Ultrasound imaging of maternal birth trauma

Do some levator avulsions improve over time?

OBJECTIVE

To determine whether the sonographic appearance of levator ani muscle avulsion after vaginal birth can improve significantly over the first few years postpartum.

METHODS

This was a retrospective study of women seen in the context of two prospective perinatal imaging studies. All subjects had undergone an interview, clinical examination and four-dimensional translabial ultrasound on average 4.3 months and 3.1 years postpartum. Volume datasets were analyzed at a later date, with the examiner blinded against all other data. The number of abnormal slices at both timepoints was compared using the Mann-Whitney U-test. Patients in whom findings had changed over time were reviewed separately, in parallel, in order to reduce the impact of differences in slice location and imaging settings. The symmetry test was used to analyze changes between the two postnatal visits.

RESULTS

Of 1148 women recruited originally, 315 attended at least two postnatal visits. Forty-two were excluded, leaving 273 women for the final analysis. The mean time of first follow-up was 4.3 (range, 2.6-9.8) months after their first birth and the mean time of last follow-up was 3.1 (range, 1.4-8.0) years postpartum. Cohen's κ for the category of avulsion (normal, partial avulsion and full avulsion) at the two assessments was 0.89, with agreement in 97% (264/273) of cases. At the first visit, full levator ani muscle avulsion was diagnosed in 20, partial avulsion in 32 and no avulsion in 221 women. While seven partial avulsions appeared sonographically normal at the second visit, there were no statistically significant changes in avulsion category between visits (P = 0.4).

CONCLUSIONS

Tomographic pelvic floor imaging obtained 3-10 months after childbirth may be used as a proxy for long-term outcomes. Ultrasound findings at a mean of 3.1 years postpartum showed 97% agreement with findings obtained on imaging at a mean of 4.3 months postpartum. There was a non-significant reduction in abnormal slices at the second follow-up visit, affecting at most 3/12 slices. This may be explained by compensatory hypertrophy of the remaining intact muscle. Sonographic normalization of full levator ani muscle avulsion was not observed. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

4D transperineal ultrasound: feedback for good obstetric anal sphincter injuries reparation

BACKGROUND

Obstetric anal injury is the main risk factor for traumatic anal, faecal and flatus, incontinence in women in reproductive age. Its recognition and good reparation are crucial for long term outcomes.

CASE REPORT

We report a case of a nulliparous woman who reported a fourth-degree perineal tear after delivery. The obstetric anal sphincter injury was repaired and a four-dimensional transperineal ultrasound was performed after reparation and then one and three months after discharge. The woman did not experience any incontinence and no points of discontinuity were observed at tomographic ultrasound imaging reconstruction. In this case, 4D-TPUS was a tool in the obstetrician's hands to evaluate the surgical success of OASIS repair, which requires some expertise.

CONCLUSIONS

4D-TPUS ultrasound is useful and reliable during immediate puerperium and in the subsequent follow-up, giving positive feedback on the correct positioning of the stiches and on a good healing process. Further studies are needed to demonstrate this usefulness in the operators training and for improving their surgical skills.

Effect of postpartum pessary use on pelvic floor function: a prospective multicenter study

PURPOSE

This study evaluates the restitution of pelvic floor function in postpartum women using the Restifem® pessary in a preventive and therapeutic approach.

METHODS

In this multicentre study all postpartum women independently of their parity, mode of delivery and existing pelvic floor symptoms were offered to use the Restifem® pessary from 6 weeks postpartum for 3 to 6 months. They completed the validated German pelvic floor questionnaire (GPFQpp) via online survey at 6 weeks, 6 months and 12 months postpartum and were divided, by their own choice, into users and non-users of the pessary.

RESULTS

Initially 857 women were enrolled. After 6 weeks 137 pessary users and 133 non-users, after 12 months 53 pessary users and 45 non-users submitted a completed questionnaire. Pessary users had significantly higher (worse) scores in all domains of the GPFQpp at 6 weeks postpartum. At 12 months postpartum pessary users still had a significantly higher bladder score, compared to non-users. There was a greater improvement in the bladder score (p = 0.005) and the pelvic organ prolapse score (p < 0.001) from 6 weeks to 12 months postpartum, among pessary users compared to non-users.

CONCLUSION

Pessary users had a significantly greater improvement in pelvic floor function from 6 weeks to 12 months postpartum, compared to non-users. This effect might be in part due to wearing the pessary but also due to greater scope for recovery, given the higher level of pelvic floor dysfunction in the pessary user group.

TRIAL REGISTRATION

The trial was registered in the German Clinical Trials Register (DRKS00024733) on 19 of April 2021.

Levator Ani Muscle Avulsion After Vaginal Delivery Comparing Routine Versus Restrictive Episiotomy: A Pilot Study

INTRODUCTION AND HYPOTHESIS

The objective was to compare the rate of levator ani muscle avulsion following vaginal birth after routine and restrictive episiotomy.

METHODS

This study consists of two cohorts of pregnant women prospectively enrolled between September 2015 and December 2017 at a university hospital. The pregnant women were subject to a randomized controlled trial, in which participants received a restrictive episiotomy protocol versus a routine episiotomy protocol for vaginal delivery. Levator ani avulsion was evaluated by four-dimensional ultrasound screening.

RESULTS

Sixty-one post-partum primipara women were enrolled in our study. Thirty-two women (52.5%) had undergone routine episiotomy whereas 29 women (47.5%) had gone through restrictive episiotomy. Right mediolateral episiotomies were performed in all cases. The rate of anal sphincter tear was 12.5% in the routine episiotomy group versus 13.8% in the restrictive episiotomy group (p = 1.00). Levator ani avulsion was detected in 9.4% of the routine episiotomy group (only on the right side) and in 10.3% of the restrictive episiotomy group (p = 1.00). No bilateral levator avulsion was detected in either of the groups. There were no statistical differences in the distances of the bladder neck descent, cystocele descent, uterine descent, rectocele descent, and the ballooning of the genital hiatus area between the groups.

CONCLUSIONS

In our pilot study, there was no reduction of the rate of levator ani avulsion in women with restrictive episiotomy compared with routine episiotomy. There were no differences in pelvic floor ultrasound parameters between the two groups.

Effect of an Intrapartum Pelvic Dilator Device on Levator Ani Muscle Avulsion During Primiparous Vaginal Delivery: A Pilot Randomized Controlled Trial

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate the safety and effectiveness of an intrapartum electromechanical pelvic floor dilator designed to reduce the risk of levator ani muscle (LAM) avulsion during vaginal delivery.

METHODS

A multicenter, randomized controlled trial enrolled nulliparous participants planning vaginal delivery. During the first stage of labor, participants were randomized to receive the intravaginal device or standard-of-care labor management. The primary effectiveness endpoint was the presence of full LAM avulsion on transperineal pelvic-floor ultrasound at 3 months. Three urogynecologists performed blinded interpretation of ultrasound images. The primary safety endpoint was adverse events (AEs) through 3 months.

RESULTS

A total of 214 women were randomized to Device (n = 113) or Control (n = 101) arms. Of 113 Device assignees, 82 had a device placed, of whom 68 delivered vaginally. Of 101 Control participants, 85 delivered vaginally. At 3 months, 110 participants, 46 Device subjects who received full device treatment, and 64 Controls underwent ultrasound for the per-protocol analysis. No full LAM avulsions (0.0%) occurred in the Device group versus 7 out of 64 (10.9%) in the Control group (p = 0.040; two-tailed Fisher's test). A single maternal serious AE (laceration) was device related; no neonate serious AEs were device related.

CONCLUSIONS

The pelvic floor dilator device significantly reduced the incidence of complete LAM avulsion in nulliparous individuals undergoing first vaginal childbirth. The dilator demonstrated an acceptable safety profile and was well received by recipients. Use of the intrapartum electromechanical pelvic floor dilator in laboring nulliparous individuals may reduce the rate of LAM avulsion, an injury associated with serious sequelae including pelvic organ prolapse.

Levator-urethra gap: is there a need for individualization of cut-offs?

OBJECTIVES

To determine whether height, weight and body mass index (BMI) are associated with the levator-urethra gap (LUG) measurement, and whether these factors confound the relationship between LUG and symptoms and signs of pelvic organ prolapse (POP).

METHODS

This was a retrospective study of women seen at a tertiary urogynecology unit between January 2020 and December 2021. Postprocessing of saved ultrasound volume data was used to measure the LUG, blinded against all other data. This measurement was tested for its association with organ descent and hiatal area, and height, weight and BMI were investigated for any potential confounding effect.

RESULTS

The 624 women seen during the inclusion period presented mostly with stress urinary incontinence (448/624 (72%)), urgency urinary incontinence (469/624 (75%)) and/or prolapse (338/624 (54%)). Mean age at assessment was 58 (range, 20-94) years, mean height was 163 (range, 142-182) cm, mean weight was 80 (range, 41-153) kg and mean BMI was 30 (range, 17-65) kg/m2. LUG measurements could be obtained in 613 women, resulting in 7356 (12 × 613) measurements. The average LUG in individual women measured 2.35 cm on the right and 2.32 cm on the left side (difference not significant), with a mean ± SD of 2.34 ± 0.63 cm overall. Mean LUG was associated with symptoms and signs of prolapse, both on clinical examination (POP quantification system) and on imaging, but not with height (P = 0.36), weight (P = 0.20) or BMI (P = 0.09).

CONCLUSIONS

Levator-urethra gap measurements do not seem to be significantly associated with height, weight or BMI in our population, obviating the need for individualization of LUG. However, this does not exclude interethnic variability of this biometric measure. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Comparison of Cross-Sectional Area of Pubovisceral Muscle in Nulliparous and Primiparous Women

INTRODUCTION AND HYPOTHESIS

The main risk factor for pelvic floor disorders is vaginal delivery, which may cause levator ani muscle (LAM) injury and denervation. LAM includes pubovisceral muscle (PVM, pubococcygeus), puborectalis muscle (PRM), and iliococcygeus muscle. We hypothesize that primiparous women with low pelvic floor muscle contraction have a reduced PVM cross-sectional area (CSA) compared to nulliparous women.

METHODS (SAMPLE SIZE AND STATISTICAL APPROACHES)

This single-centre prospective observational study compared healthy nulliparous (n = 40) to primiparous (n = 40) women after vaginal delivery without LAM avulsion and Oxford score ≤ 3. Demographics, questionnaires (ICIQ-UI-SF, OAB-Q-SF, PISQ-12), POP-Q, Oxford score, ultrasound measurements (minimal anteroposterior and lateral diameters, hiatal area, PRM thickness, levator-urethra gap) and magnetic resonance imaging (MRI)-PVM CSA were evaluated. Normality was tested, and an appropriate test was used to compare the groups. Power calculation suggested 40 participants per group.

RESULTS

The primiparous group was older, had a higher BMI, and their hiatal area on ultrasound at contraction was larger compared to the nulliparous group. The CSA of the left-sided PVM (1.15 ± 0.50 cm2) was larger compared to the right side (1.03 ± 0.50 cm2), p = 0.02 in nulliparous women. The PVM CSA of primiparous women with low Oxford score was reduced compared to nulliparous (0.87 ± 0.30 versus 1.09 ± 0.50 cm2, p = 0.006). The intra-rater reliability for PVM CSA had an ICC of 0.90 and inter-rater ICC of 0.77.

CONCLUSIONS

Primiparous women after vaginal delivery with low pelvic floor contraction force had reduced PVM CSA on MRI images compared to nulliparous women.

Soft-tissue dystocia due to paradoxical contraction of the levator ani as a cause of prolonged second stage: concept, diagnosis, and potential treatment

Smaller pelvic floor dimensions seem to have been an evolutionary need to provide adequate support for the pelvic organs and the fetal head. Pelvic floor dimension and shape contributed to the complexity of human birth. Maternal pushing associated with pelvic floor muscle relaxation is key to vaginal birth. Using transperineal ultrasound, pelvic floor dimensions can be objectively measured in both static and dynamic conditions, such as pelvic floor muscle contraction and pushing. Several studies have evaluated the role of the pelvic floor in labor outcomes. Smaller levator hiatal dimensions seem to be associated with a longer duration of the second stage of labor and a higher risk of cesarean and operative deliveries. Furthermore, smaller levator hiatal dimensions are associated with a higher fetal head station at term of pregnancy, as assessed by transperineal ultrasound. With maternal pushing, most women can relax their pelvic floor, thus increasing their pelvic floor dimensions. Some women contract rather than relax their pelvic floor muscles under pushing, which is associated with a reduction in the anteroposterior diameter of the levator hiatus. This phenomenon is called levator ani muscle coactivation. Coactivation in nulliparous women at term of pregnancy before the onset of labor is associated with a higher fetal head station at term of pregnancy and a longer duration of the second stage of labor. In addition, levator ani muscle coactivation in nulliparous women undergoing induction of labor is associated with a longer duration of the active second stage of labor. Whether we can improve maternal pelvic floor relaxation with consequent improvement in labor outcomes remains a matter of debate. Maternal education, physiotherapy, and visual feedback are promising interventions. In particular, ultrasound visual feedback before the onset of labor can help women increase their levator hiatal dimensions and correct levator ani muscle coactivation in some cases. Ultrasound visual feedback in the second stage of labor was found to help women push more efficiently, thus obtaining a lower fetal head station at ultrasound and a shorter duration of the second stage of labor. The available evidence on the role of any intervention aimed to aid women to better relax their pelvic floor remains limited, and more studies are needed before considering its routine clinical application.

Parturition at term: induction, second and third stages of labor, and optimal management of life-threatening complications-hemorrhage, infection, and uterine rupture

Childbirth is a defining moment in anyone's life, and it occurs 140 million times per year. Largely a physiologic process, parturition does come with risks; one mother dies every two minutes. These deaths occur mostly among healthy women, and many are considered preventable. For each death, 20 to 30 mothers experience complications that compromise their short- and long-term health. The risk of birth extends to the newborn, and, in 2020, 2.4 million neonates died, 25% in the first day of life. Hence, intrapartum care is an important priority for society. The American Journal of Obstetrics & Gynecology has devoted two special Supplements in 2023 and 2024 to the clinical aspects of labor at term. This article describes the content of the Supplements and highlights new developments in the induction of labor (a comparison of methods, definition of failed induction, new pharmacologic agents), management of the second stage, the value of intrapartum sonography, new concepts on soft tissue dystocia, optimal care during the third stage, and common complications that account for maternal death, such as infection, hemorrhage, and uterine rupture. All articles are available to subscribers and non-subscribers and have supporting video content to enhance dissemination and improve intrapartum care. Our hope is that no mother suffers because of lack of information.

Pelvic floor status in opera singers. a pilot study using transperineal ultrasound

BACKGROUND

Control of pelvic floor muscles (PFM) is emphasized as important to obtain functional breath support in opera singing, but there is not much research that proves PFM function as part of breath support in classical singing. Transperineal ultrasound is a reliable method for quantification of PFM contraction in urogynecology. Our aim was to establish if transperineal ultrasound can be used for observation of movement of the PFM during singing and to quantify pelvic floor contraction.

METHODS

Cross sectional study of 10 professional opera singers examined with transperineal ultrasound in the supine position at rest and contraction, and standing at rest and during singing. Levator hiatal area was measured in a 3D rendered volume. Levator hiatal anteroposterior (AP) diameter and bladder neck distance from symphysis were measured in 2D images.

RESULTS

The AP diameter was shortened from supine rest to contraction (15 mm), standing (6 mm) and singing (9 mm), all p < 0.01. The bladder neck had a non-significant descent of 3 mm during singing. The mean proportional change in AP diameter from rest to contraction was 24.2% (moderate to strong contraction) and from rest to singing was 15% (weak to moderate contraction).

CONCLUSIONS

Transperineal ultrasound can be used to examine the PFM during singing. The classically trained singers had good voluntary PFM contraction and moderate contraction during singing. AP diameter was significantly shortened from supine to upright position, with further shortening during singing, confirming that female opera singers contracted their pelvic floor during singing.

Evaluating compliance and applicability of postpartum pessary use for preventing and treating pelvic floor dysfunction: a prospective multicenter study

PURPOSE

Pelvic floor disorders are common and associated with pregnancy and childbirth. For restitution of pelvic floor connective tissue and thereby therapy of postpartum pelvic organ prolapse and stress urinary incontinence, the Restifem® pessary is approved. It supports the anterior vaginal wall behind the symphysis, the lateral sulci and the sacro-uterine ligaments and stabilises the connective tissue. We evaluated the compliance and applicability of Restifem® use in women postpartum in a preventive and therapeutic approach.

METHODS

Restifem® pessary was handed out to 857 women. Six weeks after birth, they started the pessary use. After 8 weeks, 3 and 6 months postpartum, women received a questionnaire via online survey for evaluation of pessary applicability and efficacy.

RESULTS

After 8 weeks, 209 women answered the questionnaire. 119 women used the pessary. Common problems were discomfort, pain and the pessary use was to circuitous. Vaginal infections were rare. After 3 months, 85 women and after 6 months, 38 women still used the pessary. 3 months postpartum, 94% of women with POP, 72% of women with UI and 66% of women with OAB stated to have an improvement of their symptoms using the pessary. 88% women without any disorder felt an improvement of stability.

CONCLUSIONS

Use of the Restifem® pessary in the postpartum period is feasible and accompanied with less complications. It reduces POP and UI and leads to an increased sense of stability. So, Restifem® pessary can be offered to women postpartum to improve pelvic floor dysfunction.

Diagnosis of maternal birth trauma by pelvic floor ultrasound

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.

Assessment of Perineal Scars on Translabial Pelvic Floor Ultrasound: A Pilot Study

OBJECTIVE

We aimed to describe a method for identifying and evaluating perineal scars using translabial pelvic floor ultrasound. We hypothesized that translabial ultrasound can identify a perineal scar and can differentiate episiotomies from spontaneous tears.

METHODS

This pilot study is a secondary analysis of data obtained in the Epi-No® trial. Perineal integrity was assessed using volumes acquired on pelvic floor muscle contraction according to the method previously described for anal sphincter imaging. A scar was diagnosed if a hypoechoic distortion in the perineum was noted. We postulated that an episiotomy would result in a linear scar visible on four dimensional translabial ultrasound whereas nonlinear scars were considered the result of spontaneous perineal tear of grade 2 or higher. The results of this assessment were compared with data retrieved from electronic medical records.

RESULTS

A scar was identified in 79/120 women (66%): 42 (35%) linear and 37 (31%) nonlinear. Sonographic and clinical diagnosis agreed on the presence or absence of perineal trauma in 66%. Agreement for the type of laceration was 50%.

CONCLUSION

In this retrospective pilot study, a blinded assessment of translabial ultrasound volume data showed agreement between clinical data and sonographic assessment of perineal integrity in 66% and of type of laceration in 50%. More work is needed to optimize the method in assessment of perineal scars to improve its performance before it can be used in clinical audit and research.

Morphological differences in the female anal sphincter complex between endoanal and exoanal ultrasound

INTRODUCTION AND HYPOTHESIS

This study was aimed at describing the morphological characteristics of the normal female anal sphincter complex (ASC) by high-resolution transperineal ultrasound (TPUS) and endoanal ultrasound (EAUS).

METHODS

Thirty volunteers, including 19 nulliparous and 11 women who had only given birth by Cesarean section, were recruited. The ASC was shown in a set of five slices by EAUS and 8 slices by TPUS. EAUS slices 1 and 5 matched TPUS slices 1 and 8; EAUS slices 2, 3, and 4 were approximately at the levels of TPUS slices 3, 5, and 7. The anterior and lateral EAS and IAS thicknesses were measured and the two methods were compared.

RESULTS

The median age was 29 years. The mean body mass index (BMI) was 20.6 kg/m². All measured values obtained by TPUS were normally distributed. The EAS thickness on EAUS slice 2 and the IAS thickness on EAUS slices 2 and 3 were not normally distributed. The mean anterior EAS thickness was 2.51 mm, 2.96 mm, and 3.53 mm in slices 3, 5, and 7 on TPUS and was significantly thinner than that in slices 2 (2.62 mm), 3 (3.77 mm), and 4 (4.62 mm) on EAUS. In contrast, the IAS was markedly thicker on TPUS. The ratio of sphincter thickness anteriorly to laterally was similar using the two methods.

CONCLUSIONS

The morphological characteristics of EAS shown by TPUS and EAUS were similar. EAS was thinner, and IAS was thicker on TPUS. The IAS seems to be distorted on endoanal imaging.

Episiotomy in vacuum extraction, do we cut the levator ani muscle? A prospective cohort study

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.

Comparison of diagnostic criteria for significant anal sphincter defects between endoanal and transperineal ultrasound

OBJECTIVE

To evaluate the agreement between three-dimensional endoanal ultrasound (EAUS) and four-dimensional transperineal ultrasound (TPUS) in measuring anal sphincter defect angle.

METHODS

This was a secondary analysis of the PERINEAL study, which evaluated the effect of perineal wound infection on anal sphincter integrity. Women were reviewed once a week, until their perineal wound had healed or for up to a maximum of 16 weeks. At each visit, both EAUS and TPUS (the latter at rest and on maximum pelvic floor muscle contraction (PFMC)) were performed to evaluate the presence of external (EAS) and internal (IAS) anal sphincter defect and measure the defect size. The largest angle size of a defect at the same sphincter level was analyzed. A defect was deemed significant if it was > 30°. Kappa coefficient (κ), intraclass correlation coefficient and standard error of measurement (SEM) were calculated, using EAUS as the reference standard.

RESULTS

In 73 women scanned at weekly intervals, a total of 250 EAUS and 250 TPUS scans were performed. An EAS defect was found in 55 (22.0%) EAUS images and 47 (18.8%) TPUS images. An IAS defect was found in 26 (10.4%) images on both modalities. There was excellent agreement (κ = 0.87) between TPUS and EAUS in diagnosing the presence of an EAS defect and perfect agreement (κ = 1.00) in diagnosing the presence of an IAS defect. TPUS performed at rest had poor and moderate agreement with EAUS in measuring EAS and IAS defect size, respectively, with respective SEMs of ± 16.1° and ± 27.9°. TPUS performed during maximum PFMC had poor and moderate agreement with EAUS in measuring EAS and IAS defect size, respectively, with respective SEMs of ± 16.5° and ± 26.4°. Based on the SEMs, if the diagnostic cut-off of 30° for defect size on TPUS was used, an incorrect diagnosis of significant EAS defect could occur in approximately 9-36% of women and an incorrect diagnosis of a significant IAS defect could occur in approximately 4-15% of women, using EAUS as the reference.

CONCLUSIONS

This is the first study to compare directly anal sphincter defect angle measurements obtained on EAUS and TPUS. A cut-off angle of 30° should not be used for the diagnosis of a significant residual anal sphincter defect during TPUS examination. Further research is required to determine the optimal defect cut-off angle for TPUS. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

3D Ultrasound in Pelvic Floor: Is It Useful as a Prognostic Tool in Type of Labor Development and Subsequent Pelvic Floor Diseases?

The objective of our study is to determine the thickness of the pubovisceral fasciculus of the levator ani muscle and the area of the genital hiatus by means of three-dimensional perineal ultrasound, in pregnant women in the 2nd trimester, and to analyze the related maternal, perinatal and postpartum clinical variables. Furthermore, to compare the results of our study with two similar series previously published. An observational, prospective study of pelvic floor ultrasound was carried out, performed at week 20, whose delivery was attended in the obstetrics service of the Hospital General Universitario Gregorio Marañón de Madrid (HGUGM), during the period of August from 2021 to June 2022. Maternal, ultrasound, perinatal and postpartum clinical variables were collected from each participant. During the study period, a total of 54 patients were included in it. The mean gestational age at which the ultrasound was performed was 19.81 ± 0.91 weeks. In relation to the ultrasound variables, the mean thickness of the pubovisceral muscle was 0.87 ± 0.13 cm (95% CI, 0.64-1.38 cm), while, in the plane of minimum dimension of the genital hiatus, the hiatal area at rest was 13.41 ± 3.22 (95% CI, 4.60-18.78) cm2. There is a significant correlation between the age of pregnant women (over 35 years of age) and the increase in the area of the genital hiatus (r = 0.295, p = 0.031). 3D ultrasound of the pelvic floor performed at week 20 of gestation can to be an effective, non-invasive, reproducible and cheap tool in the prognosis of the development of labor and of possible subsequent perineal dysfunctions.

Associations of Maternal Complaints to Levator Ani Muscle Trauma within 9 Months after Vaginal Birth: A Prospective Observational Cohort Study

Introduction

Pelvic floor trauma in the form of partial or complete avulsions of the levator ani muscle (LAM) affects 6-42% of women after vaginal birth and can cause tremendous long-term morbidity. Many studies assessed morphological pelvic floor trauma after childbirth but lacked to evaluate women's associated short-term complaints. A proper assessment of trauma and subjective complaints after birth could help to assess possible associations between them and their relevance to women's daily life. Therefore, we aimed to assess women's complaints within the first months after birth in association to their LAM trauma.

Materials and Methods

Between 3/2017 and 4/2019, we prospectively evaluated vaginal births of 212 primiparous women with singletons in vertex presentation ≥ 36 + 0 gestational weeks for levator ani muscle (LAM) trauma by translabial ultrasound, for pelvic organ prolapse by clinical examination, and for urogynecological complaints using questionnaires 1-4 days (P1), 6-10 weeks (P2), and 6-9 months (P3) after birth. The questionnaires were self-designed but oriented to and modified from validated questionnaires. Women's complaints were evaluated for P1-P3 according to their LAM trauma state.

Results

At P1, 67% of women showed an intact LAM, whereas 14.6% presented a hematoma, 6.6% a partial avulsion (PAV), and 11.8% a complete avulsion (CAV). At P2, 75.9% showed an intact LAM, 9.9% a PAV, and 14.2% a CAV. At P3, 72.9% of women with a LAM trauma in P1 and/or P2 were assessed with 21.6% being intact and 39.2% having a PAV and CAV, respectively. Obstetrical and baseline characteristics differed slightly between the groups. When comparing the time before and during pregnancy with the time after childbirth, birth itself affected women's complaints in all LAM state groups, but the presence of a LAM trauma, especially a CAV, had more negative effects.

Conclusions

Vaginal birth changes the anatomical structure of the maternal birth canal and genital tract, and it alters women's perceptions and body function. In our study, LAM trauma did not change these effects tremendously within the first months. Therefore, other maternal, fetal, and obstetrical factors need consideration for the explanation of maternal complaints, in addition to long-term effects of trauma and dysfunction of the LAM and other birth canal structures.

When to assess residual anal sphincter defect after OASI by ultrasound

OBJECTIVES

Obstetrical anal sphincter injuries (OASIS) are complications of vaginal delivery. Unrepaired anal sphincter after delivery increases the risk of anal incontinence. The aim of our study is to search for residual defect after OASI repair by 4D introital ultrasound (US). We hypothesised that imaging prior to hospital discharge would show the same number of defects as assessment at 3 months.

STUDY DESIGN

This is a retrospective analysis of 138 patients with immediate repair after OASIS. Since 2009, we have been routinely inviting all our patients with OASIS to the perineal clinic for postoperative follow-up. We scheduled the first visit before discharge from hospital and followed up with a second visit after three months. During both visits, patients underwent transperineal 4D ultrasound examination. We provided examination while at rest and during contraction; volumes were saved for further evaluation.

RESULTS

Eighty-one patients (58.7%) completed both exams and were included in the analysis. Residual external anal sphincter defect was found in 17.3% at the first visit versus 13.6% at the second (delayed) visit. We were not able to assess the sphincter in 9.9% at early versus none in the delayed examination. In 9.9%, the residual defect was not confirmed by the second examination, and in 4.9% the residual defect was missed by the first examination.

CONCLUSIONS

In conclusion, we have found that a 3 month scan yields a smaller number of defects than a scan before discharge.

The maternal pelvic floor and labor outcome

Vaginal birth is the major cause of pelvic floor damage. The development of transperineal ultrasound has improved our understanding of the relationship between vaginal birth and pelvic floor dysfunction. The female pelvic floor dimensions and function can be assessed reliably in pregnant women. Maternal pushing associated with pelvic floor muscle relaxation is the central requirement of vaginal birth. Many studies have evaluated the role of the pelvic floor on labor outcomes. Smaller levator hiatal dimensions and incomplete or absent levator ani muscle relaxation seem to be associated with a longer duration of the second stage of labor and a higher risk of cesarean and operative deliveries. Here, we presented an overview of the current knowledge of the correlation between female pelvic floor dimension and function, as assessed by transperineal ultrasound, and labor outcome.

Postpartum ultrasound for the diagnosis of obstetrical anal sphincter injury

This review presents the available data on the diagnosis of obstetrical anal sphincter injury by postnatal ultrasound imaging. There is increasing evidence that anal sphincter tears are often missed after childbirth and, even when diagnosed, often suboptimally repaired, with a high rate of residual defects after reconstruction. Even after postpartum diagnosis and primary repair, 25% to 50% of patients will have persistent anal incontinence. As clinical diagnosis may fail in the detection and classification of obstetrical anal sphincter injury, the use of imaging has been proposed to improve the detection and treatment of these lacerations. Notably, 3-dimensional endoanal ultrasound is considered the gold standard in the detection of obstetrical anal sphincter injury, and recently, 4-dimensional transperineal ultrasound, commonly available in obstetrical and gynecologic settings, has proven to be effective as well. Avoidance of forceps delivery when possible, performance of a rectal examination after vaginal delivery and before repair of any severe perineal tear, and offering sonographic follow-up at 10 to 12 weeks after vaginal delivery in high-risk women (maternal age of ≥35 years, vaginal birth after cesarean delivery, forceps, prolonged second stage of labor, overt obstetrical anal sphincter injury, shoulder dystocia, and macrosomia) may help reduce morbidity arising from anal sphincter tears.