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Youssef A, Del Magno A, Nedu B, Dapoto F, Brunelli E. Feasibility and reproducibility of new technique for measurement of transverse diameter of levator ani muscle hiatus using two-dimensional transperineal ultrasound in nulliparous women with term pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:824-832. [PMID: 38308852 DOI: 10.1002/uog.27595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/17/2023] [Accepted: 01/15/2024] [Indexed: 02/05/2024]
Abstract
OBJECTIVES The aim of the present study was two-fold. Firstly, we aimed to develop and describe a technique for measurement of the transverse diameter (TD) of the levator ani muscle (LAM) hiatus in the coronal view using two-dimensional (2D) transperineal ultrasound (TPUS) in nulliparous women with a term pregnancy. Secondly, we aimed to evaluate the feasibility and reproducibility of 2D-TPUS assessment of LAM hiatal TD and assess intermethod agreement between 2D-TPUS and three-dimensional (3D) TPUS measurement of TD in the axial plane, which is considered the gold standard in nulliparous women with term pregnancy. METHODS We recruited a group of nulliparous women with term pregnancy before the onset of labor. The study was conducted in two phases: Phase 1 involved developing and describing the 2D-TPUS technique for measuring LAM hiatal TD, and Phase 2 focused on assessing the technique's feasibility, reproducibility and intermethod agreement with 3D-TPUS measurement of LAM hiatal TD. In Phase 1, we enrolled 30 women. Each woman underwent acquisition of a 3D-TPUS volume, which was analyzed using multiplanar mode to identify and determine the appearance of the lateral borders of the LAM in the coronal plane, at the level of the plane of minimal hiatal dimensions. These borders were used as landmarks for TD measurement. Additionally, we measured the distance between the plane used for TD measurement and the center of the urethra in the axial view. In Phase 2, we recruited 100 women. Each woman underwent acquisition of three 2D-TPUS videoclips in the coronal plane, each encompassing a sweep of the entire LAM hiatus, and a 3D volume, all obtained during rest. On the 2D videoclips, TD was measured twice by one operator and once by another operator. In the 3D volume, TD was measured once, by one operator, in the axial plane; this measurement was considered the gold standard. Each operator was blinded to all other measurements during their assessments. We analyzed intraobserver and interobserver reproducibility and performed an intermethod (2D vs 3D) comparison. Bland-Altman analysis was conducted, and Levene's W0 test and Student's t-test were performed to explore clinical factors that might contribute to systematic differences. RESULTS In Phase 1, we identified successfully the landmarks denoting the lateral borders of the LAM hiatal TD in the coronal view. These appeared as two symmetrical hypoechogenic indentations located at the inner border of the hyperechogenic structure of the LAM, at the point of maximum distance between the two sides of the LAM. The distance between the urethra and the plane where TD should be measured using 3D-TPUS in the axial plane had a median of 4 mm and varied from 0 to 9 mm. This enabled us to describe a method for assessing LAM hiatal TD in the coronal plane using 2D-TPUS. In Phase 2, LAM hiatal TD was measured successfully in all 2D and 3D acquisitions from the entire group of 100 women. The analyses for intraobserver and interobserver reproducibility and the intermethod comparison (2D vs 3D) revealed almost perfect agreement in TD measurements using 2D-TPUS, with intraclass correlation coefficients of 0.95 (95% CI, 0.92-0.96), 0.87 (95% CI, 0.78-0.92) and 0.85 (95% CI, 0.78-0.90), respectively. The average differences between measurements were 0.1 mm for intraobserver, 1.0 mm for interobserver and 0.2 mm for intermethod repeatability. No systematic differences were observed in any of the measurement sets, except in the interobserver analysis, although this difference was clinically not significant (38.2 vs 37.2 mm, P = 0.01). None of the examined clinical factors (maternal body mass index and maternal age) exhibited a statistically significant impact on intraobserver, interobserver or intermethod reliability. CONCLUSIONS Utilizing our technique, described herein, to measure the LAM hiatal TD in the coronal view using 2D-TPUS is not only feasible but also highly reproducible and accurate in nulliparous women with term pregnancy. Moreover, it yields measurements that are comparable to those obtained in the reconstructed axial plane generated by 3D-TPUS. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A Youssef
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - A Del Magno
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - B Nedu
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - F Dapoto
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - E Brunelli
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Rodríguez-Benítez E, López-García K, Xelhuantzi N, Corona-Quintanilla DL, Castelán F, Martínez-Gómez M. Shift from Pro- to Anti-Inflammatory Phase in Pelvic Floor Muscles at Postpartum Matches Histological Signs of Regeneration in Multiparous Rabbits. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:675. [PMID: 38674321 PMCID: PMC11052351 DOI: 10.3390/medicina60040675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/31/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024]
Abstract
Background and Objectives: Pelvic floor muscles (PFM) play a core role in defecation and micturition. Weakening of PFM underlies urogynecological disorders such as pelvic organ prolapse and stress urinary incontinence. Vaginal delivery damages PFM. Muscle trauma implies an inflammatory response mediated by myeloid cells, essential for subsequent recovery. Molecular signaling characterizing the pro-inflammatory phase shifts M1 macrophages to M2 macrophages, which modulate muscle repair. The present study aimed to evaluate histological characteristics and the presence of M1 and M2 macrophages in bulbospongiosus (Bsm) and pubococcygeus muscles (Pcm). Materials and Methods: Muscles from young nulliparous (N) and multiparous rabbits on postpartum days three (M3) and twenty (M20) were excised and histologically processed to measure the myofiber cross-sectional area (CSA) and count the centralized myonuclei in hematoxylin-eosinstained sections. Using immunohistochemistry, M1 and M2 macrophages were estimated in muscle sections. Kruskal-Wallis or one-way ANOVA testing, followed by post hoc tests, were conducted to identify significant differences (p < 0.05). Results: The myofiber CSA of both the Bsm and Pcm of the M3 group were more extensive than those of the N and M20 groups. Centralized myonuclei estimated in sections from both muscles of M20 rabbits were higher than those of N rabbits. Such histological outcomes matched significant increases in HLA-DR immunostaining in M3 rabbits with the CD206 immunostaining in muscle sections from M20 rabbits. Conclusions: A shift from the pro- to anti-inflammatory phase in the bulbospongiosus and pubococcygeus muscles of multiparous rabbits matches with centralized myonuclei, suggesting the ongoing regeneration of muscles.
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Affiliation(s)
- Esteban Rodríguez-Benítez
- Centro Tlaxcala de Biología de la Conducta, Universidad Autónoma de Tlaxcala, Tlaxcala 90070, Mexico; (E.R.-B.); (D.L.C.-Q.); (F.C.)
- Doctorado en Ciencias Biológicas, Universidad Autónoma de Tlaxcala, Tlaxcala 90070, Mexico;
| | - Kenia López-García
- Doctorado en Ciencias Biológicas, Universidad Autónoma de Tlaxcala, Tlaxcala 90070, Mexico;
| | - Nicte Xelhuantzi
- Facultad de Ciencias de la Salud, Universidad Autónoma de Tlaxcala, Zacatelco 90750, Mexico;
| | - Dora Luz Corona-Quintanilla
- Centro Tlaxcala de Biología de la Conducta, Universidad Autónoma de Tlaxcala, Tlaxcala 90070, Mexico; (E.R.-B.); (D.L.C.-Q.); (F.C.)
| | - Francisco Castelán
- Centro Tlaxcala de Biología de la Conducta, Universidad Autónoma de Tlaxcala, Tlaxcala 90070, Mexico; (E.R.-B.); (D.L.C.-Q.); (F.C.)
- Departamento de Biología Celular y Fisiología, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Carretera Federal Tlaxcala-Puebla km 1.5 s/n, Tlaxcala 90070, Mexico
| | - Margarita Martínez-Gómez
- Centro Tlaxcala de Biología de la Conducta, Universidad Autónoma de Tlaxcala, Tlaxcala 90070, Mexico; (E.R.-B.); (D.L.C.-Q.); (F.C.)
- Departamento de Biología Celular y Fisiología, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Carretera Federal Tlaxcala-Puebla km 1.5 s/n, Tlaxcala 90070, Mexico
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Yan Y, Xing C, Chen J, Zheng Y, Li X, Liu Y, Wang Z, Gong K. Provincial Maternal and Child Information System in Inner Mongolia, China: Descriptive Implementation Study. JMIR Pediatr Parent 2024; 7:e46813. [PMID: 38526553 PMCID: PMC11002736 DOI: 10.2196/46813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 11/26/2023] [Accepted: 02/28/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND After the implementation of 2- and 3-child policies, the rising proportion of high-age and high-risk pregnancies put enormous pressure on maternal and child health (MCH) services for China. This populous nation with an increasing population flow imperatively required the support of large-scale information systems for management. Municipal MCH information systems were commonly applied in developed cities of eastern provinces in China. However, implementation of provincial MCH information systems in relatively low-income areas is lacking. In 2020, the implementation of a regional maternal and child information system (RMCIS) in Inner Mongolia filled this gap. OBJECTIVE This paper aimed to demonstrate the construction process and evaluate the implementation effect of an RMCIS in improving the regional MCH in Inner Mongolia. METHODS We conducted a descriptive study for the implementation of an RMCIS in Inner Mongolia. Based on the role analysis and information reporting process, the system architecture design had 10 modules, supporting basic health care services, special case management, health support, and administration and supervision. Five-color management was applied for pregnancy risk stratification. We collected data on the construction cost, key characteristics of patients, and use count of the main services from January 1, 2020, to October 31, 2022, in Inner Mongolia. Descriptive analysis was used to demonstrate the implementation effects of the RMCIS. RESULTS The construction and implementation of the RMCIS cost CNY 8 million (US $1.1 million), with a duration of 13 months. Between 2020 and 2022, the system recorded 221,772 registered pregnant women, with a 44.75% early pregnancy registry rate and 147,264 newborns, covering 278 hospitals and 225 community health care centers in 12 cities. Five-color management of high-risk pregnancies resulted in 76,975 (45.45%) pregnancies stratified as yellow (general risk), 36,627 (21.63%) as orange (relatively high risk), 156 (0.09%) as red (high risk), and 3888 (2.30%) as purple (infectious disease). A scarred uterus (n=28,159, 36.58%), BMI≥28 (n=14,164, 38.67%), aggressive placenta praevia (n=32, 20.51%), and viral hepatitis (n=1787, 45.96%) were the top factors of high-risk pregnancies (yellow, orange, red, and purple). In addition, 132,079 pregnancies, including 65,018 (49.23%) high-risk pregnancies, were registered in 2022 compared to 32,466 pregnancies, including 21,849 (67.30%) high-risk pregnancies, registered in 2020. CONCLUSIONS The implementation of an RMCIS in Inner Mongolia achieved the provincial MCH data interconnection for basic services and obtained both social and economic benefits, which could provide valuable experience to medical administration departments, practitioners, and medical informatics constructors worldwide.
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Affiliation(s)
- Yiwei Yan
- Biomedical Big Data Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Congyan Xing
- Equipment and Materials Department, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | | | - Yingbin Zheng
- Biomedical Big Data Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | | | - Yirong Liu
- School of Health Management, Fujian Medical University, Fuzhou, China
| | - Zhanxiang Wang
- Biomedical Big Data Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Kai Gong
- Biomedical Big Data Center, The First Affiliated Hospital of Xiamen University, Xiamen, China
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Youssef A, Brunelli E, Fiorentini M, Pilu G, Spelzini F. Soft-tissue dystocia due to paradoxical contraction of the levator ani as a cause of prolonged second stage: concept, diagnosis, and potential treatment. Am J Obstet Gynecol 2024; 230:S856-S864. [PMID: 38462259 DOI: 10.1016/j.ajog.2022.12.323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 12/23/2022] [Accepted: 12/26/2022] [Indexed: 03/12/2024]
Abstract
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.
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Affiliation(s)
- Aly Youssef
- Obstetric and Prenatal Medicine Unit, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria Policlinico Sant'Orsola Malpighi, Bologna, Italy.
| | - Elena Brunelli
- Obstetric and Prenatal Medicine Unit, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria Policlinico Sant'Orsola Malpighi, Bologna, Italy
| | - Marta Fiorentini
- Obstetric and Prenatal Medicine Unit, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria Policlinico Sant'Orsola Malpighi, Bologna, Italy
| | - Gianluigi Pilu
- Obstetric and Prenatal Medicine Unit, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria Policlinico Sant'Orsola Malpighi, Bologna, Italy
| | - Federico Spelzini
- Azienda Unità Sanitaria Locale della Romagna, Infermi Hospital, Rimini, Italy
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DeLancey JOL, Masteling M, Pipitone F, LaCross J, Mastrovito S, Ashton-Miller JA. Pelvic floor injury during vaginal birth is life-altering and preventable: what can we do about it? Am J Obstet Gynecol 2024; 230:279-294.e2. [PMID: 38168908 PMCID: PMC11177602 DOI: 10.1016/j.ajog.2023.11.1253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/20/2023] [Accepted: 11/20/2023] [Indexed: 01/05/2024]
Abstract
Pelvic floor disorders after childbirth have distressing lifelong consequences for women, requiring more than 300,000 women to have surgery annually. This represents approximately 10% of the 3 million women who give birth vaginally each year. Vaginal birth is the largest modifiable risk factor for prolapse, the pelvic floor disorder most strongly associated with birth, and is an important contributor to stress incontinence. These disorders require 10 times as many operations as anal sphincter injuries. Imaging shows that injuries of the levator ani muscle, perineal body, and membrane occur in up to 19% of primiparous women. During birth, the levator muscle and birth canal tissues must stretch to more than 3 times their original length; it is this overstretching that is responsible for the muscle tear visible on imaging rather than compression or neuropathy. The injury is present in 55% of women with prolapse later in life, with an odds ratio of 7.3, compared with women with normal support. In addition, levator damage can affect other aspects of hiatal closure, such as the perineal body and membrane. These injuries are associated with an enlarged urogenital hiatus, now known as antedate prolapse, and with prolapse surgery failure. Risk factors for levator injury are multifactorial and include forceps delivery, occiput posterior birth, older maternal age, long second stage of labor, and birthweight of >4000 g. Delivery with a vacuum device is associated with reduced levator damage. Other steps that might logically reduce injuries include manual rotation from occiput posterior to occiput anterior, slow gradual delivery, perineal massage or compresses, and early induction of labor, but these require study to document protection. In addition, teaching women to avoid pushing against a contracted levator muscle would likely decrease injury risk by decreasing tension on the vulnerable muscle origin. Providing care for women who have experienced difficult deliveries can be enhanced with early recognition, physical therapy, and attention to recovery. It is only right that women be made aware of these risks during pregnancy. Educating women on the long-term pelvic floor sequelae of childbirth should be performed antenatally so that they can be empowered to make informed decisions about management decisions during labor.
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Affiliation(s)
- John O L DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI.
| | - Mariana Masteling
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI
| | - Fernanda Pipitone
- Faculty of Medicine, Hospital das Clinicas of the University of São Paulo, São Paulo, Brazil
| | - Jennifer LaCross
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Sara Mastrovito
- Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - James A Ashton-Miller
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI
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Resta S, De Vito M, Patelli C, Lu JLA, Gabrielli G, Chiodo E, Mappa I, Rizzo G. Validation of an automated software (Smartpelvic™) in assessing hiatal area from three dimensional transperineal pelvic volumes of pregnant women: comparison with manual analysis. J Perinat Med 2024; 52:165-170. [PMID: 37938105 DOI: 10.1515/jpm-2023-0323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/02/2023] [Indexed: 11/09/2023]
Abstract
OBJECTIVES The aim of this investigation was to evaluate the agreement between a manual and an automatic technique in assessing levator hiatus area (LHA) during pregnancy from three-dimensional (3D) pelvic floor volumes obtained by trans-perineal ultrasound (TPUS). METHODS 3D volumes were acquired during rest, maximum pelvic floor contraction and Valsalva maneuver from 66 pregnant women. Manual selection of LHA and automatic software (Smart Pelvic™) were applied on TPUS volume starting from a C-plane view. To evaluate intra- and inter-observer variability measurements of LHA were performed twice by the same operator and once by a second sonographer. Reference hiatal contours obtained manually by the first operator were compared with the automated ones. Reproducibility was evaluated by intraclass correlation coefficients (ICC) and Bland-Altman plots. RESULTS LHA measurement, using automatic software, achieved excellent intra-observer and inter-observer reproducibility in pregnant women both at rest and after dynamic analysis (ICC>0.9). Further, an excellent agreement resulted between manual selection of the LHA and automatic imaging (ICC>0.9). The average time taken to obtain LHA manually was significantly longer when compared to the automatic analysis (p≤0.0001). CONCLUSIONS Smart pelvic software resulted from a reliable method for automatically measuring the LHA, showing high reproducibility and accuracy.
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Affiliation(s)
- Serena Resta
- Department of Obstetrics and Gynecology, Università di Roma Tor Vergata, Rome, Italy
| | - Marika De Vito
- Department of Obstetrics and Gynecology, Università di Roma Tor Vergata, Rome, Italy
| | - Chiara Patelli
- Department of Obstetrics and Gynecology, Università di Verona, Verona Italy
| | - Jia Li Angela Lu
- Department of Obstetrics and Gynecology, Università di Roma Tor Vergata, Rome, Italy
| | - Gianluca Gabrielli
- Department of Obstetrics and Gynecology, Università di Roma Tor Vergata, Rome, Italy
| | - Erika Chiodo
- Department of Obstetrics and Gynecology, Università di Roma Tor Vergata, Rome, Italy
| | - Ilenia Mappa
- Department of Obstetrics and Gynecology, Università di Roma Tor Vergata, Rome, Italy
| | - Giuseppe Rizzo
- Department of Obstetrics and Gynecology, Università di Roma Tor Vergata, Rome, Italy
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Youssef A. Time to standardise terminology in the ultrasound study of the pelvic floor in pregnant women. BJOG 2024. [PMID: 38221507 DOI: 10.1111/1471-0528.17765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/02/2024] [Indexed: 01/16/2024]
Affiliation(s)
- Aly Youssef
- Obstetric and Prenatal Medicine Unit, IRCCS Azienda Ospedaliero-Universitaria S.Orsola-Malpighi, Bologna, Italy
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Youssef A, Nedu B, Dapoto F, Brunelli E. Time to focus on the role of the pelvic floor in vaginal delivery. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:125-126. [PMID: 38165999 DOI: 10.1002/uog.27556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 11/11/2023] [Indexed: 01/04/2024]
Abstract
Linked article: This Correspondence comments on Preuss et al. Click here to view the article.
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Affiliation(s)
- A Youssef
- Obstetric and Prenatal Medicine Unit, IRCCS Azienda Ospedaliero-Universitaria Sant'Orsola-Malpighi, Bologna, Italy
| | - B Nedu
- Obstetric and Prenatal Medicine Unit, IRCCS Azienda Ospedaliero-Universitaria Sant'Orsola-Malpighi, Bologna, Italy
| | - F Dapoto
- Obstetric and Prenatal Medicine Unit, IRCCS Azienda Ospedaliero-Universitaria Sant'Orsola-Malpighi, Bologna, Italy
| | - E Brunelli
- Obstetric and Prenatal Medicine Unit, IRCCS Azienda Ospedaliero-Universitaria Sant'Orsola-Malpighi, Bologna, Italy
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Xodo S, Trombetta G, Morassutto C, Baccarini G, Celante L, Driul L, Londero AP. Does transperineal ultrasound predict the risk of perineal trauma in women with term pregnancy? A prospective observational study. Ultrasonography 2024; 43:47-56. [PMID: 38029735 PMCID: PMC10766888 DOI: 10.14366/usg.23045] [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: 03/15/2023] [Revised: 08/09/2023] [Accepted: 09/19/2023] [Indexed: 12/01/2023] Open
Abstract
PURPOSE This study was conducted to evaluate the prevalence of perineal trauma during childbirth and to assess the correlations of the pelvic floor dimensions and fetal head station with obstetric trauma in a prospectively recruited cohort of women. METHODS The study included women with a gestational age of at least 37 weeks, who were carrying a single fetus in a cephalic presentation. Transperineal ultrasound (TPU) was performed prior to the onset of labor or labor induction. The purpose was to measure the anteroposterior diameter (APD) of the levator ani muscle (LAM) and the angle of progression, at both rest and maximum Valsalva maneuver. The head-perineum distance was assessed only at rest. RESULTS A total of 296 women were included. Of the 253 women who delivered vaginally, 19% (48/253) experienced no perineal trauma, 18.2% (46/253) received an episiotomy during childbirth, 34.4% (87/253) sustained a first-degree laceration, 25.3% (64/253) had a second-degree laceration, and 3.2% had a third- or fourth-degree laceration (8/253). Women with episiotomy had a significantly shorter median APD under Valsalva than women without perineal trauma. Furthermore, women with LAM coactivation (identified by a negative difference between the APD at Valsalva and the APD at rest) were approximately three times more likely to undergo an operative vaginal delivery and over five times more likely to sustain a third- or fourth-degree tear during childbirth than women who exhibited normal relaxation of the LAM during the Valsalva maneuver. CONCLUSION TPU may predict the risk of perineal trauma in women with term pregnancy during childbirth.
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Affiliation(s)
- Serena Xodo
- Clinic of Gynecology and Obstetrics, University of Udine, Udine, Italy
| | - Giulia Trombetta
- Clinic of Gynecology and Obstetrics, University of Udine, Udine, Italy
| | - Caterina Morassutto
- SC Politiche del Farmaco, Dispositivi Medici e Protesica dell’Azienda Regionale di Coordinamento per la Salute, Udine, Italy
| | | | - Lisa Celante
- Clinic of Gynecology and Obstetrics, University of Udine, Udine, Italy
| | - Lorenza Driul
- Clinic of Gynecology and Obstetrics, University of Udine, Udine, Italy
- Department of Medical Area (DAME), University of Udine, Udine, Italy
| | - Ambrogio P Londero
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health, University of Genoa, Genova, Italy
- Obstetrics and Gynecology Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
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Kuczera A, Opala-Berdzik A, Malá J, Sodowski M, Chmielewska D. Comparison of First Childbirth Characteristics between Elite Judo Athletes and Non-Athletes: The Preliminary Retrospective Case-Control Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13218. [PMID: 36293804 PMCID: PMC9602800 DOI: 10.3390/ijerph192013218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 06/16/2023]
Abstract
It has been speculated that elite athletes are more likely to have obstetric interventions during labor and delivery. So far, the impact of many years of competitive sports participation on childbirth characteristics has not been well-established. This preliminary retrospective case-control study aimed to determine whether the first labors of elite judo competitors required obstetric interventions more frequently and were longer than those of non-athletes. The study comprised 32 parous women: 16 elite judo athletes and 16 non-athletes. Women were included if they had access to the following obstetric data (from their first childbirth hospital discharge reports and/or first child's health record books): induction and augmentation of labor, mode of delivery, the duration of labor and its second stage, episiotomy, perineal tear, and the neonate's Apgar score. Electronic surveys were completed concerning childbirth characteristics, level of "eliteness" (judo athletes), and recreational physical activity (non-athletes). The statistical analysis showed no significant between-group differences in any of the first childbirth outcomes under analysis. The preliminary results indicate elite judo practice before first pregnancy had no negative impact on the rates of labor induction and augmentation, delivery mode, duration of labor, the rates of episiotomy and perineal tear, and the neonate's Apgar score. Due to the small sample size, the conclusions should be considered with caution.
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Affiliation(s)
- Anna Kuczera
- Students Scientific Association on the Analysis of the Influence of Pregnancy on the Musculoskeletal System, Physiotherapy Faculty, The Jerzy Kukuczka Academy of Physical Education, 40-065 Katowice, Poland
| | - Agnieszka Opala-Berdzik
- Department of Physiotherapy in Internal Diseases, Institute of Physiotherapy and Health Sciences, The Jerzy Kukuczka Academy of Physical Education, 40-065 Katowice, Poland
| | - Jitka Malá
- Physiotherapy Department, Faculty of Physical Education and Sport, Charles University, 121 08 Prague, Czech Republic
| | - Marcin Sodowski
- Gynecology and Obstetrics Ward, City Hospital in Siemianowice Śląskie, 41-100 Siemianowice Slaskie, Poland
| | - Daria Chmielewska
- Electromyography and Pelvic Floor Muscles Laboratory, Department of Physical Medicine, Institute of Physiotherapy and Health Sciences, The Jerzy Kukuczka Academy of Physical Education, 40-065 Katowice, Poland
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Barca JA, Bravo C, Tizón SG, Aracil-Rodriguez R, Pina-Moreno JM, Cueto-Hernández I, Pintado-Recarte MP, Alvarez-Mon M, Ortega MA, De León-Luis JA. 3D Ultrasound in Pelvic Floor: Is It Useful as a Prognostic Tool in Type of Labor Development and Subsequent Pelvic Floor Diseases? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11479. [PMID: 36141753 PMCID: PMC9517123 DOI: 10.3390/ijerph191811479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/31/2022] [Accepted: 09/09/2022] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
- Juan A. Barca
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
| | - Coral Bravo
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
| | - Santiago García Tizón
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
| | - Rocío Aracil-Rodriguez
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
| | - Juan Manuel Pina-Moreno
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
| | - Ignacio Cueto-Hernández
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
| | - Maria P. Pintado-Recarte
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
| | - Melchor Alvarez-Mon
- Ramón y Cajal Institute of Healthcare Research (IRYCIS), 28034 Madrid, Spain
- Department of Medicine and Medical Specialties, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
- Immune System Diseases-Rheumatology, Oncology Service an Internal Medicine (CIBEREHD), University Hospital Príncipe de Asturias, 28801 Alcalá de Henares, Spain
| | - Miguel A. Ortega
- Ramón y Cajal Institute of Healthcare Research (IRYCIS), 28034 Madrid, Spain
- Department of Medicine and Medical Specialties, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain
| | - Juan A. De León-Luis
- Department of Public and Maternal and Child Health, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
- Health Research Institute Gregorio Marañón, 28009 Madrid, Spain
- Department of Obstetrics and Gynecology, University Hospital Gregorio Marañón, 28009 Madrid, Spain
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Youssef A, Brunelli E, Fiorentini M, Pilu G, El-Balat A. The correlation between levator ani co-activation and fetal head regression on maternal pushing at term. J Matern Fetal Neonatal Med 2022; 35:9654-9660. [PMID: 35282757 DOI: 10.1080/14767058.2022.2050363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To assess the correlation between fetal head regression and levator ani muscle (LAM) co-activation under Valsalva maneuver. STUDY DESIGN This study was a secondary analysis of a prospective cohort study on the association between the angle of progression (AoP) and labor outcome. We scanned a group of nulliparous women at term before the onset of labor at rest and under maximum Valsalva maneuver. In addition to the previously calculated AoP, in the present study, we measured the anteroposterior diameter of LAM hiatus (APD) on each ultrasound image. LAM co-activation was defined as APD at Valsalva less than that at rest, whereas fetal head regression was defined as AoP at Valsalva less than that at rest. We calculated the correlation between the two phenomena. Finally, we examined various labor outcomes according to the presence, absence, or co-existence of these two phenomena. RESULTS We included 469 women. A total of 129 (27.5%) women presented LAM co-activation while 50 (10.7%) showed head regression. Only 15 (3.2%) women showed simultaneous head regression and LAM co-activation. Women with coexisting LAM co-activation and head regression had the narrowest AoP at Valsalva in comparison with other study groups (p < .001). In addition, they had the highest risk of Cesarean delivery (40%) and longest first, second, and active second stage durations, although none of these reached statistical significance. CONCLUSION In nulliparous women at term before the onset of labor fetal head regression and LAM co-activation at Valsalva are two distinct phenomena that uncommonly coexist.
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Affiliation(s)
- Aly Youssef
- Obstetric Unit, Department of Medical and Surgical Sciences, IRCCS Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Elena Brunelli
- Obstetric Unit, Department of Medical and Surgical Sciences, IRCCS Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Marta Fiorentini
- Obstetric Unit, Department of Medical and Surgical Sciences, IRCCS Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Gianluigi Pilu
- Obstetric Unit, Department of Medical and Surgical Sciences, IRCCS Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Ahmed El-Balat
- Department of Obstetrics and Gynecology, Goethe University Frankfurt, Frankfurt, Germany
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