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Montaguti E, Raspollini A, Montedoro C, Nedu B, Pilu G. 4D transperineal ultrasound: feedback for good obstetric anal sphincter injuries reparation. J Ultrasound 2024:10.1007/s40477-024-00933-5. [PMID: 39014262 DOI: 10.1007/s40477-024-00933-5] [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: 02/27/2024] [Accepted: 05/10/2024] [Indexed: 07/18/2024] Open
Abstract
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.
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Affiliation(s)
- Elisa Montaguti
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 13, 40138, Bologna, Italy.
| | - Arianna Raspollini
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 13, 40138, Bologna, Italy
| | - Chiara Montedoro
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 13, 40138, Bologna, Italy
| | - Bianca Nedu
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 13, 40138, Bologna, Italy
| | - Gianluigi Pilu
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 13, 40138, Bologna, Italy
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Cattani L, Packet B, Samešova A, Williams H, Van Schoubroeck D, Deprest J. Three-Dimensional Transperineal Ultrasound Assessment of the Anal Sphincter Immediately After Vaginal Birth: An Exploratory Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024. [PMID: 38867553 DOI: 10.1002/jum.16490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 04/22/2024] [Accepted: 05/16/2024] [Indexed: 06/14/2024]
Abstract
OBJECTIVES To assess the feasibility of acquiring adequate transperineal ultrasound (TPUS) volumes of the anal sphincter (AS) immediately after vaginal birth, the reproducibility of its measurements, and detecting defects therein. METHODS Secondary analysis of TPUS volumes of the AS, acquired immediately after vaginal birth with a transversely oriented convex probe. Two independent experts ranked off-line image quality as "inadequate," "adequate," or "ideal" using the Point-of-Care Ultrasound Image Quality scale. On "adequate" and "ideal" quality volumes, the length of the external AS at 6 and 12 o'clock, and the volume of the external and internal AS were measured. Additionally, volumes were screened for AS defects on tomographic ultrasound imaging. Subsequently, we rated the intra- and interrater agreement on those findings. RESULTS Of 183 volumes, 162 were considered "adequate" or of "ideal" quality (88.5%). Reasons for "inadequacy" were shadow artifacts (16/21), poor resolution (3/21), incomplete acquisition (1/21), or aberrant AS morphology (1/21). The intrarater reliability of two-dimensional (2D) and three-dimensional (3D) measurements was excellent, whereas interrater reliability was fair to good for 2D measurements and good for 3D measurements. In those tomographic ultrasound imaging (TUI) sequences including AS defects, the intra- and interrater reliability of the defect measurement were excellent [intraclass correlation coefficient (ICC) = 0.92 (0.80-0.94)] and moderate [ICC = 0.72 (0.63-0.79)]. In this cohort, there were only few (4/48; 8.3%) AS defects. However, grading them was poorly reproducible between experts. CONCLUSION TPUS of the AS immediately after vaginal birth yields adequate image quality and allows for reproducible measurements. In the few patients with AS defects, there was good agreement on the presence, but it was poor for the extent of defects.
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Affiliation(s)
- Laura Cattani
- Department of Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Department of Gynaecology and Obstetrics, UZ Leuven, Leuven, Belgium
| | - Bram Packet
- Department of Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Department of Gynaecology and Obstetrics, UZ Leuven, Leuven, Belgium
| | - Adela Samešova
- Department of Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Third Faculty of Medicine, Institute for the Care of Mother and Child, Charles University, Prague, Czech Republic
| | - Helena Williams
- Department of Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Dominique Van Schoubroeck
- Department of Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Department of Gynaecology and Obstetrics, UZ Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Urogenital Surgery, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Department of Gynaecology and Obstetrics, UZ Leuven, Leuven, Belgium
- Research Department of Maternal Fetal Medicine, Institute for Women's Health, University College London, London, UK
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Huber M, Larsson C, Harrysson M, Strigård K, Lehmann J, Nordin P, Tunón K. Use of endoanal ultrasound in detecting obstetric anal sphincter injury immediately after birth. Acta Obstet Gynecol Scand 2023; 102:389-395. [PMID: 36683208 PMCID: PMC9951293 DOI: 10.1111/aogs.14514] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 12/21/2022] [Accepted: 01/02/2023] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Obstetric anal sphincter injury (OASI) complicates around 5% of deliveries in primiparas. The study objective was to assess the utility of three-dimensional endoanal ultrasonography (3D-EAUS) in the diagnosis of OASI. MATERIAL AND METHODS The present study was designed to mirror screening settings with an unselected cohort of nulliparous women. All enrolled patients underwent clinical examination of the perineum by the caregiver, and 3D-EAUS was conducted. Post-processing of ultrasonography volume data was performed by an experienced colorectal surgeon who was blinded to all other data. The sensitivity, specificity, negative predictive value, and positive predictive value of 3D-EAUS in the diagnosis of OASI was evaluated. The trial is registered at ISCRTN: 18006769. RESULTS A total of 680 scans were performed, of which 18.5% were judged as "non-assessable", resulting in 554 assessable recordings. Sphincter defects were observed in 12.8% of all assessable recordings on 3D-EAUS (n = 71). With clinical examination set as the reference standard, ultrasound sensitivity in the diagnosis of OASI was 30.4%, whereas its specificity was 87.9%. The negative predictive value was 96.7% and the positive predictive value was only 9.9%. Comments were left on 175 examinations, of which 74% referred to the management of the examination. CONCLUSIONS Using 3D-EAUS in a maternity ward is demanding because staff generally have little experience in endoanal ultrasound, which contributes to difficulties in obtaining good image quality. When 3D-EAUS is performed to mirror screening settings, it adds no convincing diagnostic power to clinical examination in the diagnosis of OASI.
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Affiliation(s)
- Malin Huber
- Department of Clinical Sciences, Obstetrics and GynecologyUmeå UniversityUmeåSweden
| | - Charlotta Larsson
- Department of Surgical and Perioperative SciencesUniversity of UmeåUmeåSweden
| | - Mathilda Harrysson
- Department of Obstetrics and GynecologyÖstersund HospitalÖstersundSweden
| | - Karin Strigård
- Department of Surgical and Perioperative SciencesUniversity of UmeåUmeåSweden
| | | | - Pär Nordin
- Department of Surgical and Perioperative SciencesUniversity of UmeåUmeåSweden
| | - Katarina Tunón
- Department of Clinical Sciences, Obstetrics and GynecologyUmeå UniversityUmeåSweden
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Risk Factors in Third and Fourth Degree Perineal Tears in Women in a Tertiary Centre: An Observational Ambispective Cohort Study. J Pers Med 2021; 11:jpm11080685. [PMID: 34442329 PMCID: PMC8398826 DOI: 10.3390/jpm11080685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/17/2021] [Accepted: 07/19/2021] [Indexed: 12/21/2022] Open
Abstract
Objectives: To analyze the main risk factors associated with third and fourth degree postpartum perineal tears in women attended to in our obstetrics service. Methods: An observational, retrospective, hospital cohort study was carried out in women whose deliveries were attended to in the obstetrics service of the Hospital General Universitario Gregorio Marañón de Madrid (HGUGM), during the period from January 2010 to April 2017. Results: During the study period, a total of 33,026 patients were included in the study. For maternal variables, the associated increased risk of severe perineal tearing in nulliparous women is OR = 3.48, for induced labor OR = 1.29, and for instrumental delivery by forceps OR = 4.52 or spatulas OR = 4.35; for the obstetric variable of episiotomy, it is OR = 3.41. For the neonatal variables, the weight of the newborns has a directly proportional relationship with the risk of severe tears, and for birth weights of 3000 g (OR = 2.41), 3500 g (OR = 1.97), and 4000 g (OR = 2.17), statistically significant differences were found in each of the groups (p < 0.05). Conclusion: Primiparity, induction of labor, episiotomy, instrumental delivery with forceps or spatula, and a birth weight of 3000 g or more are significantly associated with an increased risk of third and fourth degree perineal tears.
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Bellussi F, Dietz HP. Postpartum ultrasound for the diagnosis of obstetrical anal sphincter injury. Am J Obstet Gynecol MFM 2021; 3:100421. [PMID: 34129995 DOI: 10.1016/j.ajogmf.2021.100421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/20/2021] [Accepted: 05/26/2021] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Federica Bellussi
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, PA (Dr Bellussi).
| | - Hans Peter Dietz
- Department of Obstetrics, Gynecology, and Neonatology, Sydney Medical School Nepean, University of Sydney, Kingswood, New South Wales, Australia
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Seidenari A, Cuicchi D, Youssef A, Oliver EA, Montaguti E, Bellussi F. Obstetric anal sphincter injuries: strategies for prevention, diagnosis, and management. Minerva Obstet Gynecol 2020; 73:74-81. [PMID: 33249818 DOI: 10.23736/s2724-606x.20.04668-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Obstetric anal sphincter injuries (OASIS) are one of the most common causes of anal incontinence (AI) in women of reproductive age and can have a significant impact on quality of life. However, many women do not report symptoms to their physicians because of embarrassment and shame. Therefore, prevention and diagnosis of the tear is essential. Diagnostic strategies have evolved considerably in recent years, with an increase in prevalence of OASIS as a consequence. The use of 3D endoanal (3D-EAUS) and 4D transperineal ultrasound (4D-TPUS), in addition to standard clinical examination have enhanced the detection of OASIS. Once identified, adequate repair by a skilled practitioner and optimal postpartum management should be ensured in order to reduce the risk of anal incontinence. This review presents the available evidence on strategies for prevention, diagnosis, and management of OASIS.
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Affiliation(s)
- Anna Seidenari
- Department of Medical and Surgical Sciences, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Dajana Cuicchi
- Unit of General Surgery, Medical and Surgical Department, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna Italy
| | - Aly Youssef
- Department of Medical and Surgical Sciences, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Emily A Oliver
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Elisa Montaguti
- Department of Medical and Surgical Sciences, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Federica Bellussi
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, PA, USA -
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