Pregnancy, labour and delivery as risk factors for pelvic organ prolapse: a systematic review

Levator ani muscle avulsion and subsequent vaginal delivery: 8-year longitudinal follow-up

OBJECTIVES

To assess the evolution of levator ani muscle (LAM) avulsion from 1 year to 8 years after first delivery in women with and those without subsequent vaginal delivery. In addition, to assess whether women with full or partial avulsion 8 years after first delivery have larger LAM hiatal area and more symptoms of pelvic organ prolapse compared to women with normal LAM insertion.

METHODS

In this single-center longitudinal study, 195 women who were primiparous at the start of the study were included and underwent transperineal ultrasound examination 1 year and 8 years after first delivery. Muscle insertion was assessed by tomographic ultrasound imaging in the axial plane. Full LAM avulsion was defined as abnormal muscle insertion in all three central slices. Partial LAM avulsion was defined as abnormal muscle insertion in one or two central slices. Eight years after the first delivery, LAM hiatal area was assessed at rest, during maximum pelvic floor muscle contraction and on maximum Valsalva maneuver. To assess symptoms of pelvic organ prolapse, the vaginal symptoms module of the International Consultation on Incontinence Questionnaire was used.

RESULTS

At 1-year follow-up, 25 (12.8%) women showed signs of LAM avulsion, of whom 20 fulfilled the sonographic criteria of full avulsion and five of partial avulsion. Eight years after the first delivery, 35 (17.9%) women were diagnosed with avulsion, of whom 25 were diagnosed with full avulsion and 10 with partial avulsion. No woman with partial or full avulsion at 1 year had improved avulsion status at 8-year follow-up. Of the 150 women who had subsequent vaginal delivery, 21 (14.0%) women were diagnosed with partial or full LAM avulsion 1 year after first delivery, and 31 (20.7%) women were diagnosed with partial or full avulsion 8 years after first delivery. Of the 45 women without subsequent vaginal delivery, one woman with partial avulsion 1 year after first delivery was diagnosed with full avulsion at 8-year follow-up. All women with full avulsion at 1-year follow-up were diagnosed with full avulsion at 8-year follow-up regardless of whether they had subsequent vaginal delivery. At 8-year follow-up, women with full avulsion had statistically significantly larger LAM hiatal area compared to women with normal muscle insertion. Mean ± SD vaginal symptom scores ranged between 5.5 ± 5.7 and 6.0 ± 4.0 and vaginal symptom quality of life scores ranged between 0.9 ± 1.4 and 1.5 ± 2.2 and did not differ significantly between women with normal muscle insertion and women with partial or full avulsion at 8-year follow-up.

CONCLUSIONS

More LAM avulsions were present 8 years compared with 1 year after first delivery in women with subsequent vaginal delivery. Except for one primipara, all women without subsequent vaginal delivery had unchanged LAM avulsion status between 1 year and 8 years after their first delivery. Larger LAM hiatal area was found in women with full avulsion compared to those with normal muscle insertion at 8-year follow-up. Vaginal symptoms scores were low and did not differ between women with normal muscle insertion and those with partial or full avulsion at 8-year follow-up. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

The rs2018736 fibulin-5 polymorphism as a determinant for pelvic organ prolapse: a case-control study

OBJECTIVE

Fibulin-5 is a connective tissue component and may play a role in pelvic organ prolapse (POP) pathogenesis. This study aimed to verify the association of the rs2018736 polymorphism of the fibulin-5 gene with POP in postmenopausal Brazilian women, and to determine the risk factors for POP.

METHOD

This observational, cross-sectional, case-control study assessed postmenopausal women with advanced POP (stages III and IV) and control women (stages 0 and I) by examination and peripheral blood sample collection. DNA sequences were analyzed by real-time reverse-transcriptase polymerase chain reaction. A logistic regression model was used with p < 0.05 for significance.

RESULTS

A total of 565 participants were evaluated (325 POP and 240 control). The homozygous C allele of rs2018736 (CC) was protective against POP (odds ratio [OR] 0.49, 95% confidence interval [CI] 0.26-0.91). Age (OR 1.09, 95% CI 1.05-1.13), number of pregnancies (OR 1.14, 95% CI 1.01-1.28), vaginal delivery (OR 5.32, 95% CI 2.58-11.01), forceps delivery (OR 3.34, 95% CI 1.72-6.47), weight of newborn (OR 1.0007, 95% CI 1.0002-1.0011), family history of POP (OR 2.35, 95% CI 1.24-4.44), hypertension (OR 1.74, 95% CI 1.01-3.00) and diabetes (OR 2.19, 95% CI 1.07-4.48)] were independent predictors for POP; cesarean (OR 0.02, 95% CI 0.005-0.09) was protective.

CONCLUSION

The rs2018736-CC genotype of the fibulin-5 gene has a protective role against POP.

Roles and mechanisms of biomechanical-biochemical coupling in pelvic organ prolapse

Pelvic organ prolapse (POP) is a significant contributor to hysterectomy among middle-aged and elderly women. However, there are challenges in terms of dedicated pharmaceutical solutions and targeted interventions for POP. The primary characteristics of POP include compromised mechanical properties of uterine ligaments and dysfunction within the vaginal support structure, often resulting from delivery-related injuries. Fibroblasts secrete extracellular matrix, which, along with the cytoskeleton, forms the structural foundation that ensures proper biomechanical function of the fascial system. This system is crucial for maintaining the anatomical position of each pelvic floor organ. By systematically exploring the roles and mechanisms of biomechanical-biochemical transformations in POP, we can understand the impact of forces on the injury and repair of these organs. A comprehensive analysis of the literature revealed that the extracellular matrix produced by fibroblasts, as well as their cytoskeleton, undergoes alterations in patient tissues and cellular models of POP. Additionally, various signaling pathways, including TGF-β1/Smad, Gpx1, PI3K/AKT, p38/MAPK, and Nr4a1, are implicated in the biomechanical-biochemical interplay of fibroblasts. This systematic review of the biomechanical-biochemical interplay in fibroblasts in POP not only enhances our understanding of its underlying causes but also establishes a theoretical foundation for future clinical interventions.

Single-cell analysis of uterosacral ligament revealed cellular heterogeneity in women with pelvic organ prolapse

Pelvic organ prolapse (POP) markedly affects the quality of life of women, including significant financial burden. Using single-cell RNA sequencing, we constructed a transcriptional profile of 30,452 single cells of the uterosacral ligament in POP and control samples, which has never been constructed before. We identified 10 major cell types, including smooth muscle cells, endothelial cells, fibroblasts, neutrophils, macrophages, monocytes, mast cells, T cells, B cells, and dendritic cells. We performed subpopulation analysis and pseudo-time analysis of POP primary cells, and explored differentially expressed genes. We verified previous cell clusters of human neutrophils of uterosacral ligaments. We found a significant reduction in receptor-ligand pairs related to ECM and cell adhesion between fibroblasts and endothelial cells in POP. The transcription factors related to the extracellular matrix, development, and immunity were identified in USL. Here we provide insight into the molecular mechanisms of POP and valuable information for future research directions.

Neglected medium-term and long-term consequences of labour and childbirth: a systematic analysis of the burden, recommended practices, and a way forward

Over the past three decades, substantial progress has been made in reducing maternal mortality worldwide. However, the historical focus on mortality reduction has been accompanied by comparative neglect of labour and birth complications that can emerge or persist months or years postnatally. This paper addresses these overlooked conditions, arguing that their absence from the global health agenda and national action plans has led to the misconception that they are uncommon or unimportant. The historical limitation of postnatal care services to the 6 weeks after birth is also a contributing factor. We reviewed epidemiological data on medium-term and long-term complications arising from labour and childbirth beyond 6 weeks, along with high-quality clinical guidelines for their prevention, identification, and treatment. We explore the complex interplay of human evolution, maternal physiology, and inherent predispositions that contribute to these complications. We offer actionable recommendations to change the current trajectories of these neglected conditions and help achieve the targets of Sustainable Development Goal 3. This paper is the third in a Series of four papers about maternal health in the perinatal period and beyond.

Projecting future prolapse outcomes with induction of labor at 39 weeks: a decision analysis

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.

Effectiveness of exercise interventions on urinary incontinence and pelvic organ prolapse in pregnant and postpartum women: umbrella review and clinical guideline development

INTRODUCTION AND AIMS

Dysfunction related to pelvic floor muscles (PFM) is common among pregnant and postpartum women and can cause symptoms such as urinary incontinence or pelvic organ prolapse (POP). As part of developing a nationwide clinical practice guideline for nursing in Finland, the aim of this umbrella review is to summarize the existing evidence about the effectiveness of exercise interventions on urinary incontinence and POP in pregnant and postpartum women. To promote knowledge translation, recommendations for health care professionals are presented.

METHODS

We conducted an umbrella review to summarize the existing evidence. The JBI methodology for umbrella reviews was used to guide the review. The level of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, and recommendations based on the evidence were formulated by a clinical guideline working group.

RESULTS

Altogether, 9 systematic reviews, reporting findings from 89 original studies, were included. The methodological quality of the reviews was evaluated using JBI's checklist. The highest level of evidence was found for preventing the symptoms of postpartum urinary incontinence through exercise and pelvic floor muscle training (PFMT) during pregnancy. Moderate-level evidence showed that exercise and PFMT are likely to reduce the symptoms and severity of urinary incontinence, but the level of evidence was low on PFMT reducing the symptoms of POP.

CONCLUSION

We recommend encouraging and guiding pregnant and postpartum women to exercise and train PFM. We also recommend identifying pregnant and postpartum women with symptoms of PFM dysfunction and directing them to a physiotherapist or other health care professional specializing in pelvic floor function.

Pelvic organ prolapse after delivery: effects on sexual function, quality of life, and psychological health

BACKGROUND

Living with pelvic organ prolapse (POP) after delivery negatively impacted women's daily living and was detrimental to their psychological health.

AIM

The purpose of the present study was to explore the effects of POP after delivery on women's sexual function, quality of life (QoL), and psychological health within the first year following delivery.

METHODS

A cross-sectional study was conducted with 640 female participants at obstetric clinic in 2 hospitals in Shenzhen, China.

OUTCOMES

All women completed following questionnaires: short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) on sexual function, Pelvic Floor Distress Inventory-20 (PFDI-20) on well-being and QoL, Symptom Checklist-90-Revised (SCL-90-R) on psychological health, and International Consultation on Incontinence Questionnaire Short Form.

RESULTS

Women with symptomatic POP (N = 250) had higher mean scores (P < .05) than those without symptoms (N = 390) in PISQ-12, PFDI-20, and SCL-90-R domains. In the symptomatic POP group (N = 250), the sexually dysfunctional group (N = 137) had significantly higher mean scores (P < .001) than the sexually functional group (N = 113) in PISQ-12, PFDI-20, and SCL-90-R domains. Women with POP duration ≥6 months (N = 132) had significantly higher mean scores (P < .001) than women with POP duration <6 months (N = 118) in PISQ-12, PFDI-20, and SCL-90-R domains. The multiple linear regression model of PISQ-12 showed that constipation history, regular pelvic floor muscle training, parity, and symptomatic POP were independently correlated with the questionnaire score (P < .05).

CLINICAL IMPLICATIONS

The significantly pervasive nature of POP often leads to the neglect of a substantial percentage of sexual problems and related emotional suffering, emphasizing the critical importance of raising awareness about this issue among clinicians and the general public.

STRENGTHS AND LIMITATIONS

The current study brought attention to significant aspects of postpartum POP; the findings suggest issues concerning POP occurrences and their impacts on sexual function, QoL, and psychological health. Primary constraints are linked to the utilization of self-report assessments.

CONCLUSION

The current study reveals a robust correlation between POP in postpartum women and compromised sexual function, QoL, and psychological health.

Impact of parity on pelvic floor morphology and function: A retrospective study

To analyze the effect of parity on pelvic floor morphology and function during the postpartum period. A total of 971 participants, who attended the Fujian Maternity and Child Health Hospital (Fuzhou, China) between December 2019 and August 2021, were included. All participants were assessed using the modified Oxford scale (MOS), pelvic floor surface electromyography, and 3-dimensional pelvic floor ultrasound to assess pelvic floor morphology and function. Multivariate analysis revealed no differences among primipara, deuteripara, and tertipara in pre-baseline rest, phasic contraction, endurance contraction, post-baseline rest, and MOS, except for tonic contraction (P = .020), the amplitude of which was lower in primipara than in deuteripara in post hoc comparison (P = .008). Differences in bladder neck presentation and bladder neck descent were statistically significant in multivariate analysis (P = .002, P = .001, respectively), with the value of bladder neck presentation in primiparas being greater than that of deuteriparas and tertipara (P = .002, P = .008, respectively), and the value of bladder neck descent was lower than that of deuteripara and tertipara in further post hoc comparisons (P = .002, P = .003, respectively). Functional impairment was not statistically associated with parity according to the MOS score or surface electromyography. However, parity was significantly correlated with descent of the bladder neck, and most of the effects appeared to occur during the first delivery.

Association between the rs1036819 polymorphism of the ZFAT gene and pelvic organ prolapse: a case-control study

INTRODUCTION AND HYPOTHESIS

The identification of risk factors for pelvic organ prolapse (POP) would contribute to planning prevention strategies. This study tests the hypothesis that the rs1036819 polymorphism in the ZFAT gene is associated with POP and investigates other risk factors for prolapse development.

METHODS

A case-control study was carried out including 826 postmenopausal women divided into POP cases (stages III and IV) and controls (stages 0 and I), assessed by anamnesis, examination, and peripheral blood samples. DNA was extracted from blood and genotyped by real-time RT-PCR. We used logistic regression models for the association analyses of variables, with p < 0.05 for significance.

RESULTS

Five hundred and sixty-eight women were evaluated (315 POP and 253 controls). The minor allele C was found in 19.3% of our sample and the genotype frequencies of AA, AC, and CC were similar in both groups. Age (OR 1.09, 95% CI 1.06-1.13), number of pregnancies (OR 1.23, 95% CI 1.08-1.41), history of one vaginal delivery (OR 3.39, 95% CI 1.38-8.33) or two or more (OR 2.51, 95% CI 1.04-6.07), weight of the largest newborn (OR 1.0001, 95% CI 1-1.001), and family history of POP (OR 2.27, 95% CI 1.24-4.13) were independent risk factors for POP, whereas one cesarean section (OR 0.48, 95% CI 0.27-0.88) or two or more (OR 0.14, 95% CI 0.05-0.38) were protective.

CONCLUSIONS

No association was detected between the rs1036819 polymorphism of the ZFAT gene and advanced POP. Age, number of pregnancies, at least one vaginal delivery, weight of the newborn, and POP family history were independent risk factors for POP.

Ultrasound examination of the pelvic floor during active labor: A longitudinal cohort study

INTRODUCTION

There is limited evidence about changes in the pelvic floor during active labor. We aimed to investigate changes in hiatal dimensions during the active first stage of labor and associations with fetal descent and head position.

MATERIAL AND METHODS

We conducted a longitudinal, prospective cohort study at the National University Hospital of Iceland, from 2016 to 2018. Nulliparous women with spontaneous onset of labor, a single fetus in cephalic presentation, and gestational age ≥37 weeks were eligible. Fetal position was assessed with transabdominal ultrasound and fetal descent was measured with transperineal ultrasound. Three-dimensional volumes were acquired from transperineal scanning at the start of the active phase of labor and in late first stage or early second stage. The largest transverse hiatal diameter was measured in the plane of minimal hiatal dimensions. The levator urethral gap was measured as the distance between the center of the urethra and the levator insertion using tomographic ultrasound imaging. Measurements of the levator urethral gap were made in the plane of minimal hiatal dimensions and 2.5 and 5 mm cranial to this.

RESULTS

The final study population comprised 78 women. The mean transverse hiatal diameter increased 12.4% between the two examinations, from 39.4 ± 4.1 mm (±standard deviation) at the first examination to 44.3 ± 5.8 mm at the last examination (p < 0.01). We found a moderate correlation between the transverse hiatal diameter and fetal station at the last examination (r = 0.44, r2  = 0.19; p < 0.01; regression equation y = 2.71 + 0.014x), and a weak correlation between the change in transverse hiatal diameter and change in fetal station (r = 0.29; r2  = 0.08; p = 0.01; regression equation y = 0.24 + 0.012x). Levator urethral gap increased significantly in all three planes on both the left and right sides. Head position was not associated with hiatal measurements after adjusting for fetal station.

CONCLUSIONS

We found a significant, but only modest, increase of the hiatal dimensions during the first stage of labor. The risk of levator ani trauma will therefore be low during this stage. The change in transverse hiatal diameter was associated with fetal descent but not with head position.

Characteristics Associated with Pelvic Floor Disorders among Female Canadian Armed Forces Members

OBJECTIVES

Urinary incontinence (UI) and pelvic organ prolapse (POP) are prevalent pelvic floor disorders (PFDs) among the female population. In the military environment, being a non-commissioned member (NCM), and physically demanding occupations are factors associated with higher PFD risk. This study seeks to characterize the profile of female Canadian Armed Forces (CAF) members reporting symptoms of UI and/or POP.

METHODS

Present CAF members (18-65 years) responded to an online survey. Only current members were included in the analysis. Symptoms of UI and POP were collected. Multivariate logistic regressions analyzed the relationships between PFD symptoms and associated characteristics.

RESULTS

765 active members responded to female-specific questions. The prevalence of self-reported POP and UI symptoms were 14.5% and 57.0%, respectively, with 10.6% of respondents reporting both. Advanced age (adjusted odds ratio [aOR]: 1.062, CI 1.038-1.087), a body mass index (BMI) categorized as obese (aOR: 1.909, [1.183-3.081]), parity ≥1 (e.g., aOR for 1: 2.420, [1.352-4.334]) and NCMs (aOR: 1.662, [1.144-2.414]) were factors associated with urine leakage. Parity of ≥2 (aOR: 2.351, [1.370-4.037]) compared to nulliparous and having a perception of a physically demanding job (aOR: 1.933, [1.186-3.148]) were associated with experiencing POP symptoms. Parity of ≥2 increased the odds of reporting both PFD symptoms (aOR: 5.709, [2.650-12.297]).

CONCLUSION

Parity was associated with greater odds of experiencing symptoms of UI and POP. Higher age, higher BMI, and being an NCM were associated with more symptoms of UI, and the perception of having a physically demanding role increased the likelihood of reporting POP symptoms.

Bearing the burden of spill-over effects: Living with a woman affected by symptomatic pelvic organ prolapse after vaginal birth - from a partner's perspective

INTRODUCTION

Symptomatic pelvic organ prolapse (sPOP) can have a negative impact on a woman's health. While research exists about the impact of sPOP on women, little is known about the effect on their partners. Therefore, this study aimed to explore, from the partner's perspective, what it means to live with a woman with symptomatic pelvic organ prolapse after vaginal birth.

METHODS

A qualitative explorative design with a constructed grounded theory approach was taken to analyse the interviews of 13 partners who experienced living with a woman who had sPOP after vaginal birth.

RESULTS

"The theory of bearing the burden of spill-over effects" was constructed based on a core category: "Facing a new restricted life", with related categories "Giving up valued activities"; "Struggling with added demands"; "Changing intimate behaviour" and "Redefining future family planning". The theory also contains factors constraining and enabling adjustment to the new reality. While the shortcomings of healthcare constrained the process of adjustment, getting competent treatment and the feeling of love for the family enabled it.

CONCLUSION

This study demonstrated that women's sPOP had an apparently negative impact on partners' health behaviours, sexual health, relationship harmony, and psychological well-being. The partners indicated they were unprepared for post-birth adversities and distressed by the lack of treatment options. There is a need to develop prenatal information highlighting the potential risks of sPOP which may be accompanied by levator ani muscle injury, implement guidelines for the prevention and management of these conditions, and offer targeted support to partners if needed.

PEOPLE: Lifestyle and comorbidities as risk factors for pelvic organ prolapse-a systematic review and meta-analysis PEOPLE: PElvic Organ Prolapse Lifestyle comorbiditiEs

INTRODUCTION AND HYPOTHESIS

The literature is scarce regarding the effects of comorbidities, clinical parameters, and lifestyle as risk factors for pelvic organ prolapse (POP). This study was performed to systematically review the literature related to body mass index (BMI), waist circumference, diabetes mellitus (DM), hypertension (HT), dyslipidemia, chronic constipation, smoking, chronic cough, occupation, and striae and varicose veins as determinants for POP.

METHODS

Search terms in accordance with Medical Subject Headings were used in PubMed, Embase, LILACS, and the Cochrane Library. Clinical comparative studies between women with and without POP and containing demographic and/or clinical raw data related to lifestyle and/or comorbidities were included. The ROBINS-I (risk of bias in non-randomized studies of interventions) instrument was used. Fixed-effects and random-effects models were used for homogeneous and heterogeneous studies, respectively.

RESULTS

Forty-three studies were included in the meta-analysis. BMI < 25 kg/m2 was found to be a protective factor for POP [OR 0.71 (0.51, 0.99); p = 0.04], and BMI > 30 kg/m2 was a risk factor for POP [OR 1.44 (1.37, 1.52); p < 0.00001]. Waist circumference (≥ 88 cm) was reported as a risk factor for POP [OR 1.80 (1.37, 2.38); p < 0.00001], along with HT [OR 1.18 (1.09, 1.27); p = 0.04], constipation [OR 1.77 (1.23, 2.54); p < 0.00001], occupation [OR 1.86 (1.21, 2.86); p < 0.00001], persistent cough [OR 1.52 (1.18, 1.94); p < 0.0001]), and varicose veins [OR 2.01 (1.50, 2.70); p = 0.12].

CONCLUSIONS

BMI < 25 kg/m2 is protective while BMI > 30 kg/m2 is a risk factor for POP. Large waist circumference, dyslipidemia, HT, constipation, occupation, persistent cough, and varicose veins are also determinants for POP.

Maternal pesticide exposure and risk of preterm birth: A systematic review and meta-analysis

BACKGROUND

Maternal pesticide exposure might be associated with adverse pregnancy outcomes through triggering inflammation and oxidative stress and disrupting endocrine functions. Yet the association between prenatal pesticide exposure and risk of preterm birth remains inconclusive.

OBJECTIVES

To conduct a systematic review and meta-analysis of human observational studies using the Office of Health Assessment and Translation (OHAT) framework to explore the association of per ten-fold increase of pesticide concentrations in maternal biological samples during pregnancy with risk of preterm birth and length of gestational age at birth.

DATA SOURCE

Five English (PubMed, Embase, Cochrane Library, Web of Science and Scopus) and 3 Chinese databases (China national knowledge infrastructure (CNKI), Wanfang Data, and Chinese Biomedical Literature Database (CBM)) were searched till Jan 18th, 2023.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

To be included, pesticide exposure should be measured in maternal biological samples during pregnancy and in log-transformed forms. The primary outcome was preterm birth and the secondary outcome was gestational age at birth.

STUDY APPRAISAL, SYNTHESIS METHODS AND CONFIDENCE ASSESSMENT

Quality of studies was evaluated using OHAT Risk of Bias Tool. Evidence was quantitatively synthesized with Correlated and Hierarchical Effects (CHE) model. The confidence rating in the body of evidence was done using OHAT.

RESULTS

A total of 21 studies reported by 18 papers were included, with 7 studies for preterm birth and 19 for gestational age at birth. The meta-analysis found a ten-fold increase of pesticide concentrations was potentially associated with risk of preterm birth (pooled OR = 1.28; 95%CI: 0.93, 1.78) and shortened gestational age at birth (β = -0.10; 95%CI: -0.21, 0.01). Sampling biospecimens in different trimesters was identified as a potential modifier in the association between pesticide exposure and length of gestational age (F = 2.77, P < 0.05). For studies that collected samples at any time during pregnancy, pesticide exposure was found to be associated with shortened length of gestational age (β = -0.43; 95%CI: -0.81, -0.06). The confidence rating in the body of evidence was "moderate" and "very low" for preterm birth and gestational age at birth, respectively.

CONCLUSION

Our result suggested moderate evidence of an association between pesticide exposure and higher risk of preterm birth. Yet more studies are still needed with larger sample size and careful considerations of confounders and accuracy of outcome measurements. Attention is also required on other pesticide compounds in addition to organochlorine and organophosphorus pesticides, and on windows of susceptibility.

Effect of Timing of Second-Stage Pushing on Pelvic Floor Morbidity After Birth

The author describes a recent trial on the effect of the timing of pushing during the second stage of labor on postpartum pelvic floor morbidity.

Lifestyle factors, metabolic factors and socioeconomic status for pelvic organ prolapse: a Mendelian randomization study

BACKGROUND

Previous observational studies have reported that lifestyle factors, metabolic factors and socioeconomic status are associated with the development of female pelvic organ prolapse (POP); however, whether these associations are causal remains unclear. The current study aimed to assess the causal effect of lifestyle factors, metabolic factors and socioeconomic status on POP risk.

METHODS

We conducted a two-sample Mendelian randomization (MR) study based on summary-level data from the largest available genome-wide association studies (GWAS) to evaluate whether lifestyle factors, metabolic factors and socioeconomic status are causally related to POP. We used single nucleotide polymorphisms that are strongly associated with exposure at the genome-wide significance level (P < 5 × 10-8) as instrumental variables from genome-wide association studies. The method of random-effect inverse-variance weighting (IVW) was used as the primary analysis method, supplemented with the weighted median, MR-Egger and the MR pleiotropy residual sum and outlier applied to verify the MR assumptions. Two-step MR was conducted to investigate potential intermediate factors that are on the causal pathway from exposure to POP.

RESULTS

There were associations with POP for genetically predicted waist-to-hip ratio (WHR) (odds ratio (OR) 1.02, 95% confidence interval (CI) 1.01-1.03 per SD-increase, P < 0.001), WHR adjusted for body mass index (WHRadjBMI) (OR 1.017, 95% CI 1.01-1.025 per SD-increase, P < 0.001) and education attainment (OR 0.986, 95% CI 0.98-0.991 per SD-increase) in the meta-analysis. Additionally, genetically predicted coffee consumption (OR per 50% increase 0.67, 95% CI 0.47-0.96, P = 0.03), vigorous physical activity (OR 0.83, 95% CI 0.69-0.98, P = 0.043) and high-density lipoprotein cholesterol (HDL-C) (OR 0.91, 95% CI 0.84-0.98 per SD-increase, P = 0.049) were inversely associated with POP in the FinnGen Consortium. The mediation analysis showed that the indirect effects of education attainment on POP were partly mediated by WHR and WHRadjBMI, with a mediated proportion of 27% and 13% in the UK Biobank study, respectively.

CONCLUSIONS

Our study provides MR evidence of a robust causal association of WHR, WHRadjBMI and education attainment with POP.

Longitudinal changes in pelvic organ support among primiparas with postpartum pelvic organ prolapse: A follow-up magnetic resonance imaging study

OBJECTIVE

To quantify morphological changes of pelvic floor in primiparas with postpartum pelvic organ prolapse (POP) during the early postpartum period.

METHODS

A total of 309 primiparas underwent pelvic floor magnetic resonance imaging (MRI) at 6 weeks postpartum. Those primiparas diagnosed with postpartum POP by MRI criterion were followed up at 3 and 6 months postpartum. Normal primiparas were enrolled in the control group. The puborectal hiatus line, muscular pelvic floor relaxation line, levator hiatus area, iliococcygeus angle, levator plate angle, uterus-pubococcygeal line, and bladder-pubococcygeal line were assessed on MRI. Longitudinal changes in pelvic floor measurements between the two groups were compared by repeated-measures analysis of variance.

RESULTS

Compared with the control group, enlarged puborectal hiatus line, levator hiatus area, and RICA and decreased uterus-pubococcygeal line were observed at rest in the POP group (all P < 0.05). All of the pelvic floor measurements were significantly different in the POP group compared with the control group at the maximum Valsalva maneuver (all P < 0.05). All of the pelvic floor measurements showed no significant change over time in both the POP and control groups (all P > 0.05).

CONCLUSIONS

Postpartum POP accompanied by poor pelvic floor support will persist in the early postpartum period.

Obstetric risk factors for anal sphincter trauma in a urogynecological population

INTRODUCTION AND HYPOTHESIS

Obstetric anal sphincter tears are the single major modifiable risk factor for anal incontinence (AI) in women. We undertook a retrospective observational study in a tertiary urogynecology unit to describe the prevalence of sonographic anal sphincter defects in a urogynecological population and investigate obstetric risk factors.

METHODS

Files of women seen for investigation of pelvic floor disorders between January 2014 and May 2021 were reviewed. Sonographic defects of the external anal sphincter were analyzed using stored 4D ultrasound imaging data. Explanatory parameters were number of vaginal births, delivery mode, age at first vaginal birth, and birthweight of the first vaginally born baby.

RESULTS

Of 3,037 women seen during the inclusion period, data were missing in 219, leaving 2,818. AI was reported by 508 (18%), with a mean St Marks score of 11 (1-23) and a mean bother score of 5.9 (0-10). External sphincter defects were detected in 945 women (34%), with a "residual defect" in 343 (12%). The strongest risk factors for a residual defect were first vaginal birth and forceps, with higher-order multiparity adding risk. On multivariate analysis, forceps and vaginal parity >5 remained significant predictors, as opposed to age at first birth and birthweight of the firstborn.

CONCLUSIONS

In this observational study in urogynecological patients, 12% showed a residual EAS defect on imaging. The most obvious risk factors for the diagnosis of a residual defect on exo-anal imaging were the first vaginal birth and forceps, with higher-order vaginal parity conveying additional risk.

Prevalence of symptomatic pelvic organ prolapse and associated factors in Southern Nations, Nationalities, People's Region referral hospitals, Ethiopia

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse is one of the major causes of morbidity among women that affect their quality of life. Despite the severity of the problem, there is limited information in Ethiopia. Therefore, this study was aimed at assessing the prevalence of symptomatic POP and its associated factors.

METHODS

An institution-based cross-sectional study was carried out in the referral hospitals of Southern Nations, Nationalities, People's Region, Ethiopia. Women were initially interviewed about their prolapse symptoms using validated questionnaires, and if they answered yes to one or more of the questions, they were examined by gynecologists using simplified POP quantification. Pelvic examination results and patient-reported symptoms were used to determine symptomatic POP. A multivariate logistic regression analysis model was used to identify factors associated with symptomatic prolapse.

RESULTS

A total of 1,196 respondents were included in this study. The prevalence of symptomatic POP was found to be 20.1%. Age of women ≥55 years (AOR=8.39; 95% CI 3.41-20.62), carrying heavy objects for ≥ 5 h (AOR= 5.18; 95% CI 2.51-10.69), parity ≥4 times (AOR=2.98; 95% CI 1.60-5.53), history of home delivery (AOR= 2.90; 95% CI 1.50-5.61), giving birth through assisted vaginal delivery (AOR=5.01; 95% CI 1.73-14.53), history of chronic constipation (AOR=2.66; 95% CI 1.38-5.15), and a history of a chronic cough (AOR=9.18; 95% CI 4.52-18.61) were associated with symptomatic POP.

CONCLUSIONS

In this study the prevalence of symptomatic POP is high. Older age, long hours of carrying heavy objects, a high parity, last birth through assisted vaginal delivery, a history of home delivery, a history of chronic constipation, and a history of a chronic cough were found to be associated with symptomatic POP.

All or nothing? A second look at partial levator avulsion

OBJECTIVE

To define associations between partial levator trauma and symptoms and signs of pelvic organ prolapse (POP).

METHODS

This was a retrospective study of 3484 women attending a tertiary urogynecology unit for symptoms of pelvic floor dysfunction between January 2012 and February 2020. All women underwent a standardized interview, clinical pelvic organ prolapse quantification (POP-Q) examination and tomographic ultrasound imaging of the pelvic floor. Women with full levator avulsion were excluded from analysis. Partial levator avulsion was quantified using the tomographic trauma score (TTS), in which slices 3-8 are scored bilaterally for abnormal insertions. Binomial multiple logistic regression was analyzed independently for the outcome variables prolapse symptoms, symptom bother and objective prolapse on clinical examination and imaging, with age and body mass index as covariates. Two continuous outcome variables, prolapse bother score and hiatal area on Valsalva, were analyzed using multiple linear regression.

RESULTS

Of the 3484 women, ultrasound data were missing or incomplete in 164 due to lack of equipment, clerical error and/or inadequate image quality. Full levator avulsion was diagnosed in 807 women, leaving 2513 for analysis. TTS ranged from 0-10, with a median of 0. Partial trauma (TTS > 0) was observed in 667/2513 (26.5%) women. All subjective and objective measures of POP were associated significantly with TTS, most strongly for cystocele. Associations were broadly linear and similar for all slice locations but disappeared after accounting for hiatal area on Valsalva.

CONCLUSION

Partial avulsion is associated with POP and prolapse symptoms. This association was strongest for cystocele, both on POP-Q and ultrasound imaging. The effect of partial avulsion on POP and prolapse symptoms is explained fully by its effect on hiatal area. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Risk factors of pelvic organ prolapse at Asella Teaching and Referral Hospital: Unmatched case control study

Background

Prolapse is one of the sub-types of pelvic floor dysfunction (PFD) which occurs due to abnormal fall of the pelvic organs from their normal anatomic positions. Although the cause of prolapse is multifactorial, it primarily occurs due to pregnancy and vaginal delivery. Hence, the present study aimed to identify risk factors of prolapse among women who undergo gynecological surgery.

Materials and methods

Facility-based-unmatched case–control design was employed. Cases were all gynecological women who were diagnosed with pelvic organ prolapse (POP) at Asella teaching referral hospital (ATRH) while controls were all charts of gynecological women who were diagnosed with other gynecological problems rather than POP at ATRH. For each case, two controls were selected using a simple random sampling technique. The data were entered into Epidata version 4.3.1 and finally exported to SPSS version 25 for further analysis. Then variables that had an association in the bivariate model (p &lt; 0.25) were entered and analyzed by a multivariable conditional logistic regression model to identify the independent effect of different factors. Statistical significance was declared at p &lt; 0.05.

Results

A total of 147 cases and 293 controls were included in this study. Women who had a history of chronic cough, previous pelvic floor surgery, constipation, and vaginal tear during delivery, history of pelvic trauma, age of the women, rural resident, and maternal gravidity were strongly associated with prolapse at p-value of &lt; 0.05. Multigravida [adjusted odds ratio (AOR) 2.987 (95% CI 1.237–6.853), p = 0.014], age &gt;50 years [AOR: 2.496 (95% CI 1.372–4.539), p = 0.003], women with a history of pelvic floor surgery [AOR: 0.3.666 (95% CI 1.328–10.124), p = 0.012], women who had diabetes mellitus [AOR: 4.676 (95% CI 0.908–24.075), p = 0.065], and resided in rural areas [AOR = 1.878; (95% CI: 0.984–3.585), I2 = 47.5%, p = 0.056] were the independent predictors were of prolapse.

Conclusions

In this study, women with diabetes mellitus, previous pelvic floor surgery, rural residents, being multigravida, and age &gt;40 were independent predictors of prolapse. Therefore, delivering health education by focusing on the identified risk factors was strongly recommended.

Risk factors of pelvic floor muscle strength in south Chinese women: a retrospective study

Objectives

To evaluate pelvic floor muscle strength using surface electromyography and risk factors for pelvic floor muscle strength in the early postpartum period.

Methods

This retrospective study included 21,302 participants who visited Fujian Maternity and Child Health Hospital from September 2019 to February 2022. All participants were assessed by medical professionals for general information and surface electromyography.

Results

Univariate analysis indicated that age was inversely related to tonic and endurance contractions. In contrast, all the other variables, including education level, body mass index, neonatal weight, and number of fetuses, had a positive impact on rapid, tonic, and endurance contractions. Likewise, parity was also positively associated with rapid contractions. In addition, compared with vaginal delivery, cesarean section delivery had a protective effect on the amplitude of the three types of contractions. Stepwise regression analysis showed that both age and neonatal weight had a negative linear relationship with the amplitude of rapid, tonic and endurance contractions. In contrast, the amplitude of rapid, tonic and endurance contractions significantly increased as body mass index, parity (≤ 3), education level and gestational weight gain (endurance contractions only) increased. Participants with cesarean section delivery showed positive effects on rapid, tonic, and endurance contractions compared to participants with vaginal delivery.

Conclusions

We found that age, neonatal weight, vaginal delivery, episiotomy, and forceps delivery were risk factors for pelvic floor muscle strength; in contrast, body mass index, parity (≤ 3) and gestational weight gain had a positive relationship with pelvic floor muscle strength.

Risk factors for primary pelvic organ prolapse and prolapse recurrence: an updated systematic review and meta-analysis

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.

The rs2165241 polymorphism of the Loxl1 gene in postmenopausal women with pelvic organ prolapse

OBJECTIVE

This study aimed to verify the presence of polymorphism rs2165241 of the lysyl oxidase-like 1 (Loxl1) gene and its association with pelvic organ prolapse (POP) in Brazilian women and determine risk factors for POP development.

METHODS

The study was previously approved by the local research and ethics board. Postmenopausal women were included and divided into POP (stages III and IV) and control (stages 0 and I) groups. Peripheral blood samples were collected, and the DNA sequence of interest was analyzed by real-time reverse-transcriptase polymerase chain reaction. We used logistic regression and considered a recessive model of inheritance for the analysis, with p < 0.05 for significance.

RESULTS

A total of 836 women were assessed: 426 POP cases and 410 controls. The frequencies of CC, CT and TT genotypes were similar in both groups. Age (odds ratio [OR] = 1.1, 95% confidence interval [CI] = 1.07; 1.14), number of vaginal births (OR = 17.06, 95% CI = 5.94; 48.97), family history (OR = 2.87, 95% CI = 1.57; 5.22) and weight of largest newborn (OR = 1.001, 95% CI = 1.0003; 1.001) were independent risk factors for POP, while multiple cesarean sections (two or more) was protective (OR = 0.17, 95% CI = 0.07; 0.42).

CONCLUSION

No association was detected between rs2165241 of the Loxl1 gene and POP.

International Urogynecological Consultation (IUC): pathophysiology of pelvic organ prolapse (POP)

INTRODUCTION AND HYPOTHESIS

This manuscript is the International Urogynecology Consultation (IUC) on pelvic organ prolapse (POP) chapter one, committee three, on the Pathophysiology of Pelvic Organ Prolapse assessing genetics, pregnancy, labor and delivery, age and menopause and animal models.

MATERIALS AND METHODS

An international group of urogynecologists and basic scientists performed comprehensive literature searches using pre-specified terms in selected biomedical databases to summarize the current knowledge on the pathophysiology of the development of POP, exploring specifically factors including (1) genetics, (2) pregnancy, labor and delivery, (3) age and menopause and (4) non-genetic animal models. This manuscript represents the summary of three systematic reviews with meta-analyses and one narrative review, to which a basic scientific comment on the current understanding of pathophysiologic mechanisms was added.

RESULTS

The original searches revealed over 15,000 manuscripts and abstracts which were screened, resulting in 202 manuscripts that were ultimately used. In the area of genetics the DNA polymorphisms rs2228480 at the ESR1 gene, rs12589592 at the FBLN5 gene, rs1036819 at the PGR gene and rs1800215 at the COL1A1 gene are significantly associated to POP. In the area of pregnancy, labor and delivery, the analysis confirmed a strong etiologic link between vaginal birth and symptoms of POP, with the first vaginal delivery (OR: 2.65; 95% CI: 1.81-3.88) and forceps delivery (OR: 2.51; 95% CI: 1.24-3.83) being the main determinants. Regarding age and menopause, only age was identified as a risk factor (OR : 1.102; 95% CI: 1.02-1.19) but current data do not identify postmenopausal status as being statistically associated with POP. In several animal models, there are measurable effects of pregnancy, delivery and iatrogenic menopause on the structure/function of vaginal support components, though not on the development of POP.

CONCLUSIONS

Genetics, vaginal birth and age all have a strong etiologic link to the development of POP, to which other factors may add or protect against the risk.

Mouse Knockout Models for Pelvic Organ Prolapse: a Systematic Review

INTRODUCTION AND HYPOTHESIS

Mouse knockout (KO) models of pelvic organ prolapse (POP) have contributed mechanistic evidence for the role of connective tissue defects, specifically impaired elastic matrix remodeling. Our objective was to summarize what mouse KO models for POP are available and what have we learned from these mouse models about the pathophysiological mechanisms of POP development.

METHODS

We conducted a systematic review and reported narrative findings according to PRISMA guidelines. Two independent reviewers searched PubMed, Scopus and Embase for relevant manuscripts and conference abstracts for the time frame of January 1, 2000, to March 31, 2021. Conference abstracts were limited to the past 5 years.

RESULTS

The search strategy resulted in 294 total titles. We ultimately included 25 articles and an additional 11 conference abstracts. Five KO models have been studied: Loxl1, Fbln5, Fbln3, Hoxa11 and Upii-sv40t. Loxl1 and Fbln5 KO models have provided the most reliable and predictable POP phenotype. Loxl1 KO mice develop POP primarily from failure to heal after giving birth, whereas Fbln5 KO mice develop POP with aging. These mouse KO models have been used for a wide variety of investigations including genetic pathways involved in development of POP, biomechanical properties of the pelvic floor, elastic fiber deposition, POP therapies and the pathophysiology associated with mesh complications.

CONCLUSIONS

Mouse KO models have proved to be a valuable tool in the study of specific genes and their role in the development and progression of POP. They may be useful to study POP treatments and POP complications.