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Addis NA, Abraham D, Getnet M, Bishaw A, Mengistu Z. Prevalence and associated factors of maternal birth trauma following vaginal delivery at University of Gondar Comprehensive Specialized Hospital, North-West Ethiopia, 2022. BMC Pregnancy Childbirth 2024; 24:445. [PMID: 38937688 PMCID: PMC11210169 DOI: 10.1186/s12884-024-06635-4] [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: 02/22/2024] [Accepted: 06/11/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Maternal injury with any form of perineal trauma following vaginal delivery is very common which ranges globally from 16.2 to 90.4%. The frequency of Obstetric anal sphincter Injuries and the incidence of cervical laceration increases rapidly. However, in Ethiopia, there is limited evidence on the prevalence of maternal birth trauma and its determinant factors after vaginal delivery. OBJECTIVE To assess the magnitude and associated factors of Maternal Birth Trauma after vaginal delivery at University of Gondar Comprehensive Specialized Hospital, Gondar, North-West Ethiopia, 2022. METHODS An Institution based cross-sectional study was conducted among mothers with singleton vaginal delivery at University of Gondar Comprehensive Specialized Hospital from 9th May to 9th August 2022 among 424 study participants. Pre-tested semi-structured questioner was utilized. Epi-Data version 4.6 was used for data entry and exported to SPSS version 25 for data management and analysis. To identify the determinant factors, binary logistic regression model was fitted and variables with p-value < 0.2 were considered for the multivariable binary logistic regression analysis. In the multivariable binary logistic regression analysis, Variables with P-value < 0.05 were considered to have statistical significant association with the outcome variable. The Adjusted Odds Ratio (AOR) with 95% CI was reported to declare the statistical significance and strength of association between Maternal Birth Trauma and independent variables. RESULTS A total of 424 mothers who delivered vaginally were included. The mean age of participants was 26.83 years (± 5.220 years). The proportion of birth trauma among mothers after vaginal delivery was47.4% (95%CI: 43.1, 51.7). Of different forms of perineal trauma, First degree tear in 42.8%, OASIs in 1.5% and Cervical laceration in 2.5% study participants. In the multivariable binary logistic regression analysis being primiparous (AOR = 3.00; 95%CI: 1.68, 5.38), Gestational age ≥ 39 weeks at delivery (AOR = 2.96; 95%CI: 1.57, 5.57), heavier birth weight (AOR = 12.3; 95%CI: 7.21, 40.1), bigger head circumference (AOR = 5.45; 95%CI: 2.62, 11.31), operative vaginal delivery (AOR = 6.59; 95%CI: 1.44, 30.03) and delivery without perineum and/or fetal head support (AOR = 6.30; 95%CI: 2.21, 17.94) were significantly associated with the presence of maternal birth trauma. CONCLUSION AND RECOMMENDATION Maternal birth trauma following vaginal delivery was relatively high in this study. Prim parity, gestational age beyond 39 weeks at delivery, heavier birth weight, bigger head circumference, operative vaginal delivery and delivery without perineum and/or fetal head supported were factors affecting perineal outcome. The Ministry of Health of Ethiopia should provide regular interventional training as to reduce maternal birth trauma.
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Affiliation(s)
- Nigat Amsalu Addis
- Department of Gynecology and Obstetrics, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Demelash Abraham
- Department of Gynecology and Obstetrics, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mihret Getnet
- Department of Human Physiology, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
- Department of Epidemiology and biostatistics, Institute of public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Alehegn Bishaw
- Department of Reproductive and Child Health, Institute of public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Zelalem Mengistu
- Department of Obstetrics and Gynecology, Division for Clinical Medicine, University of Global Health Equity, Kigali, Rwanda
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Woon Wong K, Okeahialam N, Thakar R, Sultan AH. Obstetric risk factors for levator ani muscle avulsion: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2024; 296:99-106. [PMID: 38422805 DOI: 10.1016/j.ejogrb.2024.02.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 11/15/2023] [Accepted: 02/22/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVES Women have a 11% lifetime risk of undergoing surgery for vaginal prolapse. Levator ani muscle (LAM) avulsion is one etiological factor associated with primary and recurrent pelvic organ prolapse. Pelvic organ prolapse has been shown to greatly affect the quality of life and well-being of women. Conduct a meta-analysis identifying risk factors associated with LAM avulsion recognised on transperineal ultrasound (TPUS) or magnetic resonance imaging (MRI) in primiparous women after vaginal birth. STUDY DESIGN OVID Medline, Embase and the Cochrane Library from inception to January 2021 were searched. Review Manager 5.3 (The Cochrane Collaboration) was used to analyse data. Odds ratios (OR) with 95% confidence intervals (95% CIs) were calculated. The heterogeneity among studies was calculated using the I2statistic. RESULTS Twenty-five studies were eligible for inclusion (n = 9333 women). Major LAM avulsion was diagnosed in an average of 22 % (range 12.7-39.5 %) of cases. Twenty-two studies used TPUS and three used MRI to diagnose avulsion. Modifiable and non-modifiable risk factors were identified. Significant predictors identified were forceps (OR 6.25 [4.33 - 9.0]), obstetric anal sphincter injuries (OR 3.93 [2.85-5.42]), vacuum (OR 2.41 [1.40-4.16]), and maternal age (OR 1.06 [1.02-1.10]). CONCLUSIONS This is the first meta-analysis of both modifiable and non-modifiable risk factors associated with LAM avulsion. This information could be used to develop a clinically applicable risk prediction model to target postnatal women at risk of LAM avulsion with a view to prevent the onset of pelvic floor organ prolapse.
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Affiliation(s)
| | | | - Ranee Thakar
- Croydon University Hospital, UK; St George's University of London, UK
| | - Abdul H Sultan
- Croydon University Hospital, UK; St George's University of London, UK.
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Cadish LA, Shepherd JP, Bretschneider CE. Projecting future prolapse outcomes with induction of labor at 39 weeks: a decision analysis. Int Urogynecol J 2024; 35:311-317. [PMID: 37646803 DOI: 10.1007/s00192-023-05637-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/17/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION AND HYPOTHESIS In 2018, the ARRIVE trial (A Randomized Trial of Induction Versus Expectant Management) concluded that routine induction of labor (IOL) at 39 weeks gestation decreases cesarean delivery risk, with slightly lighter birthweight infants. We debated whether routine IOL would improve, worsen, or not change POP risk compared with expectant management (EM). METHODS We constructed a decision analysis model with a lifetime horizon where nulliparous women reaching 39 weeks underwent IOL or EM. Subsequent vaginal versus cesarean delivery varied based on prior deliveries for up to four births. Subsequent delivery prior to 39 weeks and distribution of gestational age, birthweight, and delivery mode between 24 and 39 weeks was modeled from national data. We modeled increased POP risk with increasing vaginal parity, forceps delivery, and weight of largest infant delivered vaginally, accounting for differential infant weights in each strategy. RESULTS IOL and EM have similar population-wide POP risk (15.9% and 15.7% respectively). Among women with only spontaneous vaginal deliveries that reached 39 weeks or beyond, the prevalence of POP was 20% after one delivery and 29% after four deliveries, with no difference between groups. The cesarean rate was lower with IOL (27.8% versus 29.8%). Sensitivity analysis revealed no meaningful thresholds among the variables, supporting model robustness. CONCLUSION While routine induction of labor at 39 weeks results in a meaningfully higher vaginal delivery rate, there was no increase in POP, possibly due to the protective effect of lower birthweight.
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Affiliation(s)
- Lauren A Cadish
- Urogynecology, Department of Obstetrics and Gynecology, Providence Saint John's Health Center, 2001 Santa Monica Blvd, Suite 680W, Santa Monica, CA, 90404, USA.
| | - Jonathan P Shepherd
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Connecticut Health Center, Hartford, CT, USA
| | - C Emi Bretschneider
- Division of Urogynecology, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL, USA
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Wagner JR, Fink T, Arabin B. Analysis of questions by patients with pelvic organ prolapse about vaginal pessaries resulting in a checklist for their physicians. Arch Gynecol Obstet 2024; 309:329-337. [PMID: 37597024 DOI: 10.1007/s00404-023-07177-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/26/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVE International guidelines recommend vaginal pessaries as a first-choice treatment of symptomatic pelvic organ prolapse (POP). Gynecologists rarely receive systematic training or just do not take the time to communicate with their patients. We hypothesized that we could identify key deficits and limitations of counseling before or during pessary therapy from questions directed to manufacturers with the aim to improve and promote health literacy of women with POP. METHODS We approached five manufacturers to provide anonymized inquiries related to pessary use. After exclusion of duplicates and questions about obstetric pessaries, 174 data sets from 145 patients remained. RESULTS In 19/145 patients (13.1%), a 2nd degree, and in 94/145 (64.8%), a 3rd-4th degree of POP was identified. Four patients had additional urinary incontinence. In 32/145 (22.1%), the severity of POP could not be identified. The age of patients ranged from 27 to 98 (mean = 63.7) years. Most inquiries were related to the selected pessary models or sizes (40/174; 22.9%), self-management (20/174; 11.5%), and technical aspects such as shelf life or appropriate cleaning (26/174; 14.9%). Pain or voiding dysfunction was present in 17/174 remarks (9.7%). Lifestyle questions related to the use of pessaries during sport, menstruation, or mechanical anticonception. The cube pessary was in the focus of interest followed by the sieve bowl, urethra, ring, and Gellhorn device. The list of questions was summarized as a checklist stratified according to priorities. CONCLUSION The checklist should help improve counseling and self-management of patients to optimize the benefit/risk ratio of conservative treatment of pelvic floor diseases.
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Affiliation(s)
| | - Thomas Fink
- Pelvic Floor Center, Sana Hospital Lichtenberg, Fanningerstraße 32, 10365, Berlin, Germany
| | - Birgit Arabin
- Clara Angela Foundation, Koenigsallee 36, 14193, Berlin, Germany
- Department Obstetrics Charité, Humboldt University Berlin, Berlin, Germany
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Burkett LS, Canavan TP, Glass Clark SM, Giugale LE, Artsen AM, Moalli PA. Reducing pelvic floor injury by induction of labor. Int Urogynecol J 2022; 33:3355-3364. [PMID: 35976420 PMCID: PMC9383672 DOI: 10.1007/s00192-022-05296-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/27/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We hypothesized that elective induction of labor (eIOL) at 39 weeks is protective of levator ani muscle injury (LAMI) and is associated with decreased pelvic symptoms at 6 weeks postpartum compared to expectant management of labor. METHODS Prospective cohort pilot study of uncomplicated, primiparous women with a singleton, vertex gestation enrolled immediately post-vaginal delivery (VD). Subjects were dichotomized into two groups based on labor management: eIOL without complication defined by the ARRIVE trial versus spontaneous VD between 39 weeks0/7 and 42 weeks5/7 or no indication for IOL prior to 40 weeks5/7. The primary outcome was LAMI at 6 weeks postpartum as evidenced by any of the following ultrasound measures: (1) increased levator hiatal area (LHA) > 2500 mm2, (2) increased elasticity index (EI, > 75th quartile) or (3) levator enthesis avulsion. RESULTS Analysis represents 45/102 consented women from July 2019-October 2020 (eIOL n = 22 and spontaneous VD, n = 23). Neither maternal, clinical, sociodemographic characteristics nor pelvic symptoms differed between groups. Fewer women had LAMI as defined by the primary outcome with eIOL (n = 5, 23.8%) compared to spontaneous VD (n = 15, 65.2%), p = 0.008. Levator enthesis was more deformable (increased EI) with spontaneous VD as compared to the eIOL [10.66 (8.99) vs. 5.68 (2.93), p = 0.046]. On univariate logistic regression women undergoing spontaneous VD had unadjusted OR of 6.0 (1.6-22.5, p = 0.008) of sustaining LAMI compared to those undergoing eIOL. CONCLUSIONS Composite measures of LAMI though not pelvic floor symptoms were markedly increased in women undergoing spontaneous VD compared to those undergoing eIOL at 39 weeks.
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Affiliation(s)
- Linda S Burkett
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA
- Virginia Commonwealth University Health System, 1250 East Marshall Street, Richmond, VA, 23298, USA
| | - Timothy P Canavan
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA
| | - Stephanie M Glass Clark
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA
| | - Lauren E Giugale
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA
| | - Amanda M Artsen
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA
| | - Pamela A Moalli
- Magee-Womens Hospital University of Pittsburgh Medical Center, 300 Halket Street, Pittsburgh, PA, 15232, USA.
- Magee-Womens Research Institute (MWRI), 204 Craft Street, Pittsburgh, PA, 15232, USA.
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Chill HH, Karavani G, Lipschuetz M, Yishai K, Winer J, Shimonovitz T, Shveiky D. Birthweight difference between deliveries and the risk of obstetric anal sphincter injury in parous women. Int Urogynecol J 2022; 33:3401-3406. [PMID: 35471584 DOI: 10.1007/s00192-022-05207-4] [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: 01/12/2022] [Accepted: 04/05/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION AND HYPOTHESIS While obstetric anal sphincter injury (OASI) is less frequent in parous compared to nulliparous women, it remains a major concern affecting quality of life of women worldwide. The aim of this study was to evaluate the association between birthweight (BW) difference between deliveries and risk of OASI in parous women. METHODS We performed a retrospective case-control study including parous women with at least one previous vaginal delivery who were diagnosed with OASI. The control group consisted of parous women who did not have OASI during vaginal delivery. Controls were matched in a 1:2 ratio by year of birth, maternal age, and parity. Medical history, obstetric background, and current labor-related data were compared. Further univariate and multivariable analyses were performed, assessing for risk factors for OASI. RESULTS One hundred eight parous women who had a diagnosis of OASI and a control group of 216 parturients who delivered without OASI were included in the final analysis. Differences between the current BW and the preceding and maximal previous BW were evaluated. There were significantly higher rates of women who had a larger neonate with > 500 g difference between the current and previous BW in the OASI group than in those with no OASI (28.7% vs. 12.30%, respectively; p < 0.001). Following a multivariable analysis for the dependent parameter of OASI, the following parameters were found to be independently associated with OASI outcome: previous operative vaginal delivery, BW ≥ 90th percentile, and current BW ≥ 500 g compared to previous maximal BW. CONCLUSIONS In parous women, neonatal BW increase between deliveries of > 500 g is associated with OASI.
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Affiliation(s)
- Henry H Chill
- Division of Urogynecology, University of Chicago Pritzker School of Medicine, NorthShore University HealthSystem, Skokie, IL, USA.
| | - Gilad Karavani
- Department of Obstetrics and Gynecology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Michal Lipschuetz
- Department of Obstetrics and Gynecology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Keren Yishai
- Hebrew University Medical School, Jerusalem, Israel
| | - Joel Winer
- Division of Urogynecology, University of Chicago Pritzker School of Medicine, NorthShore University HealthSystem, Skokie, IL, USA
| | - Tzvika Shimonovitz
- Department of Obstetrics and Gynecology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - David Shveiky
- Department of Obstetrics and Gynecology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Episiotomy in vacuum extraction, do we cut the levator ani muscle? A prospective cohort study. Int Urogynecol J 2022; 33:3391-3399. [PMID: 35467140 DOI: 10.1007/s00192-022-05188-4] [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: 01/31/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Vaginal delivery may lead to levator ani muscle (LAM) injury or avulsion. Episiotomy may reduce obstetric anal sphincter injury in operative vaginal delivery, but may increase the risk of LAM injury. Our aim was to assess whether lateral episiotomy in vacuum extraction (VE) in primiparous women causes LAM injury. METHODS A prospective cohort study of 58 primiparous women with episiotomy nested within an ongoing multicenter randomized controlled trial of lateral episiotomy versus no episiotomy in VE (EVA trial) was carried out in Sweden. LAM injury was evaluated using 3D endovaginal ultrasound 6-12 months after delivery and Levator Ani Deficiency (LAD) score. Episiotomy scar properties were measured. Characteristics were described and compared using Chi-squared tests. We stipulated that if a lateral episiotomy cuts the LAM, ≥50% would have a LAM injury. Among those, ≥50% would be side specific. We compared the observed prevalence with a test of one proportion. RESULTS Twelve (20.7%, 95% CI 10.9-32.9) of 58 women had a LAD (p < 0.001, compared with the stipulated 50%). Six (50.0%, 95% CI 21.1% to 78.9%) of 12 women had a LAD on the episiotomy side, including those with bilateral LAD (p = 1.00). Two (16.7%, 95% CI 2.1% to 48.4%) of 12 women had a LAD exclusively on the episiotomy side (p = 0.02). CONCLUSIONS There was no excessive risk of cutting the LAM while performing a lateral episiotomy. LAD was not seen in women with episiotomies shorter than 18 mm.
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Tugume R, Lugobe HM, Kato PK, Kajabwangu R, Kanyesigye H, Masembe S, Kayondo M. Pelvic Organ Prolapse and Its Associated Factors Among Women Attending the Gynecology Outpatient Clinic at a Tertiary Hospital in Southwestern Uganda. Int J Womens Health 2022; 14:625-633. [PMID: 35510129 PMCID: PMC9060809 DOI: 10.2147/ijwh.s355461] [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: 01/12/2022] [Accepted: 04/12/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To determine the prevalence, clinical stage at presentation and factors associated with pelvic organ prolapse (POP) among women attending the gynecology outpatient clinic at Mbarara Regional Referral Hospital (MRRH), Uganda. Methods We conducted a cross-sectional study at the gynecology outpatient clinic of MRRH from September 2019 to January 2020. Women aged 18–90 years were systematically sampled and recruited into this study. An interviewer administered questionnaire was used to collect participants’ socio-demographic, obstetric, gynecological and medical factors. POP stage was obtained by using the pelvic organ prolapse-quantification system. Multivariable logistic regression analysis was done to determine factors associated with pelvic organ prolapse. Results Of 338 participants enrolled, the prevalence of POP was 27.5% [n = 93, 95% Cl: 23.0–32.5]. POP stages were stage I 11.8% (n = 11), stage II 63.4% (n = 59), stage III 16.1% (n = 15) and stage IV 8.9% (n = 8). Grand-multiparity (aOR 17.1, 95% CI: 1.1–66.6), birth weight more than 3.5kg (aOR 3.7, 95% CI: 1.1–12.6), perineal tears (aOR 6.5, 95% CI: 2.1–20.2), peasant farmer (aOR 6.9, 95% CI: 1.6–29.9) and duration of labour in the first delivery >24 hours (aOR 5.7, 95% CI: 1.2–29) were significantly associated with POP. Conclusion POP is common among women attending the gynecology clinic at MRRH with most of them presenting with stage II. There should be routine screening for POP to enable early identification and management especially in those who are grand multiparous, peasant farmers and have a history of perineal tears.
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Affiliation(s)
- Rodgers Tugume
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Henry Mark Lugobe
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Paul Kalyebara Kato
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Rogers Kajabwangu
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Hamson Kanyesigye
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Sezalio Masembe
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Musa Kayondo
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
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Schulten SF, Claas-Quax MJ, Weemhoff M, van Eijndhoven HW, van Leijsen SA, Vergeldt TF, IntHout J, Kluivers KB. Risk factors for primary pelvic organ prolapse and prolapse recurrence: an updated systematic review and meta-analysis. Am J Obstet Gynecol 2022; 227:192-208. [PMID: 35500611 DOI: 10.1016/j.ajog.2022.04.046] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/25/2022] [Accepted: 04/23/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To update a previously published systematic review and perform a meta-analysis on the risk factors for primary pelvic organ prolapse and prolapse recurrence. DATA SOURCES PubMed and Embase were systematically searched. We searched from July 1, 2014 until July 5, 2021. The previous search was from inception until August 4, 2014. STUDY ELIGIBILITY CRITERIA Randomized controlled trials and cross-sectional and cohort studies conducted in the Western developed countries that reported on multivariable analysis of risk factors for primary prolapse or prolapse recurrence were included. The definition of prolapse was based on anatomic references, and prolapse recurrence was defined as anatomic recurrence after native tissue repair. Studies on prolapse recurrence with a median follow-up of ≥1 year after surgery were included. METHODS Quality assessment was performed with the Newcastle-Ottawa Scale. Data from the previous review and this review were combined into forest plots, and meta-analyses were performed where possible. If the data could not be pooled, "confirmed risk factors" were identified if ≥2 studies reported a significant association in multivariable analysis. RESULTS After screening, 14 additional studies were selected-8 on the risk factors for primary prolapse and 6 on prolapse recurrence. Combined with the results from the previous review, 27 studies met the inclusion criteria, representing the data of 47,429 women. Not all studies could be pooled because of heterogeneity. Meta-analyses showed that birthweight (n=3, odds ratio, 1.04; 95% confidence interval, 1.02-1.06), age (n=3, odds ratio, 1.34; 95% confidence interval, 1.23-1.47), body mass index (n=2, odds ratio, 1.75; 95% confidence interval, 1.17-2.62), and levator defect (n=2, odds ratio, 3.99; 95% confidence interval, 2.57-6.18) are statistically significant risk factors, and cesarean delivery (n=2, pooled odds ratio, 0.08; 95% confidence interval, 0.03-0.20) and smoking (n=3, odds ratio, 0.59; 95% confidence interval, 0.46-0.75) are protective factors for primary prolapse. Parity, vaginal delivery, and levator hiatal area are identified as "confirmed risk factors." For prolapse recurrence, preoperative prolapse stage (n=5, odds ratio, 2.68; 95% confidence interval, 1.93-3.73) and age (n=2, odds ratio, 3.48; 95% confidence interval, 1.99-6.08) are statistically significant risk factors. CONCLUSION Vaginal delivery, parity, birthweight, age, body mass index, levator defect, and levator hiatal area are risk factors, and cesarean delivery and smoking are protective factors for primary prolapse. Preoperative prolapse stage and younger age are risk factors for prolapse recurrence after native tissue surgery.
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Arcanjo Lino S, Shek KL, Caudwell-Hall J, Gillor M, Dietz HP. Has the prevalence of levator avulsion after forceps delivery changed over the last six decades? A retrospective study in a urogynaecological population. Eur J Obstet Gynecol Reprod Biol 2021; 264:184-188. [PMID: 34325213 DOI: 10.1016/j.ejogrb.2021.07.018] [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: 04/09/2021] [Revised: 06/15/2021] [Accepted: 07/10/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Forceps delivery is associated with a higher risk of maternal birth trauma. It is speculated that it is due to sub-optimal use of forceps in inexperienced hands. The aim of this study was to determine the association between time of forceps birth and prevalence of levator avulsion over the last six decades. STUDY DESIGN This was a retrospective analysis of datasets of women with a history of forceps delivery, seen at a tertiary urogynaecological centre between January 2014 and August 2018. They had undergone a standardized interview, clinical examination and four-dimensional translabial ultrasound. Archived imaging data was reviewed for levator avulsion offline at a later date, blinded against all clinical data. Associations between levator avulsion, maternal age at first vaginal birth, the weight of the first vaginally born baby, and time since forceps delivery categorised by decade were tested by univariable analysis. Factors found to be significant on univariable analysis were included in a multivariable logistic regression model to test the association between prevalence of levator avulsion and time of forceps delivery while controlling for confounders. RESULTS In total, 2026 patients were seen during the study period. Among them 511 (25.2%) had a history of forceps delivery. Fourteen volume datasets were incomplete or missing, leaving 497 complete datasets for analysis. Mean age at presentation was 58 ± 12 years (23-91). Mean body mass index was 29 ± 6 kg/m2. Mean age at first delivery was 25 ± 5 years. Mean birth weight of the first vaginal birth was 3454 ± 557 g. 457 women (92%) had had one forceps delivery, 31 had two forceps deliveries (6%) and 9 had three forceps deliveries (2%). Mean time interval between forceps delivery and assessment was 32 ± 13 years (0.3-64.8). 229 women (46%) were diagnosed with levator avulsion. The prevalence of avulsion after forceps increased significantly from 34% to 56% between 1950 and 2017 (P = 0.04). However this difference became insignificant when controlling for maternal age at 1st vaginal delivery and birth weight. CONCLUSIONS We found no evidence of a changed prevalence of levator avulsion at forceps delivery over the last 67 years.
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Affiliation(s)
- S Arcanjo Lino
- Hospital Geral de Fortaleza, Ginecologia e Obstetrícia, Fortaleza, Brazil; Sydney Medical School Nepean, University of Sydney, Penrith, NSW, Australia
| | - K L Shek
- Sydney Medical School Nepean, University of Sydney, Penrith, NSW, Australia; Department of O&G, Western Sydney University, Sydney, NSW, Australia.
| | - J Caudwell-Hall
- Sydney Medical School Nepean, University of Sydney, Penrith, NSW, Australia
| | - M Gillor
- Sydney Medical School Nepean, University of Sydney, Penrith, NSW, Australia; Kaplan Medical Center, Rehovot, Israel
| | - H P Dietz
- Sydney Medical School Nepean, University of Sydney, Penrith, NSW, Australia
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Cassadó J, Simó M, Rodríguez N, Porta O, Huguet E, Mora I, Girvent M, Fernández R, Gich I. Prevalence of levator ani avulsion in a multicenter study (PAMELA study). Arch Gynecol Obstet 2020; 302:273-280. [PMID: 32449062 DOI: 10.1007/s00404-020-05585-4] [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] [Received: 12/20/2019] [Accepted: 05/05/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE The objective is to determine the prevalence of levator ani muscle (LAM) avulsion using four-dimensional ultrasound in primiparous women after vaginal delivery and according to delivery mode. METHODS This prospective, multicenter study included 322 women evaluated at 6-12 months postpartum by four-dimensional transperineal ultrasound to identify levator ani muscle avulsion. The researcher who performed the ultrasound was blinded to all clinical data. Meaningful data about the birth were also recorded: mode of delivery, mother's age and body mass index, duration of second stage, episiotomy, perineal tearing, anesthesia, assistant, head circumference and fetal weight. RESULTS 303 volumes were valid for evaluation. The overall prevalence of levator ani muscle avulsion was 18.8% (95% CI 14.4-23.2%). In our multivariate analysis, only mode of delivery reached statistical significance as a risk factor for levator ani muscle avulsion (p < 0.001). The prevalence according to the different modes of delivery was 7.8% in spontaneous delivery, 28.8% in vacuum-assisted and 51.1% in forceps-assisted delivery. Compared with spontaneous delivery, the OR for LAM avulsion was 12.31 with forceps (CI 95% 5.65-26.80) and 4.78 with vacuum-assisted delivery (CI 95% 2.15-10.63). CONCLUSIONS Levator ani avulsion during vaginal delivery in primiparous women occurs in nearly one in every five deliveries. Delivery mode is a significant and modifiable intrapartum risk factor for this lesion. The incidence is lower in spontaneous delivery and significantly increases when an instrument is used to assist delivery, especially forceps.
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Affiliation(s)
- Jordi Cassadó
- Obstetrics and Gynecology Department, Hospital Universitari Mútua de Terrassa, Plaça Dr. Robert, 4, 08221, Terrassa, Spain.
| | - Marta Simó
- Obstetrics and Gynecology Department, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Nuria Rodríguez
- Obstetrics and Gynecology Department, Hospital Universitari de la Vall d'Hebrón, Barcelona, Spain
| | - Oriol Porta
- Obstetrics and Gynecology Department, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Eva Huguet
- Obstetrics and Gynecology Department, Hospital Universitari Mútua de Terrassa, Plaça Dr. Robert, 4, 08221, Terrassa, Spain
| | - Irene Mora
- Obstetrics and Gynecology Department, Consorci Sanitari d'Igualada, Igualada, Spain
| | - Marta Girvent
- Obstetrics and Gynecology Department, Hospital General de Granollers, Granollers, Spain
| | - Rebeca Fernández
- Obstetrics and Gynecology Department, Hospital Universitari Dexeus, Barcelona, Spain
| | - Ignasi Gich
- Sant Pau Biomedical Research Institute (IIB Sant Pau) and CIBER Epidemiology and Public Health (CIBERESP), Barcelona, Spain
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