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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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Regendova A, Samesova A, Zapletalova K, Horejskova S, Svata Z, Hrdouskova M, Zapletal J, Krofta L, Hajkova Hympanova L. Comparison of Cross-Sectional Area of Pubovisceral Muscle in Nulliparous and Primiparous Women. Int Urogynecol J 2024; 35:841-848. [PMID: 38376549 PMCID: PMC11052823 DOI: 10.1007/s00192-024-05733-3] [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: 03/30/2023] [Accepted: 01/02/2024] [Indexed: 02/21/2024]
Abstract
INTRODUCTION AND HYPOTHESIS The main risk factor for pelvic floor disorders is vaginal delivery, which may cause levator ani muscle (LAM) injury and denervation. LAM includes pubovisceral muscle (PVM, pubococcygeus), puborectalis muscle (PRM), and iliococcygeus muscle. We hypothesize that primiparous women with low pelvic floor muscle contraction have a reduced PVM cross-sectional area (CSA) compared to nulliparous women. METHODS (SAMPLE SIZE AND STATISTICAL APPROACHES) This single-centre prospective observational study compared healthy nulliparous (n = 40) to primiparous (n = 40) women after vaginal delivery without LAM avulsion and Oxford score ≤ 3. Demographics, questionnaires (ICIQ-UI-SF, OAB-Q-SF, PISQ-12), POP-Q, Oxford score, ultrasound measurements (minimal anteroposterior and lateral diameters, hiatal area, PRM thickness, levator-urethra gap) and magnetic resonance imaging (MRI)-PVM CSA were evaluated. Normality was tested, and an appropriate test was used to compare the groups. Power calculation suggested 40 participants per group. RESULTS The primiparous group was older, had a higher BMI, and their hiatal area on ultrasound at contraction was larger compared to the nulliparous group. The CSA of the left-sided PVM (1.15 ± 0.50 cm2) was larger compared to the right side (1.03 ± 0.50 cm2), p = 0.02 in nulliparous women. The PVM CSA of primiparous women with low Oxford score was reduced compared to nulliparous (0.87 ± 0.30 versus 1.09 ± 0.50 cm2, p = 0.006). The intra-rater reliability for PVM CSA had an ICC of 0.90 and inter-rater ICC of 0.77. CONCLUSIONS Primiparous women after vaginal delivery with low pelvic floor contraction force had reduced PVM CSA on MRI images compared to nulliparous women.
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Affiliation(s)
- Alexandra Regendova
- Charles University, Third Faculty of Medicine, Institute for the Care of Mother and Child, Prague, Czech Republic
| | - Adela Samesova
- Charles University, Third Faculty of Medicine, Institute for the Care of Mother and Child, Prague, Czech Republic
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Katerina Zapletalova
- Charles University, Third Faculty of Medicine, Institute for the Care of Mother and Child, Prague, Czech Republic
| | - Sabina Horejskova
- Charles University, Third Faculty of Medicine, Institute for the Care of Mother and Child, Prague, Czech Republic
| | | | - Monika Hrdouskova
- Charles University, Third Faculty of Medicine, Institute for the Care of Mother and Child, Prague, Czech Republic
| | - Jan Zapletal
- Department of Obstetrics and Gynaecology, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Ladislav Krofta
- Charles University, Third Faculty of Medicine, Institute for the Care of Mother and Child, Prague, Czech Republic
| | - Lucie Hajkova Hympanova
- Charles University, Third Faculty of Medicine, Institute for the Care of Mother and Child, Prague, Czech Republic.
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Romero R, Sabo Romero V, Kalache KD, Stone J. Parturition at term: induction, second and third stages of labor, and optimal management of life-threatening complications-hemorrhage, infection, and uterine rupture. Am J Obstet Gynecol 2024; 230:S653-S661. [PMID: 38462251 DOI: 10.1016/j.ajog.2024.02.005] [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] [Indexed: 03/12/2024]
Abstract
Childbirth is a defining moment in anyone's life, and it occurs 140 million times per year. Largely a physiologic process, parturition does come with risks; one mother dies every two minutes. These deaths occur mostly among healthy women, and many are considered preventable. For each death, 20 to 30 mothers experience complications that compromise their short- and long-term health. The risk of birth extends to the newborn, and, in 2020, 2.4 million neonates died, 25% in the first day of life. Hence, intrapartum care is an important priority for society. The American Journal of Obstetrics & Gynecology has devoted two special Supplements in 2023 and 2024 to the clinical aspects of labor at term. This article describes the content of the Supplements and highlights new developments in the induction of labor (a comparison of methods, definition of failed induction, new pharmacologic agents), management of the second stage, the value of intrapartum sonography, new concepts on soft tissue dystocia, optimal care during the third stage, and common complications that account for maternal death, such as infection, hemorrhage, and uterine rupture. All articles are available to subscribers and non-subscribers and have supporting video content to enhance dissemination and improve intrapartum care. Our hope is that no mother suffers because of lack of information.
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Affiliation(s)
- Roberto Romero
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI.
| | | | - Karim D Kalache
- Department of Clinical Obstetrics and Gynecology, Weill Cornell Medical College-Qatar Division, Doha, Qatar; Division of Maternal-Fetal Medicine, Women's Services, Sidra Medicine, Doha, Qatar
| | - Joanne Stone
- Department of Obstetrics and Gynecology, Icahn School of Medicine at Mount Sinai, New York, NY
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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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Packet B, Page AS, Cattani L, Bosteels J, Deprest J, Richter J. Predictive factors for obstetric anal sphincter injury in primiparous women: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:486-496. [PMID: 37329513 DOI: 10.1002/uog.26292] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/05/2023] [Accepted: 06/05/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVES The primary objective was to perform a systematic review of predictive factors for obstetric anal sphincter injury (OASI) occurrence at first vaginal delivery, with the diagnosis made by ultrasound (US-OASI). The secondary objective was to report on incidence rates of sonographic anal sphincter (AS) trauma, including trauma that was not clinically reported at childbirth, among the studies providing data for our primary objective. METHODS We conducted a systematic search of MEDLINE, EMBASE, Web of Science, CINAHL, The Cochrane Library and ClinicalTrials.gov databases. Both observational cohort studies and interventional trials were eligible for inclusion. Study eligibility was assessed independently by two authors. Random-effects meta-analyses were performed to pool effect estimates from studies reporting on similar predictive factors. Summary odds ratio (OR) or mean difference (MD) is reported with 95% CI. Heterogeneity was assessed using the I2 statistic. Methodological quality was assessed using the Quality in Prognosis Studies tool. RESULTS A total of 2805 records were screened and 21 met the inclusion criteria (16 prospective cohort studies, three retrospective cohort studies and two interventional non-randomized trials). Increasing gestational age at delivery (MD, 0.34 (95% CI, 0.04-0.64) weeks), shorter antepartum perineal body length (MD, -0.60 (95% CI, -1.09 to -0.11) cm), labor augmentation (OR, 1.81 (95% CI, 1.21-2.71)), instrumental delivery (OR, 2.13 (95% CI, 1.13-4.01)), in particular forceps extraction (OR, 3.56 (95% CI, 1.31-9.67)), shoulder dystocia (OR, 12.07 (95% CI, 1.06-137.60)), episiotomy use (OR, 1.85 (95% CI, 1.11-3.06)) and shorter episiotomy length (MD, -0.40 (95% CI, -0.75 to -0.05) cm) were associated with US-OASI. When pooling incidence rates, 26% (95% CI, 20-32%) of women who had a first vaginal delivery had US-OASI (20 studies; I2 = 88%). In studies reporting on both clinical and US-OASI rates, 20% (95% CI, 14-28%) of women had AS trauma on ultrasound that was not reported clinically at childbirth (16 studies; I2 = 90%). No differences were found in maternal age, body mass index, weight, subpubic arch angle, induction of labor, epidural analgesia, episiotomy angle, duration of first/second/active-second stages of labor, vacuum extraction, neonatal birth weight or head circumference between cases with and those without US-OASI. Antenatal perineal massage and use of an intrapartum pelvic floor muscle dilator did not affect the odds of US-OASI. Most (81%) studies were judged to be at high risk of bias in at least one domain and only four (19%) studies had an overall low risk of bias. CONCLUSION Given the ultrasound evidence of structural damage to the AS in 26% of women following a first vaginal delivery, clinicians should have a low threshold of suspicion for the condition. This systematic review identified several predictive factors for this. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- B Packet
- Department of Development and Regeneration, Unit of Woman and Child, Catholic University of Leuven (KU Leuven), Leuven, Belgium
| | - A-S Page
- Department of Development and Regeneration, Unit of Urogenital, Abdominal and Plastic Surgery, Catholic University of Leuven (KU Leuven), Leuven, Belgium
| | - L Cattani
- Department of Development and Regeneration, Unit of Urogenital, Abdominal and Plastic Surgery, Catholic University of Leuven (KU Leuven), Leuven, Belgium
| | - J Bosteels
- Department of Development and Regeneration, Unit of Urogenital, Abdominal and Plastic Surgery, Catholic University of Leuven (KU Leuven), Leuven, Belgium
- Department of Obstetrics and Gynaecology, Imelda Hospital, Bonheiden, Belgium
| | - J Deprest
- Department of Development and Regeneration, Unit of Urogenital, Abdominal and Plastic Surgery, Catholic University of Leuven (KU Leuven), Leuven, Belgium
- Research Department of Maternal-Fetal Medicine, Institute for Women's Health, University College London, London, UK
| | - J Richter
- Department of Development and Regeneration, Unit of Woman and Child, Catholic University of Leuven (KU Leuven), Leuven, Belgium
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