-80%, and greater than 80%). The primary outcome was OASIS, defined as a 3rd or 4th degree perineal laceration. Bivariable and multivariable analyses were used to examine the association between predicted VBAC probability and OASIS. RESULTS In total, 1,411 women met inclusion criteria and 73 (5.2%) sustained OASIS. The median predicted probability of VBAC was lower in women with OASIS compared with those without OASIS (60% [interquartile range {IQR}: 48-70%] vs. 66% (IQR: 52-80%), p = 0.02]. On bivariable and multivariable logistic regression, predicted probability of VBAC was associated with increased odds of OASIS (less than 41% probability: adjusted odds ratio [aOR]: 3.18, 95% confidence interval [CI]: 0.90-11.21; 41-60% probability: aOR: 3.76, 95% CI: 1.34-10.57; 61-80% probability aOR: 3.47, 95% CI: 1.25-9.69) relative to women with a predicted probability of VBAC of greater than 80%. CONCLUSION Having a lower predicted probability of VBAC is associated with an increased risk of OASIS at the time of a VBAC relative to those with greater than 80% predicted probability. Incorporation of this aspect of maternal morbidity may inform risk-stratification at the time of trial of labor after cesarean, as well as the choice of performing an operative vaginal delivery. KEY POINTS · Predicted probability of VBAC is associated with OASIS.. · Low predicted probability of VBAC is associated with increased odds of OASIS.. · Forceps delivery was associated with the highest odds of OASIS..
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Affiliation(s)
- Oluwateniola Brown
- Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, Chicago, Illinois
| | - Douglas Luchristt
- Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, Chicago, Illinois
| | - Emily S Miller
- Division of Maternal Fetal Medicine, Northwestern University, Chicago, Illinois
| | - Mahati Pidaparti
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julia Geynisman-Tan
- Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, Chicago, Illinois
| | - Kimberly Kenton
- Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, Chicago, Illinois
| | - Christina Lewicky-Gaupp
- Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, Chicago, Illinois
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Klokk R, Bakken KS, Markestad T, Holten-Andersen MN. Modifiable and non-modifiable risk factors for obstetric anal sphincter injury in a Norwegian Region: a case-control study. BMC Pregnancy Childbirth 2022; 22:277. [PMID: 35365116 PMCID: PMC8976330 DOI: 10.1186/s12884-022-04621-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/25/2022] [Indexed: 11/22/2022] Open
Abstract
Background Obstetric anal sphincter injury (OASI) is a common and severe complication of vaginal delivery and may have short- and long-term consequences, including anal incontinence, sexual dysfunction and reduced quality of life. The rate of OASI varies substantially between studies and national birth statistics, and a recent meta-analysis concluded that there is a need to identify unrecognized risk factors. Our aim was therefore to explore both potential modifiable and non-modifiable risk factors for OASI. Methods We performed a case–control study in a single center maternity clinic in South-Eastern Norway. Data were extracted retrospectively from an institutional birth registry. The main outcome measure was the occurrence of the woman’s first-time 3rd or 4th degree perineal lesion (OASI) following singleton vaginal birth after 30 weeks’ gestation. For each woman with OASI the first subsequent vaginal singleton delivery matched for parity was elected as control. The study population included 421 women with OASI and 421 matched controls who gave birth during 1990–2002. Potential risk factors for OASI were assessed by conditional logistic regression analyses. Results The mean incidence of OASI was 3.4% of vaginal deliveries, but it increased from 1.9% to 5.8% during the study period. In the final multivariate regression model, higher maternal age and birthweight for primiparous women, and higher birthweight for the multiparous women, were the only non-modifiable variables associated with OASI. Amniotomy was the strongest modifiable risk factor for OASI in both primi- (odds ratio [OR] 4.84; 95% confidence interval [CI] 2.60–9.02) and multiparous (OR 3.76; 95% CI 1.45–9.76) women, followed by augmentation with oxytocin (primiparous: OR 1.63; 95% CI 1.08–2.46, multiparous: OR 3.70; 95% CI 1.79–7.67). Vacuum extraction and forceps delivery were only significant risk factors in primiparous women (vacuum: OR 1.91; 95% CI 1.03–3.57, forceps: OR 2.37; 95% CI 1.14–4.92), and episiotomy in multiparous women (OR 2.64; 95% CI 1.36–5.14). Conclusions Amniotomy may be an unrecognized independent modifiable risk factor for OASI and should be further investigated for its potential role in preventive strategies.
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Affiliation(s)
- Ragnhild Klokk
- Department of Pediatrics, Innlandet Hospital Trust, Anders Sandvigsgate, 2619, Lillehammer, Norway
| | - Kjersti S Bakken
- Women's Clinic, Innlandet Hospital Trust, Lillehammer, Norway.,Centre for International Health, University of Bergen, Bergen, Norway
| | - Trond Markestad
- Department of Research, Innlandet Hospital Trust, Brumunddal, Norway
| | - Mads N Holten-Andersen
- Department of Pediatrics, Innlandet Hospital Trust, Anders Sandvigsgate, 2619, Lillehammer, Norway. .,Department of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
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22
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Uebergang J, Hiscock R, Hastie R, Middleton A, Pritchard N, Walker S, Tong S, Lindquist A. Risk of obstetric anal sphincter injury among women who birth vaginally after a prior caesarean section: A state-wide cohort study. BJOG 2021; 129:1325-1332. [PMID: 34913246 DOI: 10.1111/1471-0528.17063] [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: 08/28/2021] [Revised: 11/30/2021] [Accepted: 12/14/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Vaginal birth after caesarean (VBAC) has been suggested to be associated with an increased risk of obstetric anal sphincter injury (compared with primiparous women who birth vaginally). However, prior studies have been small, or used outdated methodology. We set out to validate whether the risk of obstetric anal sphincter injury among women having their first VBAC is greater than that among primiparous women having a vaginal birth. DESIGN State-wide retrospective cohort study. SETTING Victoria, Australia. POPULATION All births (455,000) between 2009-2014. METHODS The risk of severe perineal injury between first vaginal birth and first vaginal birth after previous caesarean section was compared, after adjustment for potential confounding variables. Covariates were examined using logistic regression for categorical data and Wilcoxon rank-sum test for continuous data. Missing data were handled using multiple imputation; the analysis was performed using regression adjustment and Stata v16 multiple imputation and teffects suites. RESULTS Women having a VBAC (n=5,429) were significantly more likely than primiparous women (n=123,353) to sustain a 3rd or 4th degree tear during vaginal birth (7.1 vs 5.7%, p<0.001). After adjustment for mode of birth, body mass index, maternal age, infant birthweight, episiotomy and epidural, there was a 21% increased risk of severe perineal injury (relative risk 1.21 (95%CI 1.07 - 1.38)). CONCLUSIONS Women having their first vaginal birth after caesarean section have a significant increased risk of sustaining a 3rd or 4th degree tear, compared with primiparous women having a vaginal birth. Patient counselling and professional guidelines should reflect this increased risk.
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Affiliation(s)
| | - Richard Hiscock
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia.,Department of Anaesthesia, Mercy Hospital for Women, Melbourne, Australia
| | - Roxanne Hastie
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia
| | - Anna Middleton
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
| | - Natasha Pritchard
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia
| | - Susan Walker
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia
| | - Stephen Tong
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia
| | - Anthea Lindquist
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia
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Kastora S, Kounidas G, Triantafyllidou O. Obstetric anal sphincter injury events prior and after Episcissors-60 implementation: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2021; 265:175-180. [PMID: 34508991 DOI: 10.1016/j.ejogrb.2021.08.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/25/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess the effect of Episcissors-60 upon obstetric anal sphincter injuries (OASIS) reduction in nulliparous women. STUDY DESIGN Independent literature search for relevant studies was performed up to 30th May 2021 on five databases: Embase (OVID), MEDLINE (R) (OVID), CAB Abstracts (OVID), ClinicalTrials.gov, and Google Scholar. The primary outcome was to assess OASIS events prior and after Epi-60 implementation in clinical practice in natural births (NB), whilst secondary outcomes included overall operative vaginal delivery (OVD) %/spontaneous vaginal deliveries (SVD) % deliveries, episiotomy rates and operator satisfaction. All included studies (retrospective, prospective and time-series) examined the effect of Episcissors-60 implementation upon observed OASIS %. RESULTS A total of 14,027 nulliparous females were included in the meta-analysis. Overall, study heterogeneity was high at I2: 79% with collectively fair quality of studies, as assessed by the Newcastle-Ottawa scale. Overall, this analysis highlights significant differences of OASIS events that might suggest their implementation as standard practice [RD -0.02, 95% CI -0.03 to 0.00; P = 0.03]. CONCLUSION The present analysis highlights significant differences of OASIS events pre- and post- Epi-60, that may suggest Episcissors-60 implementation as standard practice. Nonetheless, to ensure data integrity, well reported observational studies and robust randomized controlled trials (RCTs) are required prior to introduction of Epi-60 as standard episiotomy technique in clinical practice.
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Affiliation(s)
- Stavroula Kastora
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Institute of Medical Sciences, Foresterhill, Aberdeen AB25 2ZD, United Kingdom.
| | - Georgios Kounidas
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Institute of Medical Sciences, Foresterhill, Aberdeen AB25 2ZD, United Kingdom
| | - Olga Triantafyllidou
- 2(nd) Department of Obstetrics and Gynaecology, "Aretaieion" Hospital, University of Athens, Attica, Greece
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24
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Recognition and Management of Pelvic Floor Disorders in Pregnancy and the Postpartum Period. Obstet Gynecol Clin North Am 2021; 48:571-584. [PMID: 34416938 DOI: 10.1016/j.ogc.2021.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Often considered a condition of aging women, pelvic floor disorders may initially present in pregnancy and postpartum, having a negative impact on quality of life during this important time in a woman's life. This review outlines the clinical approach to implementing pelvic health into obstetric care through education and promotion of pelvic health in pregnancy, screening for pelvic floor disorders routinely, and providing support through resources, treatment, and referrals if pelvic floor disorders develop during pregnancy and postpartum.
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25
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Spinelli A, Laurenti V, Carrano FM, Gonzalez-Díaz E, Borycka-Kiciak K. Diagnosis and Treatment of Obstetric Anal Sphincter Injuries: New Evidence and Perspectives. J Clin Med 2021; 10:jcm10153261. [PMID: 34362045 PMCID: PMC8347477 DOI: 10.3390/jcm10153261] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 07/18/2021] [Accepted: 07/19/2021] [Indexed: 12/15/2022] Open
Abstract
Perineal injury during childbirth is a common event with important morbidity associated in particular with third-and-fourth degree perineal tears (also referred to as obstetric anal sphincter injuries—OASIS). Early diagnosis of these damages is mandatory to define a prompt therapeutic strategy and thus avoid the development of late-onset consequences, such as faecal incontinence. For this purpose, various diagnostic exams can be performed after a thorough clinical examination. The management of OASIS includes several measures and should be individualized according to the timing and features of the clinical presentation.
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Affiliation(s)
- Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy; (V.L.); (F.M.C.)
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
- Correspondence:
| | - Virginia Laurenti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy; (V.L.); (F.M.C.)
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Francesco Maria Carrano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Milan, Italy; (V.L.); (F.M.C.)
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Milan, Italy
| | - Enrique Gonzalez-Díaz
- Pelvic Floor Unit, Department of Obstetrics and Gynaecology, Complejo Asistencial Universitario de León (CAULE), C/Altos de Nava S/N, 24080 León, Spain;
- Department of Obstetrics and Gynaecology, Complejo Asistencial Universitario de León (CAULE), C/Altos de Nava S/N, 24080 León, Spain
| | - Katarzyna Borycka-Kiciak
- Department of Colorectal, General and Oncological Surgery, Centre of Postgraduate Medical Education, 80, Ceglowska Street, 01810 Warsaw, Poland;
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26
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Rodrigues Â, Rodrigues C, Negrão L, Afreixo V, Castro MG. Female sexual function and quality of life after pelvic floor surgery: a prospective observational study. Int Urogynecol J 2021; 32:1273-1283. [PMID: 33721058 DOI: 10.1007/s00192-021-04678-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 01/04/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Knowledge about the impact of pelvic floor surgery on sexual function is limited and inconsistent. A prospective study assessed the impact of surgery for prolapse (POP) or stress urinary incontinence (SUI) on sexual function and determined the biopsychosocial predictors for changes in sexual function after surgery. MATERIALS AND METHODS Sexually active women scheduled for correction of POP and/or SUI were recruited over a 6-month period. Consenting participants were asked to complete the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) to evaluate sexual function. The King's Health Questionnaire and Prolapse Quality-of-Life Questionnaire were used to assess UI and POP symptoms and their impact on quality of life (QoL), respectively. Women were reviewed over a period of 1 year post-surgery. RESULTS Ninety-one patients were followed up over 1 year. After stratification into only or both SUI and POP surgery, global sexual function improved significantly in each group (p < 0.001). The improvement in the overall QoL score after pelvic surgery showed a significant correlation with the improvement in global sexual function (SUI group: r = - 0.38, p < 0.01; POP group: r = - 0.44, p < 0.05). For women undergoing SUI surgery, only educational level and prior hysterectomy had a significant association with improved sexual function. For women undergoing POP surgery with or without SUI surgical repair, no sociodemographic characteristics were preditive of improvement of sexual function. CONCLUSIONS Significantly improved sexual function was observed 1 year after pelvic floor surgery, and the improvement was predicted by other social and physical factors in addition to normal functional anatomy.
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Affiliation(s)
- Ângela Rodrigues
- Faculty of Medicine, University of Coimbra, Azinhaga de Santa Comba, 3000-354, Coimbra, Portugal.
- Clinical Academic Centre of Coimbra, Coimbra, Portugal.
- Gynaecology Department, Coimbra Hospital and University Centre, Coimbra, Portugal.
| | - Carla Rodrigues
- Gynaecology Department, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - Liana Negrão
- Gynaecology Department, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - Vera Afreixo
- Centre for Research and Development in Mathematics and Applications-CIDMA, Department of Mathematics, University of Aveiro, Aveiro, Portugal
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27
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Nilsson IEK, Åkervall S, Molin M, Milsom I, Gyhagen M. Symptoms of fecal incontinence two decades after no, one, or two obstetrical anal sphincter injuries. Am J Obstet Gynecol 2021; 224:276.e1-276.e23. [PMID: 32835724 DOI: 10.1016/j.ajog.2020.08.051] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/06/2020] [Accepted: 08/19/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND The long-term effects of 1 or 2 consecutive obstetrical anal sphincter injuries on bowel continence are still inadequately investigated, and published results remain contradictory. OBJECTIVE This study aimed to present detailed descriptive measures of the current bowel incontinence 20 years after the first birth in women who had 2 vaginal deliveries with and without sphincter injuries. STUDY DESIGN Birth register data were used prospectively and linked to information from a questionnaire survey about current symptoms. Women with 2 singleton vaginal births, from 1992 to 1998, and no further births were retrieved and surveyed by the Swedish Medical Birth Register and Statistics Sweden in 2015. A simple random sample of 11,000 women was drawn from a source cohort of 64,687 women. The cumulative effect was studied in all women with a repeat sphincter injury from 1987 to 2000. Postal and web-based questionnaires were used. The study population consisted of 6760 women with no sphincter injury, 357 with 1 sphincter injury, and 324 women with 2 sphincter injuries. Women with 2 deliveries without sphincter injuries aged 40 to 60 years as reference, were compared with those of women that sustained 1 or 2 consecutive sphincter injuries. Here, third- and fourth-degree perineal tears were presented as 1 group. Fecal incontinence was defined as current involuntary leakage of solid or liquid stool, with and without concomitant leakage of gas. The Fisher exact test and the Mann-Whitney U test were used to compare the results of the 2 groups. The trend was analyzed using the Mantel-Haenszel statistics. Logistic regression models obtained the estimated age-related probability of fecal incontinence components. RESULTS The risk of sphincter injury at first delivery was 3.9%, and the risk of a repeat sphincter injury was 10.0% (odds ratio, 2.70; 95% confidence interval, 1.80-4.07). The overall prevalence of fecal incontinence in women without sphincter injuries was 11.7%, which doubled to 23.8% (odds ratio, 2.27; 95% confidence interval, 1.75-2.94) in those with 1 sphincter injury and more than tripled to 36.1% (odds ratio, 3.97; 95% confidence interval, 3.11-5.07) after 2 sphincter injuries (trend P<.0001). The proportion of women with severe fecal incontinence increased 3-fold and 5-fold from 1.8% after no obstetrical anal sphincter injury to 5.4% (95% confidence interval, 3.3-8.2) and 9.0% (95% confidence interval, 6.1-12.6) after 1 or 2 obstetrical anal sphincter injuries, respectively (trend P<.0001). In women without sphincter injuries, the estimated probability of fecal incontinence increased from 7.0% at the age of 40 years to 19.8% at the age of 60 years. In contrast, in women with 1 or 2 sphincter injuries, the estimated probability of fecal incontinence increased from 26.1% and 33.3%, respectively, at the age of 40 years to 36.8% and 48.8% at the age of 60 years. The prevalence of fecal incontinence increased after 52 years of age in women with 1 or 2 sphincter injuries. The dominant types of leakage in women with fecal incontinence were the combination of liquid stool and gas, and the triple combination consisting of solid and liquid stools and gas. The triple combination increased from 18.9% in those without sphincter injury to 28.2% in women with 2 injuries (trend P=.0204). CONCLUSION The risk of sustaining a repeat sphincter injury at the second delivery was almost tripled compared with the risk at the first delivery. Furthermore, 1 or 2 sphincter injuries brought severe long-term consequences for bowel continence. Accidental leakage of stool and gas increased with each sphincter injury, and the effect was proportionally cumulative. After the age of 52 years, the prevalence of fecal incontinence seemed to accelerate.
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Affiliation(s)
- Ida E K Nilsson
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Southern Älvsborg Hospital, Borås, Sweden
| | - Sigvard Åkervall
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Ian Milsom
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Gyhagen
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Southern Älvsborg Hospital, Borås, Sweden.
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28
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Nóbrega MA, Pereira GMV, Brito LGO, Luz AG, Lajos GJ. Severe Perineal Trauma in a Brazilian Southeastern Tertiary Hospital: A Retrospective Cohort Study. Female Pelvic Med Reconstr Surg 2021; 27:e301-e305. [PMID: 32576733 DOI: 10.1097/spv.0000000000000910] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aimed to investigate the prevalence of severe perineal trauma (obstetric and anal sphincter injury [OASIS]) in a tertiary high-risk pregnancy facility and the associated factors. METHODS A retrospective electronic chart review on perineal lacerations was performed from the period of April 2017 to February 2019. Obstetric and anal sphincter injury was diagnosed by a rectal examination. Primary outcome was the prevalence of OASIS (third- and fourth-degree perineal tear). Independent variables were maternal, intrapartum, and neonatal characteristics. Univariate and multivariate analyses with logistic regression models were performed. A P value lower than 0.05 was considered significant. RESULTS The prevalence of OASIS (third/fourth-degree laceration) was 1.51% (43/2846) in our population. Our population was mostly white (66.3%) and mostly primiparous (52.1%). By comparison, the prevalence of first/second-degree laceration was 43% (1223/2846). Selective episiotomy occurred in 18.73% (517/2761) of patients, and it was not associated with OASIS (P = 0.211). Advanced maternal age (P = 0.196), higher number of vaginal examinations (P = 0.169), fetal presentation (P = 0.533), and duration of second stage (P = 0.757) were not associated with OASIS. Univariate analysis has found that forceps delivery (odds ratio [OR], 3.68 [1.74-7.79]; P = 0.001), neonatal macrossomy (OR, 3.42 [1.02-11.43]; P = 0.045), and larger head circumference (OR, 1.15 [1.02-1.32]; P = 0.026) were risk factors for OASIS, whereas higher gravidity reduced the risk (OR, 0.61 [0.42-0.91] for OASIS. However, after multivariate analysis, only head circumference (OR, 1.86 [1.10-3.14]; P = 0.020) remained as a risk factor. CONCLUSIONS Larger neonatal head circumference increased in 86% the risk for severe perineal trauma in this cohort of women.
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Affiliation(s)
- Marina Augusto Nóbrega
- From the Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
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Fehlmann A, Reichetzer B, Ouellet S, Tremblay C, Clermont ME. Establishing a peripartum perineal trauma clinic: a narrative review. Int Urogynecol J 2021; 32:1653-1662. [PMID: 33399903 DOI: 10.1007/s00192-020-04631-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/30/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Obstetric anal sphincter injury (OASI) is not rare, and its consequences are multiple and potentially severe, especially for young women. Some dedicated perineal clinics have been established to improve the management of OASI. Despite their obvious importance, these specific clinics are underrepresented and underdeveloped. The objectives of this review are to explore various options for developing a peripartum perineal clinic and to compare the different practices regarding the mode of delivery for subsequent pregnancies after an OASI. METHODS This narrative review covers information from patients' questionnaires specific to anal incontinence, anal physiology assessment, pelvic floor and anal sphincter imaging, and the arguments for choosing the mode of delivery after an OASI. RESULTS This review highlights the extensive range of practices regarding the delivery mode after an OASI throughout national professional organizations and experienced perineal clinics. CONCLUSION This review summarizes the different choices in developing a perineal clinic to facilitate their development in promoting health care and education specific for peripartum women concerning the perineal consequences of delivery for obstetrician-gynaecologists, family doctors, and residents.
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Affiliation(s)
- Aurore Fehlmann
- Department of Obstetrics and Gynaecology, Université de Montréal and Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Canada.
- Department of Paediatrics, Gynaecology and Obstetrics, Geneva University Hospitals and Faculty of Medecine, Geneva, Switzerland.
| | - Barbara Reichetzer
- Department of Obstetrics and Gynaecology, Université de Montréal and Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Canada
| | - Stéphane Ouellet
- Department of Obstetrics and Gynaecology, Université de Montréal and Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Canada
| | - Catherine Tremblay
- Department of Obstetrics and Gynaecology, Université de Montréal and Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Canada
| | - Marie-Eve Clermont
- Department of Obstetrics and Gynaecology, Université de Montréal and Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Canada
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30
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Okeahialam NA, Thakar R, Sultan AH. Effect of a subsequent pregnancy on anal sphincter integrity and function after obstetric anal sphincter injury (OASI). Int Urogynecol J 2020; 32:1719-1726. [PMID: 33263781 PMCID: PMC8295136 DOI: 10.1007/s00192-020-04607-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/10/2020] [Indexed: 12/28/2022]
Abstract
Introduction and hypothesis Endoanal ultrasound (EAUS) and anal manometry are used in the assessment women with a history of obstetric anal sphincter injury (OASI), both postpartum and in a subsequent pregnancy, to aid counselling regarding mode of delivery (MOD). Methods A prospective observational study between 2012 to 2020 was completed. Women were reviewed 3 months postpartum following OASI and in the second half of a subsequent pregnancy. Anorectal symptoms were measured using the validated St Mark’s Incontinence Score (SMIS: asymptomatic to mild symptoms = ≤ 4). Anal manometry (incremental maximum squeeze pressure [iMSP: normal = > 20 mmHg]) and EAUS (abnormal = sphincter defect > 1 h in size) were performed. Results One hundred forty-six women were identified and 67.8% had an anal sphincter defect ≤ 1 h in size postnatally. In those with a defect ≤ 1 h, postpartum mean iMSP and SMIS significantly improved in a subsequent pregnancy (p = 0.04 and p = 0.01, respectively). In women with a defect > 1 h, there was no significant difference between the mean iMSP or SMIS score postnatally compared to a subsequent pregnancy. At both time points, significantly more women had an anal sphincter defect ≤ 1 h and SMIS of ≤ 4 (p = 0.001 and p < 0.001 respectively) compared to those with a defect < 1 h. In addition, significantly more women had an anal sphincter defect ≤ 1 h and iMSP ≥ 20 mmHg (p < 0.001). Overall, out of the 146 women included in this study, 76 (52.1%) with a defect ≤ 1 h also had an iMSP ≥ 20 mmHg and SMIS ≤ 4 at 3 months postpartum. Conclusions Women who remain asymptomatic with normal anal manometry and no abnormal sphincter defects on EAUS postnatally do not need to have these investigations repeated in a subsequent pregnancy and can be recommended to have a vaginal delivery. If our protocol was modified, over half of the women in this study could have had their MOD recommendation made in the postnatal period alone.
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Affiliation(s)
- Nicola Adanna Okeahialam
- Croydon Urogynaecology & Pelvic Floor Reconstruction Unit, Croydon University Hospital, Thornton Heath, UK
| | - Ranee Thakar
- Croydon Urogynaecology & Pelvic Floor Reconstruction Unit, Croydon University Hospital, Thornton Heath, UK.,St George's, University of London, London, UK
| | - Abdul H Sultan
- Croydon Urogynaecology & Pelvic Floor Reconstruction Unit, Croydon University Hospital, Thornton Heath, UK. .,St George's, University of London, London, UK.
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31
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Gillor M, Shek KL, Dietz HP. How comparable is clinical grading of obstetric anal sphincter injury with that determined by four-dimensional translabial ultrasound? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:618-623. [PMID: 32149422 DOI: 10.1002/uog.22011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 02/10/2020] [Accepted: 02/14/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To evaluate the agreement between grading of obstetric anal sphincter injuries (OASI) on translabial ultrasound (TLUS), using a newly developed algorithm, and grading on postpartum examination. A secondary aim was to assess the correlation between tear severity, as defined on ultrasound, and symptoms of anal incontinence and/or fecal urgency. METHODS This was a retrospective study of patients seen at a perineal clinic between 2012 and 2018, after recent primary repair of OASI. All patients underwent a standardized interview including the St Mark's anal incontinence test and four-dimensional TLUS. Post-processing of ultrasound volume data was performed blinded to all other data. Using tomographic ultrasound imaging, a set of eight slices was obtained, and the central six slices were evaluated for sphincter abnormalities. Slices with distortion, thinning or defects were rated as abnormal. The following algorithm was used to grade OASI: a Grade-3a tear was diagnosed if the external anal sphincter (EAS) was abnormal in < 4/6 slices; a Grade-3b tear was diagnosed if the EAS was abnormal in ≥ 4/6 slices; and a Grade-3c/4 tear was diagnosed if both the EAS and internal anal sphincter were abnormal in ≥ 4/6 slices. Clinical grading of OASI was determined according to the Royal College of Obstetricians and Gynaecologists guidelines. Agreement between clinical and TLUS diagnosis of OASI was evaluated using weighted κ. RESULTS Of the 260 women seen during the study period, 45 (17%) were excluded owing to missing data or a repeat OASI, leaving 215 complete datasets for analysis. The average follow-up interval was 2.4 months (range, 1-11 months) after OASI and the mean age of the women was 29 years (range, 17-42 years). One hundred and seventy-five (81%) women were vaginally primiparous. OASI was graded clinically as Grade 3a in 87 women, Grade 3b in 80, Grade 3c in 29 and Grade 4 in 19. On imaging, full agreement between clinical and TLUS grading was noted in 107 (50%) women, with a weighted κ of 0.398. In 96 (45%) women, there was disagreement by one category, with a weighted κ of 0.74 and in 12 (6%) there was disagreement by two categories. Twenty-four (11%) women were found to have a normal anal sphincter on imaging. Overall, potential clinical over-diagnosis was noted in 72 (33%) women and potential under-diagnosis in 36 (17%). The seniority of the diagnosing obstetrician did not significantly alter agreement between clinical and sonographic OASI grading (κ 0.44, 0.43, and 0.34, for specialists and senior and junior residents, respectively). The association between symptoms of anal incontinence and/or fecal urgency and TLUS grading did not reach significance (P = 0.052). CONCLUSIONS Clinical and TLUS-based grading of OASI showed fair agreement. Clinical over-diagnosis may be increasingly common in our population, although under-diagnosis may still occur in a significant minority. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M Gillor
- Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, Australia
- Kaplan Medical Centre, Rehovot, Affiliated to the Hebrew University and Hadassah School of Medicine, Jerusalem, Israel
| | - K L Shek
- Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, Australia
- Liverpool Clinical School, Western Sydney University, Sydney, Australia
| | - H P Dietz
- Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, Australia
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Levin G, Friedman T, Shai D, Alcalay M, Ram E, Meyer R. The association between vacuum-assisted vaginal delivery and anal sphincter injury. Int Urogynecol J 2020; 32:1771-1777. [PMID: 32997160 DOI: 10.1007/s00192-020-04534-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/08/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Vacuum-assisted vaginal delivery (VAVD) is considered a major risk factor for obstetric anal sphincter injuries (OASIS). However, it is difficult to estimate its true contribution to the occurrence of OASIS, as its performance may be confounded by other determinants. Therefore, we aimed to evaluate the association of VAVD with OASIS among primiparous women compared to SVD. METHODS A retrospective cohort study including all primiparous women who vaginally delivered a cephalic singleton gestation during the years 2011 to 2020. As VAVDs were not performed before 34 gestational weeks, we capped the cohort at this gestational age. Women were allocated into two groups: VAVDs and spontaneous vaginal deliveries (SVD). We compared women with OASIS to those without and performed a multivariate analysis including factors that were found significant in the univariate analysis. We further divided the whole cohort into different subcategories. The primary outcome was the rate of OASIS in VAVD compared to SVD. RESULTS Overall, 23,272 primiparous vaginal deliveries were available for evaluation. Of these, 3595 delivered by VAVD and 19,677 delivered spontaneously. OASIS occurred in 421 (1.8%) of the deliveries. OASIS were more common in VAVDs than in SVDs [83 (2.3%) vs. 338 (1.7%), respectively, OR (95% CI) 1.35 (1.06-1.72), p = 0.01]. After multivariate regression analysis, OASIS were not found to be independently associated with the mode of delivery [aOR 1.21 (95% CI) 0.88-1.68, P = 0.23]. In a categorical analysis of OASIS rates by risk factors and mode of delivery, VAVD was not associated with an increase in OASIS among women giving birth to neonates weighing > 3500 g compared to SVD [OR (95% CI) 1.02 (0.65-1.62), P = 0.90]. CONCLUSION Among primiparous women VAVD did not increase the risk of OASIS compared to SVD.
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Affiliation(s)
- Gabriel Levin
- The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Talia Friedman
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel, affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Daniel Shai
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel, affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Menachem Alcalay
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel, affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- The Department of Obstetrics and Gynecology, Urogynecology Unit, Baruch Padeh-Poria Medical Center, Tiberias, Israel, affiliated to The Faculty of Medicine at Galille, Bar Ilan University, Ramat Gan, Israel
| | - Edward Ram
- The Department of Surgery and Transplantation, the Chaim Sheba Medical Center, Ramat-Gan, Israel affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Raanan Meyer
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel, affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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Papoutsis D, Antonakou A, Gornall A, Tzavara C. The Incidence of and Predictors for Severe Perineal Trauma and Intact Perineum in Women Having a Waterbirth in England: A Hospital-Based Study. J Womens Health (Larchmt) 2020; 30:681-688. [PMID: 32907460 DOI: 10.1089/jwh.2019.8244] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: To determine the incidence of and predictors for obstetric anal sphincter injuries (OASIS) and intact perineum in women giving birth in the water and compare with the general obstetric population. Materials and Methods: Data were retrospectively collected for women who had singleton cephalic presentation vaginal births in the water and the general obstetric population between August 2007 and December 2017. Results: We identified 1,007 women who had a waterbirth and 36,924 women from the general obstetric population. There was no significant difference in the incidence of OASIS between waterbirths and the general obstetric population (2.3% vs. 2.0%). Having a waterbirth was associated with a lower probability for an intact perineum (odds ratio [OR] = 0.83; confidence interval [95% CI]: 0.73-0.94) when compared with the general obstetric population (44.7% vs. 51.3%). Nulliparous women with a waterbirth when compared with multiparous women had an eightfold higher likelihood for the occurrence of OASIS (OR = 8.28; 95% CI: 2.64-25.86). The risk for a higher degree of OASIS was associated with increased maternal age in the total sample (OR = 1.08; 95% CI: 1.06-1.11) and with a lower body mass index (BMI) at booking in multiparous women (OR = 0.96; 95% CI: 0.92-0.99). The risk for any type of perineal trauma was associated with increased maternal age in the total sample (OR = 1.10; 95% CI: 1.07-1.13) and with a lower BMI at booking in multiparous women (OR = 0.95; 95% CI: 0.91-0.99). Conclusions: We found that giving birth in the water reduced the chance of having an intact perineum. We have also shown that nulliparity, increased maternal age in all women, and a lower BMI at booking in multiparous were associated with OASIS and lower rates of intact perineum in waterbirths.
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Affiliation(s)
- Dimitrios Papoutsis
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom.,School of Health Sciences, University of Western Macedonia, Kozani, Greece
| | - Angeliki Antonakou
- Department of Midwifery, Midwifery School, International Hellenic University, Thessaloniki, Greece
| | - Adam Gornall
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom
| | - Chara Tzavara
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, University of Athens, Athens, Greece
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Albar M, Aviram A, Anabusi S, Huang T, Tunde-Byass M, Mei-Dan E. Maternal Ethnicity and the Risk of Obstetrical Anal Sphincter Injury: A Retrospective Cohort Study. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 43:469-473. [PMID: 33779551 DOI: 10.1016/j.jogc.2020.08.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 08/14/2020] [Accepted: 08/17/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To explore the role of maternal ethnicity as a risk factor for obstetrical anal sphincter injury (OASI). METHODS A retrospective cohort study of all women with singleton gestations who had a vaginal delivery at term, between January 2014 and October 2017, at a single center. OASI was defined as a third-degree perineal tear (anal sphincter complex) or a fourth-degree perineal tear (anorectal mucosa). The characteristics of women with and without OASIs were compared. Multiple logistic regression was performed to account for potential confounders, including ethnicity. RESULTS During the study period, 11 012 women were eligible for inclusion, of whom 336 (3.1%) had an OASI; 313 (93.1%) had a third-degree tear, and 23 (6.9%) had a fourth-degree tear. Women with OASIs were characterized by younger maternal age (<35 years), Asian ethnicity, nulliparity, neonatal birth weight ≥3500 grams, midline and mediolateral episiotomy, second stage of labour lasting ≥60 minutes, and assisted vaginal delivery. After adjusting for potential confounders, Asian ethnicity remained independently associated with increased risk of OASI (adjusted odds ratio 2.07; 95% CI 1.6-2.7) whereas mediolateral episiotomy was independently associated with decreased risk of OASI (adjusted odds ratio 0.64; 95% CI 0.5-0.9). CONCLUSION Asian ethnicity is independently associated with increased risk of OASI. Although midline episiotomy increases the risk of OASI, mediolateral episiotomy may protect against OASI, and should be considered in high-risk patients.
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Affiliation(s)
- Mohammad Albar
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON
| | - Amir Aviram
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
| | - Saja Anabusi
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
| | - Tianhua Huang
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON; Genetics Program, North York General Hospital, Toronto, ON
| | - Modupe Tunde-Byass
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON; Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, North York General Hospital, University of Toronto, Toronto, ON
| | - Elad Mei-Dan
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON; Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, North York General Hospital, University of Toronto, Toronto, ON.
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O'Leary BD, Bholah T, Kalisse T, Hehir MP, Geary MP. Anal Sphincter Injury Associated with Vaginal Twin Delivery. Am J Perinatol 2020; 37:1134-1139. [PMID: 31170749 DOI: 10.1055/s-0039-1692392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Obstetric anal sphincter injury remains the most common cause of fecal incontinence in women, and research in twin pregnancies is sparse. This study aimed to examine risk factors for sphincter injury in twin deliveries over a 10-year period. STUDY DESIGN This was a retrospective study of twin vaginal deliveries in a tertiary-level hospital over 10 years. We examined the demographics of women who had a vaginal delivery of at least one twin. Logistic regression analysis was used to examine risk factors. RESULTS There were 1,783 (2.1%) twin pregnancies, of which 556 (31%) had a vaginal delivery of at least one twin. Sphincter injury occurred in 1.1% (6/556) women with twins compared with 2.9% (1720/59,944) singleton vaginal deliveries. Women with sphincter injury had more instrumental deliveries (83.3 vs. 27.6%; p = 0.008). On univariate analysis, only instrumental delivery was a significant risk factor (odds ratio: 2.93; p = 0.019). CONCLUSION Sphincter injury occurs at a lower rate in vaginal twin pregnancies than in singletons. No twin-specific risk factors were identified. Discussion of the risk of sphincter injury should form part of patient counseling with regard to the mode of delivery.
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Affiliation(s)
- Bobby D O'Leary
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin, Ireland
| | - Tariq Bholah
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin, Ireland
| | - Tamara Kalisse
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin, Ireland
| | - Mark P Hehir
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin, Ireland
| | - Michael P Geary
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin, Ireland
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Djusad S, Liem R. Patient's characteristics and incidence of fecal incontinence after primary repair of Obstetric Anal Sphincter Injuries (OASIS) at three Indonesian tertiary hospitals in 2014-2016. Eur J Obstet Gynecol Reprod Biol X 2020; 7:100112. [PMID: 32715293 PMCID: PMC7379143 DOI: 10.1016/j.eurox.2020.100112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 06/09/2020] [Accepted: 06/11/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction Obstetric Anal Sphincter Injuries (OASIS) is a common complication of vaginal delivery. The incidence was 4.53 % of total vaginal deliveries. OASIS is associated with an increased risk of fecal incontinence (FI), which affects one’s quality of life. The incidence of OASIS and FI varied from study to study. In this study, we described the characteristics of patients with OASIS at three Indonesian tertiary hospitals in 2014−2016 and FI outcome among those patients. Methodology This is a descriptive study on the characteristics of OASIS patients after primary repair in three tertiary hospitals: dr. Cipto Mangunkusumo National General Hospital, Persahabatan General Hospital and Fatmawati General Hospital from 2014 to 2016. From a total of 234 patients, only 58 patients could be contacted and interviewed using Revised Fecal Incontinence Score (RFIS) questionnaires. Out of the 58 patients, only 16 patients came for transperineal ultrasound. Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 20. Results From a total of 234 patients, the mean age was 26.6 years old with a mean Body Mass Index (BMI) of 24.8 kg/m2. Most of the patients were nulliparous (67.5 %) and the median duration of second stage of labor was 45 min. Episiotomy was not performed on most patients (59.4 %) and most of them underwent spontaneous vaginal delivery (65.4 %) with mean baby’s birthweight of 3217 g. From 58 interviewed patients, three patients complained of FI (5.2 %). Sixteen patients came for transperineal ultrasound examination, and only one of them had FI. Anal sphincter defects were identified in five patients, comprising three external anal sphincter (EAS) and two internal anal sphincter (IAS) defects. All five patients did not experience FI. One patient who had FI had no anal sphincter defect. Discussion This is a pilot study for the incidence of FI among the OASIS population in Jakarta, Indonesia. The incidence of FI observed in this study was relatively low (3 out of 58 patients) compared to other studies. This could be due to differences in study population. The fact that the patient with FI had intact anal sphincter suggests that other factors may contribute to the development of FI in addition to the integrity of the anal sphincter. These factors may include pelvic floor muscle and innervation of the surrounding tissues. Conclusion The outcomes of primary repair of OASIS varied between studies. Patients’ characteristics might play an important role in the development of OASIS as well as the outcome after repair. Further studies with larger sample size are needed.
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Sideris M, McCaughey T, Hanrahan JG, Arroyo-Manzano D, Zamora J, Jha S, Knowles CH, Thakar R, Chaliha C, Thangaratinam S. Risk of obstetric anal sphincter injuries (OASIS) and anal incontinence: A meta-analysis. Eur J Obstet Gynecol Reprod Biol 2020; 252:303-312. [PMID: 32653603 DOI: 10.1016/j.ejogrb.2020.06.048] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/19/2020] [Accepted: 06/22/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Obstetric anal sphincter injuries (OASIS) are the commonest cause of anal incontinence in women of reproductive age. We determined the risk of anal sphincter defects diagnosed by ultrasound, and the risk of anal incontinence in (i) all women who deliver vaginally, (ii) in women without clinical suspicion of OASIS, and (iii) after primary repair of sphincter injury, by systematic review. METHODS We searched major databases until June 2018, without language restrictions. Random effects meta-analysis was used to obtain pooled estimates of ultrasound diagnosed OASIS and risk of anal incontinence symptoms at various time points after delivery, and of persistent sphincter defects after primary repair. We reported the association between ultrasound diagnosed OASIS and anal incontinence symptoms using relative risk (RR) with 95 % CI. RESULTS We included 103 studies involving 16,110 women. Of all women who delivered vaginally, OASIS were diagnosed on ultrasound in 26 % (95 %CI, 21-30, I2 = 91 %), and 19 % experienced anal incontinence (95 %CI, 14-25, I2 = 92 %). In women without clinical suspicion of OASIS (n = 3688), sphincter defects were observed in 13 % (10-17, I2 = 89 %) and anal incontinence experienced by 14 % (95 % CI: 6-24, I2 = 95 %). Following primary repair of OASIS, 55 % (46-63, I2 = 98 %) of 7549 women had persistent sphincter defect with 38 % experiencing anal incontinence (33-43, I2 = 92 %). There was a significant association between ultrasound diagnosed OASIS and anal incontinence (RR 3.74, 2.17-6.45, I2 = 98 %). INTERPRETATION Women and clinicians should be aware of the high risk for sphincter defects following vaginal delivery even when clinically unsuspected. This underlines the need of careful and systematic perineal assessment after birth to mitigate the risk of missing OASIS. We also noted a high rate of persistent defects and symptoms following primary repair of OASIS. This dictates the need for provision of robust training for clinicians to achieve proficiency and sustain competency in repairing OASIS.
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Affiliation(s)
- Michail Sideris
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK.
| | - Tristan McCaughey
- Department of Surgery, School of Clinical Science at Monash Health, Monash University, 3800, VIC, Australia
| | | | - David Arroyo-Manzano
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK; Clinical Biostatistics Unit, Hospital Ramon y Cajal (IRYCIS, CIBERESP), Madrid, Spain
| | - Javier Zamora
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK; Clinical Biostatistics Unit, Hospital Ramon y Cajal (IRYCIS, CIBERESP), Madrid, Spain
| | - Swati Jha
- Department of Urogynaecology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Charles H Knowles
- National Bowel Research Centre, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ranee Thakar
- Department of Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
| | - Charlotte Chaliha
- Department of Obstetrics and Gynaecology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Shakila Thangaratinam
- Barts Research Centre for Women's Health (BARC), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK; Multidisciplinary Evidence Synthesis Hub (MEsH), Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK
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Rotem R, Mastrolia SA, Rottenstreich M, Yohay D, Weintraub AY. The use of metronidazole in women undergoing obstetric anal sphincter injuries: a systematic review of the literature. Arch Gynecol Obstet 2020; 302:321-328. [PMID: 32564129 DOI: 10.1007/s00404-020-05651-x] [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] [Received: 04/21/2020] [Accepted: 06/10/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Antibiotic treatment during surgical repair of obstetric anal sphincter injuries (OASIS) had been a matter of debate. We aimed to review the available literature regarding the efficacy of metronidazole administration in women undergoing perineal repair following obstetric OASIS. STUDY DESIGN To identify potentially eligible studies, we searched PubMed, Scopus, Embase and the Cochrane Library from inception to January 13th, 2019.Reference lists of identified studies were searched. No language restrictions were applied. We used a combination of keywords and text words represented by "Metronidazole", "obstetrics", "obstetric anal sphincter injury", "OASIS", "third degree tear", "fourth degree tear", "third degree laceration", "fourth degree laceration", "antibiotic therapy", "perineal damage" and "perineal trauma". Two reviewers independently screened the titles and abstracts of records retrieved from the database searches. Both reviewers recommended studies for the full-text review. Thescreen of full-text articles recommended by at least one reviewer was done independently by the same two reviewers and assessedfor inclusion in the systematic review. Disagreements between reviewers were resolved by consensus. RESULTS The electronic database search yielded a total of 54,356 results (Fig. 1). After duplicate exclusion 28,154 references remained. Of them, 26 were relevant to the review based on title and abstract screening. None of these articles dealt with the use of metronidazole for the prevention of infections complicating anal sphincter repair in women with OASIS. A Cochrane review addressing antibiotic prophylaxis for patients following OASIS, compared prophylactic antibiotics against placebo or no antibiotics, included only one randomized controlled trial of 147 participants. This study showed that prophylactic antibiotics (not metronidazole) may be helpful to prevent perineal wound complications following OASIS. Fig. 1 Study seection process CONCLUSION: Anaerobic infections potentially complicate wound repair after OASIS. Although scientific societies recommend the use of antibiotics for the prevention of infectious morbidity after OASIS, no study has specifically assessed the role of metronidazole.
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Affiliation(s)
- Reut Rotem
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University Medical School, 12 Bayit Street, 91031, Jerusalem, Israel
| | - Salvatore Andrea Mastrolia
- Department of Obstetrics and Gynecology, Ospedaledei Bambini "Vittore Buzzi", University of Milan, Milan, Italy
| | - Misgav Rottenstreich
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University Medical School, 12 Bayit Street, 91031, Jerusalem, Israel.
| | - David Yohay
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Adi Y Weintraub
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
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Okeahialam NA, Thakar R, Naidu M, Sultan AH. Outcome of anal symptoms and anorectal function following two obstetric anal sphincter injuries (OASIS)-a nested case-controlled study. Int Urogynecol J 2020; 31:2405-2410. [PMID: 32556846 PMCID: PMC7561534 DOI: 10.1007/s00192-020-04377-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/28/2020] [Indexed: 11/24/2022]
Abstract
Introduction and hypothesis Obstetric anal sphincter injury (OASI) is a significant risk factor for developing anal incontinence. It can therefore be hypothesised that recurrent OASI in a subsequent delivery may predispose women to further anal sphincter dysfunction. Methods A nested case-controlled study based on data collected prospectively between 2006 and 2019. Women matched for age and ethnicity, with a history of one OASI and no sphincter damage in a subsequent delivery (control) were compared to women sustaining a second OASI. Assessment was carried out using the St Mark’s score (SMIS), anorectal manometry and endoanal ultrasound scan (findings quantified using the modified Starck score). Results Eighty-four women were included and equally distributed between the two groups, who were followed up 12 weeks postnatally. No difference in SMIS scores was found. Maximum resting pressure (MRP, mmHg) and maximum squeeze pressure (MSP, mmHg) were significantly reduced in the study group. Median (IQR) MRP in the study group was 40.0 (31.3–54.0) versus 46.0 (39.3–61.5) in the control group (p = 0.030). Median (IQR) MSP was 73.0 (58.3–93.5) in the study group versus 92.5 (70.5–110.8) (p = 0.006) in the control group. A significant difference (p = 0.002) was found in the modified Starck score between the study group (median 0.0 [IQR 0.0–6.0]) and control group (median 0.0 [IQR 0.0–0.0]). Conclusions We have demonstrated that women with recurrent OASI do not have significant anorectal symptoms compared to those with one OASI 12 weeks after delivery, but worse anal sphincter function and integrity. Therefore, on long-term follow-up, symptoms may possibly develop. This information will be useful when counselling women in a subsequent pregnancy.
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Affiliation(s)
| | - Ranee Thakar
- Croydon University Hospital, 530 London Rd, Thornton Heath, CR7 7YE, UK
| | | | - Abdul H Sultan
- Croydon University Hospital, 530 London Rd, Thornton Heath, CR7 7YE, UK. .,Honorary Reader at St George's University of London, London, UK.
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Risk Factors for Obstetric Anal Sphincter Injuries among Women Delivering at a Tertiary Hospital in Southwestern Uganda. Obstet Gynecol Int 2020; 2020:6035974. [PMID: 32508928 PMCID: PMC7244954 DOI: 10.1155/2020/6035974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 04/28/2020] [Indexed: 11/20/2022] Open
Abstract
Background Obstetric anal sphincter injuries (OASIS) arise from perineal trauma during vaginal delivery and are associated with poor maternal health outcomes. Most OASIS occur in unattended deliveries in resource-limited settings. However, even in facilities where deliveries are attended by skilled personnel, a number of women still get OASIS. Objectives To determine the incidence and risk factors for obstetric anal sphincter injuries among women delivering at Mbarara Regional Referral Hospital (MRRH). Methods We conducted an unmatched hospital-based case control study, with the ratio of cases to controls of 1 : 2 (80 cases and 160 controls). We defined a case as a mother who got a third- or fourth-degree perineal tear after vaginal delivery while the controls recruited were the next two mothers who delivered vaginally without a third- or fourth-degree perineal tear. A questionnaire and participants' medical records review were used to obtain sociodemographic and clinical data. We estimated the incidence of OASIS and performed univariable and multivariable logistic regression to identify the associated risk factors. Results The cumulative incidence for OASIS during the study period was 6.6%. The risk factors for OASIS were 2nd stage of labour ≥1 hour (aOR 6.07, 95%CI 1.86–19.82, p=0.003), having episiotomy performed during labour (aOR 2.57, 95%CI 1.07–6.17, p=0.035), perineum support during delivery (aOR 0.03, 95%CI 0.01–0.12, p < 0.001), and monthly income of >50,000 shillings (aOR 0.09, 95%CI 0.03–0.28, p < 0.001). Conclusions and Recommendations. The risk factors for obstetric anal sphincter injury were prolonged second stage of labour and performing episiotomies during deliveries while higher monthly income and perineum support during delivery were protective. We recommend routine support to the perineum during delivery. Care should be taken in mothers with episiotomies, as they can extend and cause OASIS.
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van Bavel J, Ravelli A, Abu-Hanna A, Roovers J, Mol BW, de Leeuw JW. Risk factors for the recurrence of obstetrical anal sphincter injury and the role of a mediolateral episiotomy: an analysis of a national registry. BJOG 2020; 127:951-956. [PMID: 32285571 DOI: 10.1111/1471-0528.16263] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The assessment of risk factors, including mediolateral episiotomy (MLE), for the recurrence of obstetric anal sphincter injury (rOASI). DESIGN Population-based cohort study. SETTING Data from the nationwide database of the Dutch Perinatal Registry (Perined). POPULATION A cohort of 391 026 women at term, of whom 9943 had an OASI in their first delivery and had a second vaginal delivery of a liveborn infant in cephalic position. METHODS Possible risk factors were tested for statistical significance using univariate and multivariate logistic regression analysis. MAIN OUTCOME MEASURES Rate of rOASI. RESULTS The rate of rOASI was 5.8%. Multivariate analysis identified a birthweight of ≥4000 g (adjusted OR, aOR, 2.1, 95% CI 1.6-2.6) and a duration of second stage of ≥30 minutes (aOR 1.8, 95% CI 1.4-2.3) as statistically significant risk factors for rOASI. Mediolateral episiotomy was associated with a statistically significant lower rate of rOASI in spontaneous vaginal delivery (SVD) (aOR 0.4, 95% CI 0.3-0.5) and in operative vaginal delivery (OVD) (aOR 0.2, 95% CI 0.1-0.5). CONCLUSIONS Women with a history of OASI have a higher rate of OASI in their next delivery. Duration of the second stage of ≥30 minutes and a birthweight of ≥4000 g are significantly associated with an increased rate of rOASI. Mediolateral episiotomy is associated with a significantly lower rate of rOASI in both SVD and OVD. TWEETABLE ABSTRACT Mediolateral episiotomy is associated with a significant lower recurrence rate of OASI in women with an OASI in their first delivery.
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Affiliation(s)
- J van Bavel
- Department of Obstetrics and Gynaecology, Amphia Hospital Breda, Breda, the Netherlands
| | - Acj Ravelli
- Department of Medical Informatics, Academic Medical Centre, Amsterdam, the Netherlands
| | - A Abu-Hanna
- Department of Medical Informatics, Academic Medical Centre, Amsterdam, the Netherlands
| | - Jpwr Roovers
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, the Netherlands
| | - B W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - J W de Leeuw
- Department of Obstetrics and Gynaecology, Ikazia Hospital, Rotterdam, the Netherlands
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Emmanuel A, Krogh K, Kirshblum S, Christensen P, Spinelli M, van Kuppevelt D, Abel R, Leder D, Santacruz BG, Bain K, Passananti V. Creation and validation of a new tool for the monitoring efficacy of neurogenic bowel dysfunction treatment on response: the MENTOR tool. Spinal Cord 2020; 58:795-802. [PMID: 31988365 PMCID: PMC7340621 DOI: 10.1038/s41393-020-0424-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 01/13/2020] [Accepted: 01/16/2020] [Indexed: 12/15/2022]
Abstract
STUDY DESIGN Prospective observational study. OBJECTIVES A tool to help decision-making tool for Neurogenic Bowel Dysfunction (NBD) in individuals with SCI is needed. We present a project to create and validate a new tool, the Monitoring Efficacy of NBD Treatment On Response (MENTOR), and to determine its level of concordance with decisions made by experienced clinicians in the field. SETTING UK, Denmark, USA, Italy, The Netherlands, Germany. METHODS The first phase was creation of the tool through a modified Delphi process. The second phase was the validation, wherein individuals with spinal cord injury with NBD were asked to complete the MENTOR tool immediately prior to clinic consultation. From the responses to the questionnaire of the tool, each participant was allocated into one of three categories reflecting the possible therapeutic recommendations ("recommend change", "further discussion" and "monitoring"). An expert clinician then assessed the participant, blinded to MENTOR results, and made an independent treatment decision. RESULTS A total of 248 MENTOR forms were completed. Strong agreement was found when the MENTOR tool recommended monitoring (92%) or treatment change (83%); the lowest concordance when the decision was for the "further discussion" option (59%). Patient acceptability was reported by 97% of individuals. CONCLUSIONS MENTOR is an easy to use tool to monitor the treatment of NBD and determinate progression through the clinical pathway. This validation study shows good correspondence between expert clinician opinion and MENTOR result. The tool has potential to be used in other patient groups, following further studies.
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Affiliation(s)
- Anton Emmanuel
- GI Physiology Unit, University College Hospital, London, UK.
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, Rutgers New Jersey Medical School, New Jersey, USA
| | | | | | | | - Rainer Abel
- Department of Orthopedic Surgery, Kinikum Bayreuth, Bayreuth, Germany
| | - Dietrich Leder
- Department Of Proctology and Endoscopy, Viszera Chirugie Zentrum, Munich, Germany
| | | | - Kimberly Bain
- Certified Facilitator, BaingGroup Consulting, Ontario, Canada
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D'Souza JC, Monga A, Tincello DG, Sultan AH, Thakar R, Hillard TC, Grigsby S, Kibria A, Jordan CF, Ashmore C. Maternal outcomes in subsequent delivery after previous obstetric anal sphincter injury (OASI): a multi-centre retrospective cohort study. Int Urogynecol J 2019; 31:627-633. [PMID: 31230097 PMCID: PMC7093337 DOI: 10.1007/s00192-019-03983-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/02/2019] [Accepted: 05/10/2019] [Indexed: 11/29/2022]
Abstract
Introduction and hypothesis Women with a history of obstetric anal sphincter injury (OASI) are at increased risk of recurrence (rOASI) at subsequent delivery; however, evidence regarding the factors influencing this risk is limited. Furthermore, little is known about what factors influence the decision to alternatively deliver by elective caesarean section (ELLSCS). Methods Retrospective univariate and multivariate logistic regression analysis of prospectively collected data from four NHS electronic maternity databases including primiparous women sustaining OASIS during a singleton, term, cephalic, vaginal delivery between 2004 and 2015, who had a subsequent delivery. Results Two thousand two hundred seventy-two women met the criteria; 10.2% delivering vaginally had a repeat OASI and 59.4% had a second-degree tear. Women having an ELLSCS were more likely to be Caucasian, older, have previously had an operative vaginal delivery (OVD) and have a more severe degree of OASI. Positive predictors for rOASI were increased birth weight and maternal age at both index and subsequent deliveries, a more severe degree of initial OASI and Asian ethnicity. The overall mediolateral episiotomy (MLE) rate was 15.6%; 77.2% of those who had an episiotomy sustained no spontaneous perineal trauma. Only 4.4% of women with a rOASI had an MLE, whilst the MLE rate was 16.9% in those without a recurrence (p < 0.001). MLE decreased the risk of rOASI by 80%. Birth weight > 4 kg increased the risk 2.5 fold. Conclusions Women with previous OASIS are at an increased risk of recurrence. A more liberal use of MLE during subsequent vaginal delivery could significantly reduce the risk of recurrence.
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Affiliation(s)
- Joanna Caroline D'Souza
- Faculty of Medicine, University of Southampton, University Hospitals NHS Foundation Trust, Southampton, UK.
- Princess Anne Hospital, University Hospitals NHS Foundation Trust, Southampton, UK.
| | - Ash Monga
- Princess Anne Hospital, University Hospitals NHS Foundation Trust, Southampton, UK
| | - Douglas G Tincello
- Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | | | | | | | - Ayisha Kibria
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Clare F Jordan
- University Hospitals of Leicester NHS Trust, Leicester, UK
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Operative vaginal delivery and pelvic floor complications. Best Pract Res Clin Obstet Gynaecol 2019; 56:81-92. [DOI: 10.1016/j.bpobgyn.2019.01.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 01/21/2019] [Accepted: 01/21/2019] [Indexed: 11/20/2022]
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Yıldırım MA, Çakır M. Non-surgical acute traumatic perianal injuries. Turk J Surg 2019; 35:44-48. [PMID: 32550302 DOI: 10.5578/turkjsurg.4188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 06/28/2018] [Indexed: 11/15/2022]
Abstract
Objectives The diagnosis of fecal incontinence is challenging and complex. One of the most significant causes of fecal incontinence is trauma in the perianal area. The most important cause of such trauma is birth trauma. It is hard to evaluate patients and plan treatment. Surgical method is determined by the severity of sphincter damage and injuries formed in the organs in the perianal area. The aim of this study, therefore, was to analyze the cases of patients who had undergone sphincter repair because of acute injuries in the perianal area. Material and Methods The cases of 15 patients with perianal area injuries who had presented to Necmettin Erbakan University Meram Medical School's General Surgery Clinic between 2010 and 2015 were retrospectively analyzed. Data on age, sex, form of injury, severity of injury, time of first response, form of repair, injury problems, and post-operative complications of the patients were investigated. The patients' long-term results were analyzed. Results While 5 of the patients were male, 10 were female. 9 of the female patients had birth trauma, while one had injury during sexual intercourse. While all of the patients received sphincteroplasty, 10 had levatoroplasty. All the female patients received vaginoplasty. Conclusion We are of the opinion that it is significant to have surgical intervention before tissue edema develops.
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Affiliation(s)
- Mehmet Aykut Yıldırım
- Necmettin Erbakan Üniversitesi Meram Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Konya, Türkiye
| | - Murat Çakır
- Necmettin Erbakan Üniversitesi Meram Tıp Fakültesi, Genel Cerrahi Anabilim Dalı, Konya, Türkiye
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Zipori Y, Grunwald O, Ginsberg Y, Beloosesky R, Weiner Z. The impact of extending the second stage of labor to prevent primary cesarean delivery on maternal and neonatal outcomes. Am J Obstet Gynecol 2019; 220:191.e1-191.e7. [PMID: 30616966 DOI: 10.1016/j.ajog.2018.10.028] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 10/15/2018] [Accepted: 10/17/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND A low rate of primary cesarean delivery is expected to reduce some of the major complications that are associated with a repeat cesarean delivery, such as uterine rupture, adhesive placental disorders, hysterectomy, and even maternal death. Since 2014, and in alignment with the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, we changed our approach to labor dystocia, defined as abnormal progression of labor, by allowing a longer duration of the second stage of labor. OBJECTIVE To examine the effect of prolonging the second stage of labor on the rate of cesarean delivery, and maternal and neonatal outcomes. MATERIALS AND METHODS In a historical control group, we compared maternal and neonatal outcomes over 2 periods. Period I (9300 patients): from May 2011 until April 2014, when a prolonged second stage in nulliparous women was considered after 3 hours with regional anesthesia or 2 hours if no such anesthesia was provided. Second-stage arrest was defined in multiparous women after 2 hours with regional anesthesia or 1 hour without it. Period II (10,531 patients): from May 2014 until April 2017, allowed nulliparous and multiparous women continuing the second stage of labor an additional 1 hour before diagnosing second-stage arrest. Singleton deliveries at or beyond 37 weeks' gestation were initially considered for eligibility. We excluded women with high-risk pregnancies and known fetal anomalies. For comparing means, we used the t test. If variables were not normally distributed, we used the Mann-Whitney test instead. For comparing proportions, we used the χ2 test with continuity correction. RESULTS The primary cesarean delivery was decreased in nulliparous women from 23.3% (819 of 3515) in period I to 15.7% (596 of 3796) in period II (relative risk [RR], 0.67; 95% CI, 0.61-0.74), a trend that was also significant in multiparous women (10.9%, 623 of 5785, in period I vs 8.1%, 544 of 6735, in period II; RR, 0.75; 95% CI, 0.67-0.84). The rate of operative vaginal deliveries in nulliparous women was higher in period II than in period I (19.2%, 732 of 3515, vs 17.7%, 622 of 3796, P < .0001). Rates of third- and fourth-degree laceration and of shoulder dystocia were also higher in period II. The rate of arterial cord pH < 7.0 and the rate of admission to the neonatal intensive care unit were higher in period II, but the early neurological outcome was not different when comparing the 2 periods. CONCLUSION The new policy of labor management successfully decreased primary cesarean deliveries, with a small rise in instrumental deliveries. However, it also increased the other immediate maternal and neonatal complications. A higher rate of lower umbilical artery cord pH was the most significant finding; however, the early neurological outcome did not change. It is possible that the ongoing adjustment to the new labor protocol will avoid, in the future, maternal and neonatal complications. The long-term maternal and neonatal consequences of our new approach will be evaluated in future studies.
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Lessons Learned From a Review of Malpractice Litigations Involving Obstetric Anal Sphincter Injury in the United States. Female Pelvic Med Reconstr Surg 2019; 26:249-258. [DOI: 10.1097/spv.0000000000000687] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gachon B. [Cesarean section and perineal protection: CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]. ACTA ACUST UNITED AC 2018; 46:968-985. [PMID: 30377093 DOI: 10.1016/j.gofs.2018.10.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The endpoint was to assess the interest of planned cesarean section in primary and secondary obstetrical perineal prevention. METHODS This is a review of the literature about the impact of the mode of delivery in urinary incontinence (UI), anal incontinence (AI), pelvic organ prolapse (POP), sexual disorders de novo or prior to delivery and history of obstetric anal sphincter injuries (OASI). RESULTS The studies about UI, AI and sexual disorders report a potential protective impact of cesarean section but with a possible selection bias and an inadequate comparability of the groups. Randomized trials do not report any protective effect of planned cesarean section for these 3 disorders. The literature about POP reports a higher risk for the women who delivered vaginally but still with a possible selection bias et there is no randomized trial for this outcome. About the secondary prevention of OASI, there is no evidence in the literature for a benefit of a systematic planned cesarean section for all women. For symptomatic women, the mode of delivery has to be discussed individually. In secondary prevention of UI, AI, POP and sexual disorders, there is no evidence in the literature for a benefit of planned cesarean section even if there is a history of surgical procedure for the disorder. CONCLUSION Planned cesarean section is not recommended in order to prevent primary or secondary obstetrical perineal disorders except for symptomatic OASI for whom an individual discussion about the mode of delivery is recommended.
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Affiliation(s)
- B Gachon
- Service de gynécologie-obstétrique et médecine de la reproduction, CHU de Poitiers, université de Poitiers, 2, rue de la Milétrie, 86000 Poitiers, France.
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Counseling after perineal laceration: does it improve functional outcome? Int Urogynecol J 2018; 30:925-931. [PMID: 29980808 DOI: 10.1007/s00192-018-3712-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 06/21/2018] [Indexed: 12/15/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Since 2006, the Lausanne University Hospital (CHUV) has offered a 12-week post-partum perineum consultation for patients with third-/fourth-degree tears, providing advice for future deliveries. This study consisted of a retrospective follow-up of these patients, focused on subsequent deliveries and current urinary and anorectal incontinence symptoms. METHODS Patients meeting eligibility criteria were invited to complete a questionnaire on their deliveries, along with validated questionnaires grading urinary (UDI-6 and IIQ-7) and anorectal (Wexner-Vaizey score) incontinence. RESULTS Sixty-two percent of third-/fourth-degree tears occurred following operative vaginal deliveries. Of 160 participants, 45.6% did not redeliver, 5.6% of whom felt traumatized by their first delivery and reluctant to have another children; 33.2% had a second vaginal delivery, 19.4% had a cesarean section (CS), and 1.2% had both vaginal and CS deliveries; 28% of the CS were not medically indicated. The recurrence rate of third-/fourth-degree tears for subsequent vaginal deliveries was 3.6%. Most patients were mildly or not affected by incontinence symptoms. Symptomatic patients reported urinary incontinence during physical activity and gas leakages; 50-60% saw no change of symptoms since the consultation, 30-40% reported partial or complete recovery. Patients redelivering by CS reported significantly less urinary incontinence (p = 0.046) and less anorectal incontinence (p = 0.069). CONCLUSION Anal sphincter laceration is associated with urinary and anorectal incontinence, but symptoms improve or disappear in most cases and are globally not invalidating. Perineal physiotherapy seems to contribute to this positive evolution. Fertility rate among these patients is unaffected, but the CS rate is higher than average. Further consideration of sexual and emotional sequelae could improve our current service.
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[Anal incontinence and obstetrical anal sphincter injuries, epidemiology and prevention]. ACTA ACUST UNITED AC 2018; 46:419-426. [PMID: 29500142 DOI: 10.1016/j.gofs.2018.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Indexed: 12/11/2022]
Abstract
Our main objectives were to identify risk factors, methods for early diagnosis, and prevention of obstetric anal sphincter injuries (OASIs), using a literature review. The main risk factors for OASIs are nulliparity, instrumental delivery, posterior presentation, median episiotomy, prolonged second phase of labor and fetal macrosomia. Asian origin, short ano-vulvar distance, ligamentous hyperlaxity, lack of expulsion control, non-visualization of the perineum or maneuvers for shoulder dystocia also appear to be risk factors. There is a risk of under-diagnosis of OASIs in the labor ward. Experience of the accoucheur is a protective factor. Secondary prevention is based on the training of birth professionals in recognition and repair of OASIs. Primary prevention of OASIs is based on training in the maneuvers of the second phase of labor; if possible, instrumental extractions should be avoided. Mediolateral episiotomy may have a preventive role in high-risk OASIs deliveries. A robust predictive model is still lacking to allow a selective use of episiotomy.
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