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Siafarikas F, Stær-Jensen J, Reimers C, Bø K, Ellström Engh M. Levator ani muscle avulsion and subsequent vaginal delivery: 8-year longitudinal follow-up. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 64:112-119. [PMID: 38285441 DOI: 10.1002/uog.27599] [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: 07/13/2023] [Revised: 01/16/2024] [Accepted: 01/19/2024] [Indexed: 01/30/2024]
Abstract
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.
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Affiliation(s)
- F Siafarikas
- University of Oslo, Faculty of Medicine, Division Akershus University Hospital, Oslo, Norway
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway
| | - J Stær-Jensen
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway
| | - C Reimers
- Department of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway
| | - K Bø
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway
- Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - M Ellström Engh
- University of Oslo, Faculty of Medicine, Division Akershus University Hospital, Oslo, Norway
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway
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Eggebø TM, Volløyhaug I. The pelvic floor during pregnancy and delivery: Can pelvic floor trauma and disorders be prevented? Acta Obstet Gynecol Scand 2024; 103:1012-1014. [PMID: 38764284 PMCID: PMC11103126 DOI: 10.1111/aogs.14875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 04/28/2024] [Accepted: 04/29/2024] [Indexed: 05/21/2024]
Affiliation(s)
- Torbjørn Moe Eggebø
- Department of Clinical and Molecular MedicineNorwegian University of Science and TechnologyTrondheimNorway
- Department of Obstetrics and GynecologyStavanger University HospitalStavangerNorway
| | - Ingrid Volløyhaug
- Department of Clinical and Molecular MedicineNorwegian University of Science and TechnologyTrondheimNorway
- Department of Obstetrics and GynecologyTrondheim University HospitalTrondheimNorway
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Yang Z, Zhou L, Yang L, He H. Restoration of bladder neck activity and levator hiatus dimensions in Asian primipara: a prospective study. J OBSTET GYNAECOL 2023; 43:2173564. [PMID: 36752287 DOI: 10.1080/01443615.2023.2173564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Pelvic floor muscle training (PFMT) reduces the symptoms in women with pelvic floor dysfunction (PFD); however, the optimal initial timing for secondary prevention of PFD by PFMT is not clear. To identify the optimal timing in Asian primiparas with vaginal delivery, bladder neck descent (BND), levator hiatus areas, and levator hiatus distensibility and contractility were assessed in 26 nulliparous women at 36 weeks of gestation and at 2, 4, 6, and 12 weeks postpartum. We found that BND increased significantly from 2 weeks onwards until 6 weeks postpartum (p = 0.004); the levator hiatus area at rest and contraction both showed the largest value at 2 weeks postpartum (p = 0.005 and p < 0.005 respectively), followed by a continuous decrease; the hiatus area during Valsalva manoeuvre, and the levator hiatus distensibility and contractility showed the lowest value at 2 weeks postpartum, followed by a continuous increase; the changes in BND showed no correlation with the changes in distensibility or hiatus area during Valsalva manoeuvre (p = 0.073 and 0.590 respectively). In Asian primiparas with vaginal delivery, the recovery of levator hiatus and bladder neck mobility begins at 2 and 6 weeks, respectively. This information could be useful in defining the best time to begin PFMT for secondary prevention of postpartum PFD in Asian primiparous women.IMPACT STATEMENTWhat is already known on this subject? Pelvic floor muscle training (PFMT) helps to reduce symptoms of pelvic floor dysfunction (PFD), however, there are no clear time strategies for the secondary prevention of PFD by PFMT in Asian primiparas with vaginal delivery.What do the results of this study add? This study was the first longitudinal study in Asian primipara to investigate the natural regeneration of pelvic floor functions in the early postpartum period by intensively monitoring the bladder neck mobility and levator hiatus dimensions at multiple time points. We found that bladder neck descent (BND) increased significantly from 2 weeks onwards until 6 weeks postpartum; the levator hiatus area at rest and contraction both showed the largest value at 2 weeks postpartum, followed by a continuous decrease; the hiatus area during Valsalva manoeuvre, and the levator hiatus distensibility and contractility showed the lowest value at 2 weeks postpartum, followed by a continuous increase; the changes in BND showed no correlation with the changes in distensibility or hiatus area during Valsalva manoeuvre.What are the implications of these findings for clinical practice and/or further research? Our study suggested that in Asian primipara, the recovery of bladder neck mobility after vaginal delivery begins at 6 weeks postpartum, while the levator hiatus muscle begins to recover within the first 2 weeks postpartum. Therefore, it could be useful in deciding the best time to start PFMT for secondary prevention of postpartum PFD in Asian primiparous women.
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Affiliation(s)
- Zexuan Yang
- Department of Ultrasound, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, The People's Republic of China (PRC)
| | - Liuying Zhou
- Department of Ultrasound, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, The People's Republic of China (PRC)
| | - Liwen Yang
- Department of Ultrasound, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, The People's Republic of China (PRC)
| | - Hui He
- Department of Ultrasound, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, The People's Republic of China (PRC)
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Eggebø TM, Benediktsdottir S, Hjartardottir H, Salvesen KÅ, Volløyhaug I. Ultrasound examination of the pelvic floor during active labor: A longitudinal cohort study. Acta Obstet Gynecol Scand 2023; 102:1203-1209. [PMID: 37417688 PMCID: PMC10407019 DOI: 10.1111/aogs.14620] [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: 02/13/2023] [Revised: 05/09/2023] [Accepted: 06/11/2023] [Indexed: 07/08/2023]
Abstract
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.
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Affiliation(s)
- Torbjørn M. Eggebø
- National Center for Fetal MedicineTrondheim University Hospital (St. Olavs Hospital)TrondheimNorway
- Institute of Clinical and Molecular MedicineNorwegian University of Science and TechnologyTrondheimNorway
- Department of Obstetrics and GynecologyStavanger University HospitalStavangerNorway
| | | | - Hulda Hjartardottir
- Department of Obstetrics and GynecologyLandspitali University HospitalReykjavikIceland
| | - Kjell Å. Salvesen
- National Center for Fetal MedicineTrondheim University Hospital (St. Olavs Hospital)TrondheimNorway
- Institute of Clinical and Molecular MedicineNorwegian University of Science and TechnologyTrondheimNorway
| | - Ingrid Volløyhaug
- Institute of Clinical and Molecular MedicineNorwegian University of Science and TechnologyTrondheimNorway
- Department of Obstetrics and GynecologyTrondheim University Hospital (St. Olavs Hospital)TrondheimNorway
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Martínez Franco E, Molinet Coll C, Altimira Queral L, Balsells S, Carreras M, Parés D. Factors involved in changes in the levator ani during pregnancy. Int Urogynecol J 2023; 34:1933-1938. [PMID: 36805781 DOI: 10.1007/s00192-023-05487-4] [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: 11/29/2022] [Accepted: 01/24/2023] [Indexed: 02/23/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Levator ani muscle (LAM) dimensions increase during pregnancy to allow the delivery of the fetus. The objective was to investigate which factors are involved in LAM modifications during pregnancy. METHODS A prospective longitudinal observational study was conducted between July 2015 and March 2018. Ninety-nine nulliparous pregnant women were included. Data on the physical examination, 4D transperineal ultrasound and hormonal concentrations (progesterone, oestradiol and relaxin) were collected during the first and third trimesters. RESULTS We found higher hiatal dimensions at the beginning of pregnancy than in other studies with nonpregnant women. Increases in the levator ani hiatal (LH) dimensions were observed at contraction (1.01 ±1.96 cm2), rest (0.82 ± 2.51 cm2) and on Valsalva (2.36 ± 3.64 cm2) throughout pregnancy. The distensibility in the third trimester was higher than in the first trimester (5.79 vs 4.24 cm2; p=0); however, the contractility was lower (-3.32 vs -3.5 cm2; p=0.04). Women with lower scores on the Modified Oxford Grading Scale in the third trimester presented with lower contractility in the LAM. A larger LH at the end of pregnancy was associated with age and body mass index. Eleven women developed ballooning during pregnancy; in these women, relaxin was higher in both trimesters than in women without ballooning, but these results were not statistically significant. The linear models to predict third-trimester Valsalva LH, distensibility and contractility were not conclusive and did not show any factors to predict LAM modifications during pregnancy. CONCLUSIONS Hormones could play a role in modifying the muscle properties of LAM from the beginning of pregnancy, but we did not find an association between LAM measurements and hormone concentration in this study.
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Affiliation(s)
- Eva Martínez Franco
- Gynecology and Obstetrics Department, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Universitat de Barcelona (UB), C/Antoni Pujadas num 42, 08830 Sant Boi de Llobregat, Barcelona, Spain.
| | - Cristina Molinet Coll
- Gynecology and Obstetrics Department, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Universitat de Barcelona (UB), C/Antoni Pujadas num 42, 08830 Sant Boi de Llobregat, Barcelona, Spain
| | - Laura Altimira Queral
- Chemistry Laboratory, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Universitat de Barcelona (UB), Barcelona, Spain
| | - Sol Balsells
- Statistical Advising Service, Fundació Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain
| | - Manel Carreras
- Gynecology and Obstetrics Department, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Universitat de Barcelona (UB), C/Antoni Pujadas num 42, 08830 Sant Boi de Llobregat, Barcelona, Spain
| | - David Parés
- Colorectal Surgery Unit, Department of Surgery, Hospital Germans Trias i Pujol, Badalona, Universitat Autònoma de Barcelona, Barcelona, Spain
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Hilde G, Stær-Jensen J, Siafarikas F, Engh ME, Bø K. Postpartum pelvic floor muscle training, levator ani avulsion and levator hiatus area: a randomized trial. Int Urogynecol J 2023; 34:413-423. [PMID: 36418566 PMCID: PMC9870957 DOI: 10.1007/s00192-022-05406-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 10/18/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Vaginal delivery may lead to tearing of the levator ani (LA) muscle from its bony insertions (complete LA avulsion) and increased levator hiatus (LH) area, both risk factors for pelvic floor dysfunctions. Early active rehabilitation is standard treatment after musculo-skeletal injury. We hypothesized that pelvic floor muscle training (PFMT) early postpartum would reduce the presence of LA avulsions and reduce LH area. METHODS We carried out a planned secondary analysis from a randomized controlled study. Primiparous women (n=175) giving birth vaginally were included 6 weeks postpartum, stratified on complete LA avulsion, and thereafter randomized to PFMT or control. The training participants (n=87) attended a supervised PFMT class once a week and performed home-based PFMT daily for 16 weeks. The control participants (n=88) received no intervention. Presence of complete LA avulsion, LH area at rest, maximal contraction, and maximal Valsalva maneuver were assessed by transperineal ultrasound. Between-group comparisons were analyzed by analysis of covariance for continuous data, and relative risk (RR) for categorical data. RESULTS Six months postpartum, the number of women who had complete LA avulsion was reduced from 27 to 14 within the PFMT group (44% reduction) and from 28 to 17 within the control group (39% reduction). The between-group difference was not significant, RR 0.85 (95% CI 0.53 to 1.37). Further, no significant between-group differences were found for LH area at rest, during contraction, or Valsalva. CONCLUSIONS Supervised PFMT class combined with home exercise early postpartum did not reduce the presence of complete LA avulsion or LH area more than natural remission.
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Affiliation(s)
- Gunvor Hilde
- Department of Rehabilitation Science and Health Technology, Faculty of Health Sciences, OsloMet – Oslo Metropolitan University, Pilestredet, P.O. Box 4, St. Olavs plass, NO-0130 Oslo, Norway
| | - Jette Stær-Jensen
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway
| | - Franziska Siafarikas
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway ,Division Akershus University Hospital, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Marie Ellström Engh
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway ,Division Akershus University Hospital, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Kari Bø
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway ,Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
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Bø K, Næss K, Stær-Jensen J, Siafarikas F, Ellström Engh M, Hilde G. Recovery of pelvic floor muscle strength and endurance 6 and 12 months postpartum in primiparous women-a prospective cohort study. Int Urogynecol J 2022; 33:3455-3464. [PMID: 36048249 PMCID: PMC9666345 DOI: 10.1007/s00192-022-05334-y] [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: 06/30/2022] [Accepted: 08/04/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION AND HYPOTHESIS To date there has been scant knowledge on the natural recovery of the pelvic floor muscles (PFMs) after childbirth. The aims of the present study were to investigate whether PFM variables at 6 and 12 months postpartum had returned to mid-pregnancy levels and assess risk factors for reduced recovery at 12 months postpartum. METHODS This was a prospective cohort study following 235 nulliparous pregnant women from mid-pregnancy to 12 months postpartum. Vaginal resting pressure (VRP), PFM strength and endurance were assessed by manometry at 22 weeks, 6 and 12 months postpartum. Multiple linear regression was used to address factors influencing PFM variables beyond birth mode. RESULTS Cesarean section was protective for change in PFM variables. From mid-pregnancy to 12 months postpartum there was a 20% reduction in VRP (p<0.001) and a 7.5 % reduction in PFM strength (p=0.007), and an increase of 9% in PFM endurance (p=0.002) in the normal vaginal birth. The instrumental vaginal group had a decline in VRP of 21% (p<0.001) and PFM strength of 15% (p=0.011), but no significant change in PFM endurance. Higher BMI at 12 months postpartum, longer second stage of labor, and major tears of the levator ani muscle had a negative influence on the PFM recovery beyond delivery mode. CONCLUSIONS At 12 months postpartum following vaginal delivery, the PFMs are not fully recovered compared with mid-pregnancy values. More follow-up physical therapy may be warranted in the postpartum period, especially for women with complicated vaginal births and higher BMI.
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Affiliation(s)
- Kari Bø
- Department of Sports Medicine, Norwegian School of Sport Sciences, PO Box 4014, Ullevål stadion, 0806, Oslo, Norway. .,Department of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, Norway.
| | - Karoline Næss
- Department of Health, Care and Welfare, Ullensaker municipality, Ullensaker, Norway.,Department of Physiotherapy, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, Oslo, Norway
| | - Jette Stær-Jensen
- Department of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, Norway
| | - Franziska Siafarikas
- Department of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, Norway.,Faculty Division Akershus University Hospital, University of Oslo, Oslo, Norway
| | - Marie Ellström Engh
- Department of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, Norway.,Faculty Division Akershus University Hospital, University of Oslo, Oslo, Norway
| | - Gunvor Hilde
- Department of Physiotherapy, Faculty of Health Sciences, OsloMet - Oslo Metropolitan University, Oslo, Norway
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Halle TK, Benth JŠ, Stær-Jensen J, Reimers C, Bø K, Ellström Engh M, Siafarikas F. Pelvic floor symptoms from first pregnancy up to 8 years after the first delivery: a longitudinal study. Am J Obstet Gynecol 2022; 227:613.e1-613.e15. [PMID: 35724758 DOI: 10.1016/j.ajog.2022.06.020] [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: 02/02/2022] [Revised: 05/23/2022] [Accepted: 06/08/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Despite the strong association between vaginal childbirth and pelvic floor dysfunction, genetic factors, pregnancy, advancing age, and lifestyle also play a role. The pelvic floor undergoes substantial changes during pregnancy which may contribute to pelvic floor dysfunction. On the other hand, these changes may be favorable to allow for vaginal delivery. However, there is a lack of studies assessing pelvic floor symptoms over time according to delivery mode, which includes women prior to delivery. OBJECTIVE The aim of this study was to describe urinary incontinence, vaginal symptoms, and bowel control symptoms from 21 weeks of gestation in the first pregnancy and up to 8 years after the first delivery, stratified by delivery mode. STUDY DESIGN This is a longitudinal observational cohort study. 300 nulliparous women were recruited during their first pregnancy. Pelvic floor symptoms were assessed at 21 and 37 weeks of gestation, and 6 weeks, 6 months, 12 months and 8 years after first delivery using the International Consultation on Incontinence Questionnaire (ICIQ) modules: the urinary incontinence sum score; the weighted vaginal symptom sum score; the vaginal-associated quality of life score; the bowel control sum score; and the bowel-associated quality of life sum score. Delivery mode at first delivery defined delivery groups as: normal vaginal, operative vaginal and cesarean delivery. A linear mixed model analysis was used to assess symptom scores over time and to assess the differences in symptom scores between the delivery groups. RESULTS Of the 300 women included in the study, of which 193 attended the 8-year follow-up. Pelvic floor symptoms differed in women with vaginal and cesarean delivery. The symptom scores showed a non-linear statistically significant trend. In women, who delivered vaginally, there was an increase of urinary incontinence and vaginal symptom scores already during pregnancy. In women, who later delivered by cesarean, there was a decrease of symptoms scores during pregnancy, and overall lower symptom scores compared to women with vaginal delivery until 12 months after first delivery. Pelvic floor symptoms scores increased from 12 months to 8 years after the first delivery and exceeded pregnancy levels in all delivery groups, however overall symptom scores were low. Differences between delivery groups were not statistically significant. CONCLUSION Pelvic floor symptoms differed in women with vaginal and cesarean delivery from the first pregnancy up to 8 years after the first delivery. These differences were recognizable already prior to first delivery.
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Affiliation(s)
- Tuva Kristine Halle
- University of Oslo, Faculty of Medicine, Division Akershus University Hospital, Oslo, Norway; Akershus University Hospital, Department of Obstetrics and Gynecology, Lørenskog, Norway
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, Campus Ahus, University of Oslo; Health Services Research Unit, Akershus University Hospital, Norway
| | - Jette Stær-Jensen
- Akershus University Hospital, Department of Obstetrics and Gynecology, Lørenskog, Norway
| | - Cathrine Reimers
- Oslo University Hospital, Department of Obstetrics and Gynecology, Oslo, Norway
| | - Kari Bø
- Akershus University Hospital, Department of Obstetrics and Gynecology, Lørenskog, Norway; Norwegian School of Sport Sciences, Department of Sports Medicine, Oslo, Norway
| | - Marie Ellström Engh
- University of Oslo, Faculty of Medicine, Division Akershus University Hospital, Oslo, Norway; Akershus University Hospital, Department of Obstetrics and Gynecology, Lørenskog, Norway
| | - Franziska Siafarikas
- University of Oslo, Faculty of Medicine, Division Akershus University Hospital, Oslo, Norway; Akershus University Hospital, Department of Obstetrics and Gynecology, Lørenskog, Norway
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Pinheiro FA, Sartorão Filho CI, Prudencio CB, Nunes SK, Pascon T, Hallur RLS, Takano L, Enriquez EMA, Catinelli BB, Carr AM, Junginger B, Rudge MVC, Barbosa AMP. Pelvic floor muscle dysfunction at 3D transperineal ultrasound in maternal exposure to gestational diabetes mellitus: A prospective cohort study during pregnancy. Neurourol Urodyn 2022; 41:1127-1138. [PMID: 35419878 DOI: 10.1002/nau.24927] [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] [Received: 06/21/2021] [Revised: 01/31/2022] [Accepted: 03/15/2022] [Indexed: 11/12/2022]
Abstract
AIM This study aimed to assess, for the first time, the dynamic morphometry of pelvic floor muscles (PFM) using three-dimensional transperineal ultrasound (3D-TPUS) and its progression at two-time points of gestation between women with and without gestational diabetes mellitus (GDM), and whether the PFM dysfunction is connected to GDM. METHODS The study comprised 83 consecutive pregnant women with (n = 38) and without (n = 45) GDM screened at 24-30 and 38-40 weeks of gestation. 3D-TPUS and a mobility test were used to quantify PFM dynamic morphometry during maximum contraction and the Valsalva maneuver. RESULTS When compared to the control group, GDM women had no significant variations in all levator hiatal dimensions at 24-30 weeks of gestation. Meanwhile, women with GDM experienced an increase in levator hiatal area (LHa) (p < 0.000) during PFM contraction and enlargement in LHa (p < 0.001) during Valsalva maneuver (p = 0.010) at 38-40 weeks of gestation. As a result, the mobility index among GDM women had a lower value (p = 0.000). The dynamic morphometry development of PFM in GDM women at two stages during pregnancy revealed a substantial decrease (p = 0.000) in all LHa dimensions of contraction, distension, and mobility. CONCLUSIONS Using 3D-TPUS, we found that GDM women had a specific pattern of PFM functional changes in the third trimester of pregnancy. These initial findings revealed alterations in PFM functionality, such as decreased contractility, distensibility, or mobility. This dysfunctional PFM could contribute to the long-term development of pelvic floor dysfunction years after a GDM pregnancy.
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Affiliation(s)
- Fabiane A Pinheiro
- Postgraduate Program on Tocogynecology, Botucatu Medical School (FMB), São Paulo State University (UNESP), Botucatu, São Paulo State, Brazil
| | - Carlos I Sartorão Filho
- Postgraduate Program on Tocogynecology, Botucatu Medical School (FMB), São Paulo State University (UNESP), Botucatu, São Paulo State, Brazil.,Department of Medical Health, Medical School, Fundação Educacional do Município de Assis (FEMA, Assis Municipality Educational Foundation (FEMA), Assis, São Paulo State, Brazil
| | - Caroline B Prudencio
- Postgraduate Program on Tocogynecology, Botucatu Medical School (FMB), São Paulo State University (UNESP), Botucatu, São Paulo State, Brazil
| | - Sthefanie K Nunes
- Postgraduate Program on Tocogynecology, Botucatu Medical School (FMB), São Paulo State University (UNESP), Botucatu, São Paulo State, Brazil
| | - Tawana Pascon
- Postgraduate Program on Tocogynecology, Botucatu Medical School (FMB), São Paulo State University (UNESP), Botucatu, São Paulo State, Brazil
| | - Ragavendra L S Hallur
- Postgraduate Program on Tocogynecology, Botucatu Medical School (FMB), São Paulo State University (UNESP), Botucatu, São Paulo State, Brazil.,Center for Biotechnology, Pravara Institute of Medical Sciences (Deemed to be University), Loni, Maharashtra, India
| | - Luis Takano
- Postgraduate Program on Tocogynecology, Botucatu Medical School (FMB), São Paulo State University (UNESP), Botucatu, São Paulo State, Brazil.,Department of Medical Health, Medical School, Fundação Educacional do Município de Assis (FEMA, Assis Municipality Educational Foundation (FEMA), Assis, São Paulo State, Brazil
| | - Eusébio M A Enriquez
- Postgraduate Program on Tocogynecology, Botucatu Medical School (FMB), São Paulo State University (UNESP), Botucatu, São Paulo State, Brazil
| | - Bruna B Catinelli
- Postgraduate Program on Tocogynecology, Botucatu Medical School (FMB), São Paulo State University (UNESP), Botucatu, São Paulo State, Brazil
| | - Aline M Carr
- Postgraduate Program on Tocogynecology, Botucatu Medical School (FMB), São Paulo State University (UNESP), Botucatu, São Paulo State, Brazil
| | - Baerbel Junginger
- Department of Gynecology, Pelvic Floor Center Charitè, Charitè University Hospital, Berlin, Germany
| | - Marilza V C Rudge
- Postgraduate Program on Tocogynecology, Botucatu Medical School (FMB), São Paulo State University (UNESP), Botucatu, São Paulo State, Brazil
| | - Angélica M P Barbosa
- Postgraduate Program on Tocogynecology, Botucatu Medical School (FMB), São Paulo State University (UNESP), Botucatu, São Paulo State, Brazil.,Department of Physiotherapy and Occupational Therapy, School of Philosophy and Sciences, São Paulo State University (UNESP), Marilia, São Paulo State, Brazil
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Lakovschek I, Trutnovsky G, Obermayer‐Pietsch B, Gold D. Longitudinal Study of Pelvic Floor Characteristics Before, During, and After Pregnancy in Nulliparous Women. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:147-155. [PMID: 33682186 PMCID: PMC9291937 DOI: 10.1002/jum.15689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 02/18/2021] [Accepted: 02/21/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To investigate the changes in the pelvic floor before, during, and after pregnancy in the same collective of nulliparous women. METHODS In a prospective observational pilot study between April 2015 and June 2019 in nulliparous women with planned pregnancy, we used the pelvic organ prolapse quantification (POP-Q) system; a 2-dimensional (2D) sonography to investigate the bladder neck, cervix, and anorectal junction positions; and a 3D/4D sonography to measure the hiatus of the levator ani muscle (LH area) during Valsalva maneuver. Five visits were planned: 1 before, 3 during, and 1 visit after pregnancy. RESULTS Twenty-four women participated in the study. We achieved a minimum of 2 visit measurements from 10 women who became pregnant. The LH area decreased during the first trimester and then increased until the third trimester. Postpartum, the LH area reached the prepregnancy state. We observed changes in the bladder neck mobility, bladder neck position, cervix, and anorectal junction from the first trimester. Postpartum, the bladder neck mobility was higher, and the position of the bladder neck and anorectal junction was lower than before pregnancy. We observed no remarkable changes in the POP-Q state during pregnancy. CONCLUSION This was the first study to investigate pelvic floor characteristics in the same collective before, during, and after pregnancy. We observed pelvic floor changes from the prepregnancy state to the first trimester to postpartum. The study results need to be confirmed in a larger study.
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Affiliation(s)
| | - Gerda Trutnovsky
- Department of Obstetrics and GynecologyMedical University of GrazGrazAustria
| | - Barbara Obermayer‐Pietsch
- Department of Internal Medicine, Division of Endocrinology and DiabetologyMedical University of GrazGrazAustria
| | - Daniela Gold
- Department of Obstetrics and GynecologyMedical University of GrazGrazAustria
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Pelvic floor function and morphological abnormalities in primiparas with postpartum symptomatic stress urinary incontinence based on the type of delivery: a 1:1 matched case-control study. Int Urogynecol J 2021; 33:245-251. [PMID: 34028579 DOI: 10.1007/s00192-021-04816-9] [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: 12/28/2020] [Accepted: 04/18/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The aim of this study was to assess pelvic floor muscle (PFM) morphology and function in primiparas with postpartum symptomatic SUI after different types of delivery. METHODS Retrospective analyses were carried out with individuals with postpartum symptomatic stress urinary incontinence (SUI). Among the women screened in our center from January 2018 to December 2019, participants were divided into elective cesarean section (eCS) and spontaneous vaginal delivery (sVD) groups, while being matched 1:1 on age (±5 years), body mass index (BMI; ±0.5 kg/m2), neonatal birth weight (±300 g), gestational age (±1 week), degree of pelvic organ prolapse quantification (POP-Q), International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) degree, Incontinence Impact Questionnaire short form (IIQ-7) score, and postpartum days (±10 days); all participants had no sphincter defects or levator ani muscle avulsion. The bioelectrical activity of the PFM was collected using an endovaginal electrode with the Glazer protocol. For the assessment of PFM function, PFM morphometry was evaluated with 3D/4D transperineal ultrasound. RESULTS A total of 78 matched pairs were recruited based on delivery mode. Regarding functional differences, both fast-twitch and slow-twitch fiber strengths in the eCS group were significantly higher than those in the sVD group, but PFMs were more hyperactive in the eCS group. Regarding morphometric differences, the retrovesical angle (RVA) and bladder neck position were not significantly different in the resting state between the two groups, nor was the RVA during the Valsalva maneuver (eCS group: 130.68 ± 17.08°, sVD group: 136.33 ± 23.93°), p > 0.05. There were differences in bladder neck descent (BND; eCS group: 16.51 ± 7.55 mm, sVD group: 23.92 ± 8.47 mm) and urethral rotation angle (URA; eCS group: 37.53 ± 26.05°, sVD group: 59.94 ± 25.87°), all p < 0.05. BND showed a negative correlation with PFM strength, p < 0.05. URAs and RVAs showed no correlation with PFM strength, p > 0.05. CONCLUSION Pelvic floor muscle function disorder, hyperactivity, and instability also occurred after eCS, which resulted in postpartum symptomatic SUI. The effects of sVD compared with eCS on abnormalities in the lower urinary tract were related to bladder neck and urethral hyperactivity, without an RVA increase.
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Does pregnancy affect pelvic floor functional anatomy? A retrospective study. Eur J Obstet Gynecol Reprod Biol 2021; 259:26-31. [PMID: 33561585 DOI: 10.1016/j.ejogrb.2021.01.047] [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: 08/25/2020] [Revised: 01/15/2021] [Accepted: 01/23/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Vaginal childbirth is an established main aetiological factor in the pathogenesis of female pelvic floor dysfunction. However, pregnancy itself is also likely to have an effect. This study investigated the effect of pregnancy on pelvic floor functional anatomy. STUDY DESIGN This was a retrospective observational study involving vaginally nulliparous women who presented to a tertiary urogynaecology unit with symptoms and signs of pelvic floor dysfunction between 2006 and 2014. Nulliparous women were compared with those who delivered exclusively by Caesarean Section (CS). All had undergone a standardised clinical interview, ICS POP-Q assessment and 3D/4D translabial pelvic floor ultrasound. Main outcome measures included sonographically determined pelvic organ position and hiatal dimensions on Valsalva and pelvic floor muscle contraction (PFMC). RESULTS Of 2930 women seen during the study period, 242 had never given birth vaginally. One hundred and twenty-nine (53 %) were nulliparous, and 113 (47 %) were delivered by CS only. The CS group demonstrated significantly higher pelvic organ mobility in the anterior compartment (all P < 0.05) and a larger hiatal area on Valsalva (P = 0.004). All sonographic measures of pelvic floor muscle function demonstrated greater tissue displacement on PFMC in the CS group (all P < 0.05). CONCLUSIONS Compared to nulliparas, women who delivered exclusively by CS showed increased pelvic organ descent on Valsalva and tissue displacement on PFMC, implying increased tissue elasticity/ compliance or reduced stiffness, consistent with a small permanent hormonal and/or mechanical effect of pregnancy.
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Sánchez-Ferrer ML, Arense-Gonzalo JJ, Prieto-Sánchez MT, Alfosea-Marhuenda E, Gómez-Carrascosa I, Iniesta MA, Mendiola J, Torres-Cantero AM. Does the anogenital distance change across pregnancy? Reprod Biomed Online 2020; 41:527-533. [PMID: 32586732 DOI: 10.1016/j.rbmo.2020.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/28/2020] [Accepted: 05/11/2020] [Indexed: 01/03/2023]
Abstract
RESEARCH QUESTION Does the length of the anogenital distance (AGD), an anthropometric biomarker of fetal androgen exposure, change across pregnancy? It has been suggested that AGD remains stable during adulthood with no changes across the menstrual cycle. No studies, however, have been carried out during pregnancy, during which women are exposed to important hormonal and anthropometric variations. DESIGN A cohort study of 186 singleton pregnant women recruited in the first trimester of pregnancy. Measurements from the anterior clitoral surface to the upper verge of the anus (AGDAC), and from the posterior fourchette to the upper verge of the anus (AGDAF) and body mass index (BMI) were obtained in each trimester. Generalized linear model for repeated measures was carried out to assess differences in AGDs and BMI across the three trimesters of the pregnancy. RESULTS In crude analyses, AGDAC was progressively and significantly longer as the pregnancy developed (first trimester: 87.69 ± 13.14mm; second trimester: 89.69 ± 13.47mm; third trimester: 91.95 ± 13.25 mm; P < 0.001), whereas AGDAF did not significantly change throughout pregnancy (first trimester: 28.37 ± 6.94 mm; second trimester: 28.09 ± 7.66 mm; third trimester: 28.94 ± 6.7 mm). In the multivariable mixed-effect models for fixed effect (trimester) and time-covariate (BMI), AGDs did not show significant associations with trimesters of pregnancy when BMI was included in the model. CONCLUSIONS Our results suggest that AGDAF and AGDAC, when adjusted by BMI, do not change throughout gestation despite maternal anthropometric variations during pregnancy. AGDAF may be a meaningful measurement at any time during pregnancy without considering BMI. Therefore, maternal AGDAF may be used as a prenatal biomarker of the mother's in-uteru hormonal exposure even during pregnancy.
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Affiliation(s)
- María L Sánchez-Ferrer
- Department of Obstetrics and Gynecology, 'Virgen de la Arrixaca' University Clinical Hospital, El Palmar Murcia 30120, Spain; Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar Mucia 30120, Spain
| | - Julian J Arense-Gonzalo
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar Mucia 30120, Spain; Division of Preventive Medicine and Public Health, Department of Public Health Sciences, University of Murcia School of Medicine, Espinardo Murcia 30100, Spain
| | - María T Prieto-Sánchez
- Department of Obstetrics and Gynecology, 'Virgen de la Arrixaca' University Clinical Hospital, El Palmar Murcia 30120, Spain; Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar Mucia 30120, Spain.
| | - Emilia Alfosea-Marhuenda
- Department of Obstetrics and Gynecology, 'Virgen de la Arrixaca' University Clinical Hospital, El Palmar Murcia 30120, Spain
| | - Inmaculada Gómez-Carrascosa
- Department of Obstetrics and Gynecology, 'Virgen de la Arrixaca' University Clinical Hospital, El Palmar Murcia 30120, Spain
| | - Miguel A Iniesta
- Department of Obstetrics and Gynecology, 'Virgen de la Arrixaca' University Clinical Hospital, El Palmar Murcia 30120, Spain
| | - Jaime Mendiola
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar Mucia 30120, Spain; Division of Preventive Medicine and Public Health, Department of Public Health Sciences, University of Murcia School of Medicine, Espinardo Murcia 30100, Spain
| | - Alberto M Torres-Cantero
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar Mucia 30120, Spain; Division of Preventive Medicine and Public Health, Department of Public Health Sciences, University of Murcia School of Medicine, Espinardo Murcia 30100, Spain; Department of Preventive Medicine, 'Virgen de la Arrixaca' University Clinical l Hospital, Murcia Murcia 30003, Spain; Biomedical Research Centre Network for Epidemiology and Public Health (CIBERESP), Madrid, Spain
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Gachon B, De Tayrac R, Schmitz T, Mahmood T, Nizard J, Fritel X. Should we advise women that pre-labor caesarean section prevents pelvic floor dysfunction? Eur J Obstet Gynecol Reprod Biol 2020; 244:31-34. [DOI: 10.1016/j.ejogrb.2019.10.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 09/30/2019] [Accepted: 10/22/2019] [Indexed: 01/04/2023]
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Abstract
More women participate in sports than ever before and the proportion of women athletes at the Olympic Games is nearly 50%. The pelvic floor in women may be the only area of the body where the positive effect of physical activity has been questioned. The aim of this narrative review is to present two widely held opposing hypotheses on the effect of general exercise on the pelvic floor and to discuss the evidence for each. Hypothesis 1: by strengthening the pelvic floor muscles (PFM) and decreasing the levator hiatus, exercise decreases the risk of urinary incontinence, anal incontinence and pelvic organ prolapse, but negatively affects the ease and safety of childbirth. Hypothesis 2: by overloading and stretching the PFM, exercise not only increases the risk of these disorders, but also makes labor and childbirth easier, as the PFM do not obstruct the exit of the fetus. Key findings of this review endorse aspects of both hypotheses. Exercising women generally have similar or stronger PFM strength and larger levator ani muscles than non-exercising women, but this does not seem to have a greater risk of obstructed labor or childbirth. Additionally, women that specifically train their PFM while pregnant are not more likely to have outcomes associated with obstructed labor. Mild-to-moderate physical activity, such as walking, decreases the risk of urinary incontinence but female athletes are about three times more likely to have urinary incontinence compared to controls. There is some evidence that strenuous exercise may cause and worsen pelvic organ prolapse, but data are inconsistent. Both intra-abdominal pressure associated with exercise and PFM strength vary between activities and between women; thus the threshold for optimal or negative effects on the pelvic floor almost certainly differs from person to person. Our review highlights many knowledge gaps that need to be understood to understand the full effects of strenuous and non-strenuous activities on pelvic floor health.
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Affiliation(s)
- Kari Bø
- Department of Sports Medicine, Norwegian School of Sport Sciences, PB 4014, Ullevål Stadion, 0806, Oslo, Norway.
- Akershus University Hospital, Lørenskog, Norway.
| | - Ingrid Elisabeth Nygaard
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, USA
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Obloza A, Toozs-Hobson P. 2D USS of the pelvic floor in the 3rd trimester versus mode of delivery. Eur J Obstet Gynecol Reprod Biol 2018; 230:153-158. [PMID: 30286365 DOI: 10.1016/j.ejogrb.2018.09.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 09/23/2018] [Accepted: 09/26/2018] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Biomechanics of pelvic floor muscles is becoming an important field of research in understanding a complex process of labour. Current evidence indicates that the levator ani stretches to allow passage of the fetus through the birth canal. We sought to identify properties of the functional female pelvic floor during pregnancy that could help to predict the mode of delivery, especially in women who underwent caesarean section in the past. METHODS A single centre prospective cohort study of pregnant women in the 3rd trimester attending antenatal clinic. Participants were categorised into three groups: 1. nulliparous, 2. previous one vaginal delivery and 3. previous one caesarean section who chose a trial of labour in their current pregnancy. All women underwent ultrasonographic evaluation of their pelvic floor muscles. Distensibility and the mode of delivery were assessed in participants' current pregnancies. The primary outcome was the mode of delivery. ANOVA test was used for statistical analysis. RESULTS 133 women were included: 55 nulliparous, 52 primiparous (previous one vaginal birth), and 26 primiparous (previous one LSCS and planned for vaginal delivery after caesarean (VBAC)). Participants were scanned at an average gestation of 32 weeks. The inter-observer reliability test for puborectalis distensibility was good (kappa 0.75). Overall, women who delivered vaginally had a more distensible puborectalis muscle than those who delivered by emergency LSCS regardless of their previous type of delivery. Women who underwent a successful VBAC had less distensible pelvic floor muscles compared to their nulliparous and primiparous counterparts (who delivered vaginally in the past). CONCLUSION These results support our basic conceptual theory of puborectalis muscle distensibility influencing the mode of delivery and endorse application of dynamic pelvic floor ultrasound in future studies. We identified measurable differences in the functional female pelvic anatomy aiding a better understanding of physiology of the labour. There are trends towards lesser distensibility in women who delivered by LSCS.
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Affiliation(s)
- Aneta Obloza
- Urogynaecology Department, University Hospitals of Leicester NHS Trust, Gwendolen Road, Leicester, LE5 4PW, UK.
| | - Philip Toozs-Hobson
- Urogynaecology Department, Birmingham Women's Hospital NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TG, UK
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Recommended standardized terminology of the anterior female pelvis based on a structured medical literature review. Am J Obstet Gynecol 2018; 219:26-39. [PMID: 29630884 DOI: 10.1016/j.ajog.2018.04.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 03/24/2018] [Accepted: 04/02/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND The use of imprecise and inaccurate terms leads to confusion amongst anatomists and medical professionals. OBJECTIVE We sought to create recommended standardized terminology to describe anatomic structures of the anterior female pelvis based on a structured review of published literature and selected text books. STUDY DESIGN We searched MEDLINE from its inception until May 2, 2016, using 11 medical subject heading terms to identify studies reporting on anterior female pelvic anatomy; any study type published in English was accepted. Nine textbooks were also included. We screened 12,264 abstracts, identifying 200 eligible studies along with 13 textbook chapters from which we extracted all pertinent anatomic terms. RESULTS In all, 67 unique structures in the anterior female pelvis were identified. A total of 59 of these have been previously recognized with accepted terms in Terminologia Anatomica, the international standard on anatomical terminology. We also identified and propose the adoption of 4 anatomic regional terms (lateral vaginal wall, pelvic sidewall, pelvic bones, and anterior compartment), and 2 structural terms not included in Terminologia Anatomica (vaginal sulcus and levator hiatus). In addition, we identified 2 controversial terms (pubourethral ligament and Grafenberg spot) that require additional research and consensus from the greater medical and scientific community prior to adoption or rejection of these terms. CONCLUSION We propose standardized terminology that should be used when discussing anatomic structures in the anterior female pelvis to help improve communication among researchers, clinicians, and surgeons.
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In vivo assessment of the levator ani muscles using shear wave elastography: a feasibility study in women. Int Urogynecol J 2018; 30:1179-1186. [DOI: 10.1007/s00192-018-3693-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 06/11/2018] [Indexed: 11/30/2022]
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de Araujo CC, Coelho SA, Stahlschmidt P, Juliato CRT. Does vaginal delivery cause more damage to the pelvic floor than cesarean section as determined by 3D ultrasound evaluation? A systematic review. Int Urogynecol J 2018; 29:639-645. [PMID: 29564512 DOI: 10.1007/s00192-018-3609-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 02/16/2018] [Indexed: 12/30/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Pregnancy and delivery are well-established risk factors for pelvic floor dysfunction (PFD), but the physiopathology, such as the delivery route, is not well understood. This study evaluated the impact of delivery route on the pelvic floor muscles via 3D ultrasound. METHODS This review is registered in the PROSPERO database. The criteria for inclusion were prospective studies with 3D translabial ultrasound assessment in primigravida women during pregnancy and postpartum published in English, Spanish or Portuguese between 1980 and 2016. We excluded studies that did not include the topic of urogenital hiatus measurement and literature reviews. The MeSH terms were obstetric delivery, postpartum period, labor, parturition, three-dimensional images, ultrasonography, pelvic floor, and pelvic floor disorders. RESULTS The search retrieved 155 articles. After analysis, 6 articles were included. Four studies showed that vaginal delivery (VD) was associated with a larger hiatal area. One study associated the hiatal area with levator ani muscle (LAM) defects in VD. Four articles evaluated the bladder neck, 3 of which showed a significant increase in bladder neck mobility associated with VD and 1 showed decreased bladder neck elevation, not associated with the delivery mode; the first 3 articles all evaluated LAM injuries and showed an association between VD and LAM injury. Women who underwent VD presented defects of the puborectalis muscle. CONCLUSIONS Vaginal delivery was associated with a higher number of LAM injuries, puborectalis defects, increased bladder neck mobility, and enlargement of the hiatal area.
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Affiliation(s)
- Camila Carvalho de Araujo
- School of Medicine, University of Campinas (UNICAMP), R. Euclides de Moraes Rosa, 180. Jardim Itália. Itapetininga, Campinas, SP, 18.201-760, Brazil.
| | - Suelene A Coelho
- School of Medicine, University of Campinas (UNICAMP), R. Euclides de Moraes Rosa, 180. Jardim Itália. Itapetininga, Campinas, SP, 18.201-760, Brazil
| | - Paulo Stahlschmidt
- School of Medicine, University of Campinas (UNICAMP), R. Euclides de Moraes Rosa, 180. Jardim Itália. Itapetininga, Campinas, SP, 18.201-760, Brazil
| | - Cassia R T Juliato
- School of Medicine, University of Campinas (UNICAMP), R. Euclides de Moraes Rosa, 180. Jardim Itália. Itapetininga, Campinas, SP, 18.201-760, Brazil
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Reimers C, Siafarikas F, Stær-Jensen J, Småstuen MC, Bø K, Ellström Engh M. Risk factors for anatomic pelvic organ prolapse at 6 weeks postpartum: a prospective observational study. Int Urogynecol J 2018; 30:477-482. [DOI: 10.1007/s00192-018-3650-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 03/30/2018] [Indexed: 12/11/2022]
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Dias NT, Ferreira LR, Fernandes MG, Resende APM, Pereira-Baldon VS. A Pilates exercise program with pelvic floor muscle contraction: Is it effective for pregnant women? A randomized controlled trial. Neurourol Urodyn 2017; 37:379-384. [PMID: 28543751 DOI: 10.1002/nau.23308] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 04/20/2017] [Indexed: 11/12/2022]
Abstract
AIMS The aim of this study was to evaluate the effectiveness of a Pilates exercise program with pelvic floor muscle (PFM) contraction compared to a conventional intervention in pregnant women. METHODS Fifty primiparous women, without gestational alterations, were randomized to the Pilates group (n = 25) and control group (n = 25). Interventions for both groups consisted of twice-weekly sessions of 1 h each during the period between the 14-16th and 32-34th gestational weeks. The Pilates group performed a Pilates exercises program with the addition of voluntary PFM contraction. Mat-based Pilates exercises were performed involving movement of the upper limbs, lower limbs and trunk in all sessions. The Control group walked for 10 min and performed strengthening exercises of the lower limbs, upper limbs, and trunk with resistance from an elastic band and body weight. Each woman was evaluated by an unblinded physiotherapist before and after intervention for primary (PFM strength using a manometer) and secondary (PFM strength using Oxford Scale, endurance and repeatability) outcomes. Covariance analysis (ANCOVA) was used to compare the groups using the baseline values as a covariate. RESULTS Thirty-six women were included in the analysis. There were no differences between the groups for manometry. An increase in the PFM strength, endurance, and repeatability was only observed in the Pilates group. In addition, the Pilates group showed greater adherence to the intervention. CONCLUSION Pilates exercise program with PFM contraction is not able to change the PFM strength assessed by manometer in pregnant women, but it improved adherence to the intervention.
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Affiliation(s)
- Naiara T Dias
- Health Sciences Post Graduation Program, Federal University of Uberlandia, Minas Gerais, Brazil
| | - Letícia R Ferreira
- Health Sciences Post Graduation Program, Federal University of Uberlandia, Minas Gerais, Brazil
| | - Mariana G Fernandes
- Physiotherapy Graduation, Federal University of Uberlandia, Minas Gerais, Brazil
| | - Ana Paula M Resende
- Health Sciences Post Graduation Program, Federal University of Uberlandia, Minas Gerais, Brazil
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Sanozidis A, Mikos T, Assimakopoulos E, Athanasiadis A, Tantanassis T, Tarlatzis BC, Papameletiou V. Changes in levator hiatus dimensions during pregnancy and after delivery in nulliparas: a prospective cohort study using 3D transperineal ultrasound. J Matern Fetal Neonatal Med 2017; 31:1505-1512. [DOI: 10.1080/14767058.2017.1319926] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- A. Sanozidis
- 1st Department of Obstetrics & Gynecology, Aristotle University of Thessaloniki, Papageorgiou General Hospital Thessaloniki, Greece
| | - T. Mikos
- 1st Department of Obstetrics & Gynecology, Aristotle University of Thessaloniki, Papageorgiou General Hospital Thessaloniki, Greece
| | - E. Assimakopoulos
- 2nd Department of Obstetrics & Gynecology, Aristotle University of Thessaloniki, Hippokration General Hospital Thessaloniki, Greece
| | - A. Athanasiadis
- 1st Department of Obstetrics & Gynecology, Aristotle University of Thessaloniki, Papageorgiou General Hospital Thessaloniki, Greece
| | - T. Tantanassis
- 2nd Department of Obstetrics & Gynecology, Aristotle University of Thessaloniki, Hippokration General Hospital Thessaloniki, Greece
| | - B. C. Tarlatzis
- 1st Department of Obstetrics & Gynecology, Aristotle University of Thessaloniki, Papageorgiou General Hospital Thessaloniki, Greece
| | - V. Papameletiou
- 1st Department of Obstetrics & Gynecology, Aristotle University of Thessaloniki, Papageorgiou General Hospital Thessaloniki, Greece
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Sperstad JB, Tennfjord MK, Hilde G, Ellström-Engh M, Bø K. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med 2016; 50:1092-6. [PMID: 27324871 PMCID: PMC5013086 DOI: 10.1136/bjsports-2016-096065] [Citation(s) in RCA: 136] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND/AIM Diastasis recti abdominis (DRA) is defined as a separation of the 2 muscle bellies of rectus abdominis. To date there is scant knowledge on prevalence, risk factors, and consequences of the condition. The present study aimed to investigate the prevalence of DRA during pregnancy and post partum, presence of possible risk factors, and the occurrence of lumbopelvic pain among women with and without DRA. METHODS This prospective cohort study followed 300 first-time pregnant women from pregnancy till 12 months post partum. Data were collected by electronic questionnaire and clinical examinations. DRA was defined as a palpated separation of ≥2 fingerbreadths either 4.5 cm above, at or 4.5 cm below the umbilicus. Women with and without DRA were compared with independent samples Student's t-test and χ(2)/Fisher exact test, and OR with significance level >0.05. RESULTS Prevalence of DRA was 33.1%, 60.0%, 45.4%, and 32.6% at gestation week 21, 6 weeks, 6 months and 12 months post partum, respectively. No difference in risk factors was found when comparing women with and without DRA. OR showed a greater likelihood for DRA among women reporting heavy lifting ≥20 times weekly (OR 2.18 95% CI 1.05 to 4.52). There was no difference in reported lumbopelvic pain (p=0.10) in women with and without DRA. CONCLUSIONS Prevalence of mild DRA was high both during pregnancy and after childbirth. Women with and without DRA reported the same amount of lumbopelvic pain 12 months post partum.
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Affiliation(s)
| | - Merete Kolberg Tennfjord
- Department of Sports Medicine, Norwegian School of Sports Sciences, Oslo, Norway Department of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, Norway
| | - Gunvor Hilde
- Department of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, Norway
| | - Marie Ellström-Engh
- Department of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, Norway Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kari Bø
- Department of Sports Medicine, Norwegian School of Sports Sciences, Oslo, Norway
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Haavik H, Murphy BA, Kruger J. Effect of Spinal Manipulation on Pelvic Floor Functional Changes in Pregnant and Nonpregnant Women: A Preliminary Study. J Manipulative Physiol Ther 2016; 39:339-347. [PMID: 27157677 DOI: 10.1016/j.jmpt.2016.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 11/10/2015] [Accepted: 11/10/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was to investigate whether a single session of spinal manipulation of pregnant women can alter pelvic floor muscle function as measured using ultrasonographic imaging. METHODS In this preliminary, prospective, comparative study, transperineal ultrasonographic imaging was used to assess pelvic floor anatomy and function in 11 primigravid women in their second trimester recruited via notice boards at obstetric caregivers, pregnancy keep-fit classes, and word of mouth and 15 nulliparous women recruited from a convenience sample of female students at the New Zealand College of Chiropractic. Following bladder voiding, 3-/4-dimensional transperineal ultrasonography was performed on all participants in the supine position. Levator hiatal area measurements at rest, on maximal pelvic floor contraction, and during maximum Valsalva maneuver were collected before and after either spinal manipulation or a control intervention. RESULTS Levator hiatal area at rest increased significantly (P < .05) after spinal manipulation in the pregnant women, with no change postmanipulation in the nonpregnant women at rest or in any of the other measured parameters. CONCLUSION Spinal manipulation of pregnant women in their second trimester increased the levator hiatal area at rest and thus appears to relax the pelvic floor muscles. This did not occur in the nonpregnant control participants, suggesting that it may be pregnancy related.
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Affiliation(s)
- Heidi Haavik
- Director of Research, Centre for Chiropractic Research, New Zealand College of Chiropractic.
| | - Bernadette A Murphy
- Professor, Kinesiology, Faculty of Health Sciences, University of Ontario Institute of Technology
| | - Jennifer Kruger
- Research Fellow, Auckland Bioengineering Institute at The University of Auckland in New Zealand
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Reimers C, Staer-Jensen J, Siafarikas F, Saltyte-Benth J, Bø K, Ellström Engh M. Change in pelvic organ support during pregnancy and the first year postpartum: a longitudinal study. BJOG 2015; 123:821-9. [DOI: 10.1111/1471-0528.13432] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2015] [Indexed: 12/17/2022]
Affiliation(s)
- C Reimers
- Department of Obstetrics and Gynaecology; Akershus University Hospital; Lørenskog Norway
- Faculty Division, Akershus University Hospital; University of Oslo; Oslo Norway
| | - J Staer-Jensen
- Department of Obstetrics and Gynaecology; Akershus University Hospital; Lørenskog Norway
| | - F Siafarikas
- Department of Obstetrics and Gynaecology; Akershus University Hospital; Lørenskog Norway
- Faculty Division, Akershus University Hospital; University of Oslo; Oslo Norway
| | - J Saltyte-Benth
- Faculty Division, Akershus University Hospital; University of Oslo; Oslo Norway
| | - K Bø
- Department of Sports Medicine; Norwegian School of Sport Sciences; Oslo Norway
| | - M Ellström Engh
- Department of Obstetrics and Gynaecology; Akershus University Hospital; Lørenskog Norway
- Faculty Division, Akershus University Hospital; University of Oslo; Oslo Norway
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26
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Postpartum recovery of levator hiatus and bladder neck mobility in relation to pregnancy. Obstet Gynecol 2015; 125:531-539. [PMID: 25730212 DOI: 10.1097/aog.0000000000000645] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To study postpartum changes in pelvic floor morphology in a cohort of primiparous women. METHODS Transperineal ultrasound measurements taken at five examination points, both prepartum and postpartum, provided data for comparison. Three hundred nulliparous pregnant women were examined at 21 weeks of gestation and 274 (91%) at 37 weeks of gestation. At 6 weeks postpartum, 285 (95%) women were examined, 198 (66%) at 6 months, and 178 (59%) at 12 months using transperineal ultrasonography at rest, during contraction, and during Valsalva maneuver. The levator hiatus area, bladder neck mobility, and rest-to-Valsalva hiatal area difference were assessed. RESULTS Approximately 85% had vaginal and 15% had cesarean deliveries. Demographic characteristics of the patients lost to follow-up were similar to the patients not lost to follow-up. In the vaginal group, a significant decrease in all measurements was seen during the first 6 months postpartum, being most pronounced for the levator hiatus area during Valsalva maneuver (-3.5 cm; P<.001). In the cesarean delivery group, no significant changes between examination points were found postpartum. Only the vaginal delivery group showed significant increases in all measurements when comparing the status at 12 months postpartum with 21 weeks of gestation, most pronounced for levator hiatus area during Valsalva maneuver (3 cm; P<.001). However, comparing the two delivery groups at 12 months postpartum, the only significant difference found was levator hiatus area during contraction. CONCLUSION The levator ani muscle has the ability to recover after pregnancy and delivery, although not all women recover to pregnancy level. Most of the recovery occurs during the first 6 months postpartum. Significant pregnancy-induced changes are not shown to persist 1 year postpartum. LEVEL OF EVIDENCE : II.
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Vergeldt TFM, Notten KJB, Weemhoff M, van Kuijk SMJ, Mulder FEM, Beets-Tan RG, Vliegen RFA, Gondrie ETCM, Bergmans MGM, Roovers JPWR, Kluivers KB. Levator hiatal area as a risk factor for cystocele recurrence after surgery: a prospective study. BJOG 2015; 122:1130-7. [PMID: 25761589 DOI: 10.1111/1471-0528.13340] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate whether increased levator hiatal area, measured preoperatively, was independently associated with anatom-ical cystocele recurrence 12 months after anterior colporrhaphy. DESIGN Multicentre prospective cohort study. SETTING Nine teaching hospitals in the Netherlands. POPULATION Women planned for conventional anterior colporrhaphy without mesh. METHODS Women underwent physical examination, translabial three-dimensional (3D) ultrasound and magnetic resonance imaging (MRI) prior to surgery. At 12 months after surgery the physical examination was repeated. MAIN OUTCOME MEASURES Women with and without anatomical cystocele recurrence were compared to assess the association with levator hiatal area on 3D ultrasound, levator hiatal area on MRI, and potential confounding factors. The receiver operating characteristic (ROC) curve was created to quantify the discriminative ability of using levator hiatal area to predict anatomical cystocele recurrence. RESULTS Of 139 included women, 76 (54.7%) had anatomical cystocele recurrence. Preoperative stage 3 or 4 and increased levator hiatal area during Valsalva on ultrasound were significantly associated with cystocele recurrence, with odds ratios of 3.47 (95% confidence interval, 95% CI 1.66-7.28) and 1.06 (95% CI 1.01-1.11) respectively. The area under the ROC curve was 0.60 (95% CI 0.51-0.70) for levator hiatal area during Valsalva on ultrasound, and 0.65 (95% CI 0.55-0.71) for preoperative Pelvic Organ Prolapse Quantification (POP-Q) stage. CONCLUSIONS Increased levator hiatal area during Valsalva on ultrasound prior to surgery and preoperative stage 3 or 4 are independent risk factors for anatomical cystocele recurrence after anterior colporrhaphy; however, increased levator hiatal area as the sole factor for predicting anatomical cystocele recurrence after surgery shows poor test characteristics.
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Affiliation(s)
- T F M Vergeldt
- Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - K J B Notten
- Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - M Weemhoff
- Obstetrics and Gynaecology, Atrium Medical Centre Parkstad, Heerlen, the Netherlands
| | - S M J van Kuijk
- Epidemiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - F E M Mulder
- Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, the Netherlands
| | - R G Beets-Tan
- Radiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - R F A Vliegen
- Radiology, Atrium Medical Centre Parkstad, Heerlen, the Netherlands
| | - E T C M Gondrie
- Obstetrics and Gynaecology, Orbis Medical Centre, Sittard, the Netherlands
| | - M G M Bergmans
- Obstetrics and Gynaecology, Laurentius Medical Centre, Roermond, the Netherlands
| | - J P W R Roovers
- Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, the Netherlands
| | - K B Kluivers
- Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, the Netherlands
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Siafarikas F, Staer-Jensen J, Hilde G, Bø K, Ellström Engh M. The levator ani muscle during pregnancy and major levator ani muscle defects diagnosed postpartum: a three- and four-dimensional transperineal ultrasound study. BJOG 2015; 122:1083-91. [PMID: 25716540 DOI: 10.1111/1471-0528.13332] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2014] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To investigate associations between levator hiatus area and levator ani muscle function during pregnancy and major levator ani muscle defects postpartum. DESIGN Observational prospective cohort study. SETTING University hospital, Norway. SAMPLE A cohort of 234 nulliparous women at 21 and 37 weeks of gestation, and at 6 weeks postpartum. METHODS Ultrasound measurements of the levator hiatus at rest, during pelvic floor muscle contraction, and during the Valsalva manoeuvre were taken at 21 and 37 weeks of gestation. Levator ani muscle function was estimated as the percentage changes in levator ani muscle length from rest to contraction, and the level of muscle stretch during the Valsalva manoeuvre. Major levator ani muscle defects were diagnosed at 6 weeks postpartum using tomographic ultrasound imaging. MAIN OUTCOME MEASURES Associations between ultrasound measurements antepartum and major levator ani muscle defects postpartum. RESULTS Women with major levator ani muscle defects postpartum had significantly smaller levator hiatus area at rest and during the Valsalva manoeuvre at mid-pregnancy (mean difference 1.03 cm(2) , 95% CI 0.31-1.76; 2.92 cm(2) , 95% CI 1.77-4.07), and at 37 weeks of gestation (mean difference 1.47 cm(2) , 95% CI 0.62-2.32; 2.84 cm(2) , 95% CI 0.88-4.80), than women without such defects. They also had significantly less shortening of the levator ani muscle during contraction at 37 weeks of gestation. CONCLUSIONS Smaller levator hiatus area at rest and during the Valsalva manoeuvre at mid and late pregnancy, and less shortening of the levator ani muscle during contraction at 37 weeks of gestation, are associated with major levator ani muscle defects postpartum.
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Affiliation(s)
- F Siafarikas
- Faculty Division Akershus University Hospital, University of Oslo, Oslo, Norway.,Department of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, Norway
| | - J Staer-Jensen
- Department of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, Norway
| | - G Hilde
- Department of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, Norway.,Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - K Bø
- Department of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, Norway.,Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - M Ellström Engh
- Faculty Division Akershus University Hospital, University of Oslo, Oslo, Norway.,Department of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, Norway
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van Veelen GA, Schweitzer KJ, van der Vaart CH. Ultrasound imaging of the pelvic floor: changes in anatomy during and after first pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:476-480. [PMID: 24436146 DOI: 10.1002/uog.13301] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Revised: 12/23/2013] [Accepted: 12/30/2013] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To describe changes in the absolute values of levator hiatal dimensions and in the contractility and distensibility of the levator hiatus during pelvic floor contraction and Valsalva maneuver, using three/four-dimensional (3D/4D) transperineal ultrasound in women during and after their first pregnancy. METHODS Two-hundred and eighty nulliparous pregnant women underwent ultrasound examination at 12 and 36 weeks' gestation and 6 months postpartum. Hiatal dimensions were measured at rest, on pelvic floor contraction and on Valsalva maneuver. The contractility and distensibility were determined by the difference between hiatal dimensions at rest and those on contraction or Valsalva, respectively. After exclusions, there were 231 datasets from women at rest, 199 for pelvic floor contraction and 230 for Valsalva maneuver. Data at 36 weeks' gestation and 6 months postpartum were compared with data at 12 weeks' gestation. RESULTS At 36 weeks' gestation, the absolute values of hiatal dimensions and the contractility and distensibility of the levator hiatus were significantly increased compared with those at 12 weeks' gestation. Women who delivered vaginally showed a persistent significant increase in hiatal dimensions on Valsalva, whereas women who delivered by prelabor or first-stage Cesarean section showed no significant changes in hiatal dimensions on Valsalva. After both vaginal and Cesarean section delivery, there was a persistent increase in the distensibility of the hiatus during Valsalva compared with in early pregnancy. CONCLUSION During first pregnancy, the absolute values of levator hiatal dimensions and the contractility and distensibility of the levator hiatus increase. Regardless of delivery mode, increased distensibility of the levator hiatus during Valsalva persists after childbirth. This increased pelvic floor distensibility may play a role in the development of pelvic floor dysfunction in later life.
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Affiliation(s)
- G A van Veelen
- Department of Reproductive Medicine and Gynecology, University Medical Center, Utrecht, The Netherlands
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Bø K, Hilde G, Stær-Jensen J, Siafarikas F, Tennfjord MK, Engh ME. Does general exercise training before and during pregnancy influence the pelvic floor “opening” and delivery outcome? A 3D/4D ultrasound study following nulliparous pregnant women from mid-pregnancy to childbirth. Br J Sports Med 2014; 49:196-9. [DOI: 10.1136/bjsports-2014-093548] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Siafarikas F, Stær-Jensen J, Hilde G, Bø K, Ellström Engh M. Levator hiatus dimensions in late pregnancy and the process of labor: a 3- and 4-dimensional transperineal ultrasound study. Am J Obstet Gynecol 2014; 210:484.e1-7. [PMID: 24569040 DOI: 10.1016/j.ajog.2014.02.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 01/16/2014] [Accepted: 02/20/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objectives of the investigation were to study the association between levator hiatus dimensions in late pregnancy and both the length of second stage of labor and also the delivery mode in women delivering their first child. STUDY DESIGN In this cohort study, 231 nulliparous women were examined with 3- and 4-dimensional transperineal ultrasonography at 37 weeks of gestation. The anteroposterior, transverse diameter, and the area of levator hiatus were measured at rest, during levator ani muscle contraction, and during Valsalva maneuver. The second stage of labor was divided into passive and active second stage and delivery modes into normal vaginal or instrumental deliveries. Spearman correlation coefficient, independent-sample t test, and standard logistic regression were used for analysis. RESULTS Larger levator hiatus dimensions at rest and during contraction at 37 weeks of gestation correlated with a shorter duration of the active second stage in women with normal vaginal delivery (Spearman correlation coefficient, -0.13 to -0.35, P ≤ .08). Women having normal vaginal deliveries had significantly larger transverse diameter at rest, during contraction, and during Valsalva maneuver compared with women having instrumental deliveries (mean difference, 0.29; 95% confidence interval (CI), 0.16-0.41; mean difference, 0.33; 95% CI, 0.21-0.44 and mean difference, 0.24; 95% CI, 0.06-0.42; P < .05). The same was true for the levator hiatus area at rest and during contraction (mean difference, 1.22; 95% CI, 0.37-2.07 and mean difference, 0.84; 95% CI, 0.22-1.46; P < .01). These estimates were unchanged by adjustments in the logistic regression analysis. CONCLUSION Larger levator hiatus dimensions in late pregnancy had a significant association with a shorter active second stage of labor and normal vaginal delivery.
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Affiliation(s)
- Franziska Siafarikas
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jette Stær-Jensen
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Gunvor Hilde
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway; Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Kari Bø
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway; Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Marie Ellström Engh
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
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