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Woon Wong K, Okeahialam N, Thakar R, Sultan AH. Obstetric risk factors for levator ani muscle avulsion: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2024; 296:99-106. [PMID: 38422805 DOI: 10.1016/j.ejogrb.2024.02.044] [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: 06/20/2023] [Revised: 11/15/2023] [Accepted: 02/22/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVES Women have a 11% lifetime risk of undergoing surgery for vaginal prolapse. Levator ani muscle (LAM) avulsion is one etiological factor associated with primary and recurrent pelvic organ prolapse. Pelvic organ prolapse has been shown to greatly affect the quality of life and well-being of women. Conduct a meta-analysis identifying risk factors associated with LAM avulsion recognised on transperineal ultrasound (TPUS) or magnetic resonance imaging (MRI) in primiparous women after vaginal birth. STUDY DESIGN OVID Medline, Embase and the Cochrane Library from inception to January 2021 were searched. Review Manager 5.3 (The Cochrane Collaboration) was used to analyse data. Odds ratios (OR) with 95% confidence intervals (95% CIs) were calculated. The heterogeneity among studies was calculated using the I2statistic. RESULTS Twenty-five studies were eligible for inclusion (n = 9333 women). Major LAM avulsion was diagnosed in an average of 22 % (range 12.7-39.5 %) of cases. Twenty-two studies used TPUS and three used MRI to diagnose avulsion. Modifiable and non-modifiable risk factors were identified. Significant predictors identified were forceps (OR 6.25 [4.33 - 9.0]), obstetric anal sphincter injuries (OR 3.93 [2.85-5.42]), vacuum (OR 2.41 [1.40-4.16]), and maternal age (OR 1.06 [1.02-1.10]). CONCLUSIONS This is the first meta-analysis of both modifiable and non-modifiable risk factors associated with LAM avulsion. This information could be used to develop a clinically applicable risk prediction model to target postnatal women at risk of LAM avulsion with a view to prevent the onset of pelvic floor organ prolapse.
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Affiliation(s)
| | | | - Ranee Thakar
- Croydon University Hospital, UK; St George's University of London, UK
| | - Abdul H Sultan
- Croydon University Hospital, UK; St George's University of London, UK.
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Bahl R, Hotton E, Crofts J, Draycott T. Assisted vaginal birth in 21st century: current practice and new innovations. Am J Obstet Gynecol 2024; 230:S917-S931. [PMID: 38462263 DOI: 10.1016/j.ajog.2022.12.305] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 03/12/2024]
Abstract
Assisted vaginal birth rates are falling globally with rising cesarean delivery rates. Cesarean delivery is not without consequence, particularly when carried out in the second stage of labor. Cesarean delivery in the second stage is not entirely protective against pelvic floor morbidity and can lead to serious complications in a subsequent pregnancy. It should be acknowledged that the likelihood of morbidity for mother and baby associated with cesarean delivery increases with advancing labor and is greater than spontaneous vaginal birth, irrespective of the method of operative birth in the second stage of labor. In this article, we argue that assisted vaginal birth is a skilled and safe option that should always be considered and be available as an option for women who need assistance in the second stage of labor. Selecting the most appropriate mode of birth at full dilatation requires accurate clinical assessment, supported decision-making, and personalized care with consideration for the woman's preferences. Achieving vaginal birth with the primary instrument is more likely with forceps than with vacuum extraction (risk ratio, 0.58; 95% confidence interval, 0.39-0.88). Midcavity forceps are associated with a greater incidence of obstetric anal sphincter injury (odds ratio, 1.83; 95% confidence interval, 1.32-2.55) but no difference in neonatal Apgar score or umbilical artery pH. The risk for adverse outcomes is minimized when the procedure is conducted by a skilled accoucheur who selects the most appropriate instrument likely to achieve vaginal birth with the primary instrument. Anticipation of potential complications and dynamic decision-making are just as important as the technique for safe instrument use. Good communication with the woman and the birthing partner is vital and there are various recommendations on how to achieve this. There have been recent developments (such as OdonAssist) in device innovation, training, and strategies for implementation at a scale that can provide opportunities for both improved outcomes and reinvigoration of an essential skill that can save mothers' and babies' lives across the world.
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Affiliation(s)
- Rachna Bahl
- Department of Obstetrics and Gynaecology, University Hospitals Bristol National Health Service Trust, Bristol, United Kingdom; Royal College of Obstetricians and Gynaecologists, London, United Kingdom.
| | | | - Joanna Crofts
- Department of Obstetrics and Gynaecology, North Bristol National Health Service Trust, Bristol, United Kingdom
| | - Tim Draycott
- Royal College of Obstetricians and Gynaecologists, London, United Kingdom; Department of Obstetrics and Gynaecology, North Bristol National Health Service Trust, Bristol, United Kingdom
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Gong Q, Wang Y, Duan L, Lei L, Liu J, Yao J, Qi J, Xu Z, Nian Y, Wu Y. Comparative study of female pelvic floor among undeformed high-resolution thin-sectional anatomical (visible human) images and MRI and ultrasound images. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024; 52:208-218. [PMID: 38108620 DOI: 10.1002/jcu.23616] [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: 08/23/2023] [Revised: 10/30/2023] [Accepted: 11/08/2023] [Indexed: 12/19/2023]
Abstract
PURPOSE Using visible human, MRI and ultrasound images, we aim to provide an anatomical basis for the identification and diagnosis of pelvic floor structure and disease by ultrasound imaging. METHODS One Chinese visible human (CVH) image, one American visible human image, 9 MRI images of normal volunteers, and 40 ultrasound images of normal volunteers or pelvic organ prolapse patients were used. Pelvic organs, pelvic floor muscles, and the connective tissue in CVH, VHP, MRI, and ultrasound images were selected for comparative study. RESULTS We successfully identified the boundary of the anal sphincter complex, including the subcutaneous, superficial, and deep parts of the external anal sphincter, conjoined longitudinal muscles and internal anal sphincter; the levator ani muscle (LAM), including the internal and external parts of the pubovisceral muscle and the superficial and deep parts of the puborectal muscle; the urethral sphincter complex, including the urethral sphincter proper and the urethral compressor; and the perineal body, the rectoperineal muscle and superficial transverse perineal muscle. CONCLUSIONS We successfully recognized and studied the location, subdivisions, 2D morphology and spatial relationships of the LAM, anal sphincter complex, urethral sphincter complex and perineal body in ultrasound images, thereby helping sonologists or clinicians accurately identify pelvic floor muscles and supporting structures in ultrasound images.
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Affiliation(s)
- Qingfang Gong
- Department of Digital Medicine, School of Biomedical Engineering and Imaging Medicine, Army Military Medical University (Third Military Medical University), Chongqing, China
| | - Yangyun Wang
- Department of Urology, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
| | - Li Duan
- Department of Ultrasound, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
| | - Ling Lei
- Department of Gynecology and Obstetrics, People's Hospital of Anshun, Anshun City, Guizhou Province, China
| | - Jia Liu
- Department of Digital Medicine, School of Biomedical Engineering and Imaging Medicine, Army Military Medical University (Third Military Medical University), Chongqing, China
| | - Jie Yao
- Department of Digital Medicine, School of Biomedical Engineering and Imaging Medicine, Army Military Medical University (Third Military Medical University), Chongqing, China
| | - Jing Qi
- Department of Digital Medicine, School of Biomedical Engineering and Imaging Medicine, Army Military Medical University (Third Military Medical University), Chongqing, China
| | - Zhou Xu
- Department of Digital Medicine, School of Biomedical Engineering and Imaging Medicine, Army Military Medical University (Third Military Medical University), Chongqing, China
| | - Yongjian Nian
- Department of Digital Medicine, School of Biomedical Engineering and Imaging Medicine, Army Military Medical University (Third Military Medical University), Chongqing, China
| | - Yi Wu
- Department of Digital Medicine, School of Biomedical Engineering and Imaging Medicine, Army Military Medical University (Third Military Medical University), Chongqing, China
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Dietz HP. Diagnosis of maternal birth trauma by pelvic floor ultrasound. Eur J Obstet Gynecol Reprod Biol 2023; 285:86-96. [PMID: 37087835 DOI: 10.1016/j.ejogrb.2023.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/01/2023] [Accepted: 04/06/2023] [Indexed: 04/25/2023]
Abstract
BRIEF SUMMARY Maternal somatic birth trauma due to vaginal delivery is more common than generally assumed and an important cause of future morbidity. Maternal birth trauma may involve both psychological and somatic morbidity, some of it long-term and permanent. Somatic birth trauma is now understood to encompass not just episiotomy, perineal tears and obstetric anal sphincter injuries (OASI), but also trauma to the levator ani muscle, termed 'avulsion'. This review will focus on recent developments in the imaging diagnosis of maternal birth trauma, discuss the most important risk factors and strategies for primary and secondary prevention. Translabial and exo-anal ultrasound allow the assessment of maternal birth trauma in routine clinical practice and enable the use of levator avulsion and anal sphincter trauma as key performance indicators of maternity services. This is likely to lead to a greater awareness of maternal birth trauma amongst maternity caregivers and improved outcomes for patients, not the least due to an increasing emphasis on patient autonomy and informed consent in antenatal and intrapartum care.
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Jiménez-Arbeláez AL, Giraldo-Giron P, Arias-Zapata C, Campo-Campo MN, Echavarria-Restrepo LG, Cuesta-Castro DP. Incidencia, complicaciones inmediatas y tempranas de desgarros perineales graves durante el parto en una institución de referencia de atención obstétrica en Medellín, Colombia. IATREIA 2023. [DOI: 10.17533/udea.iatreia.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
Abstract
Introducción: los desgarros perineales severos (DPS) son complicaciones obstétricas que se presentan durante la atención del parto. Pueden desencadenar fístulas rectales e incontinencia fecal y urinaria, morbilidad a mediano y largo plazo que requiere un diagnóstico, manejo y seguimiento adecuado. Objetivo: determinar la incidencia de los DPS y las complicaciones relacionadas inmediatas −primeras 48 horas− y tempranas −primeros tres meses− posteriores a la atención del parto.Metodología: se hizo un estudio de cohorte descriptiva de pacientes con DPS durante la atención del parto en un centro de referencia de atención obstétrica en Medellín, Colombia, entre enero del 2015 y diciembre del 2017. Se revisaron las historias clínicas y se registraron los datos clínicos y las complicaciones inmediatas y tempranas en las que asistieron a cita de control de piso pélvico. Se presentan medidas descriptivas de resumen.Resultados: se atendieron 14.247 partos vaginales. La incidencia de DPS fue del 1,6 % (233/14.247), 1,3 % (184/14.267) de grado III y 0,3 % (49/14.247) de grado IV. El 66,5 % (155/233) tuvo parto vértice instrumentado, 81,9 % (191/233) episiotomía; la mediana del periodo expulsivo fue de 19 minutos (RIQ 12-35), y el 3 % (7/233) presentó distocia de hombros. Las complicaciones inmediatas en las pacientes con DPS fueron: 0,85 % (2/233) dehiscencia de sutura e infección de la herida, 0,85 % (2/233) solo dehiscencia y 0,42 % (1/233) solo infección de la herida. El 18,4 % (43/233) asistieron al control uroginecológico al tercer mes. Entre ellas, el 38,2 % (13/43) tuvo al menos una complicación, principalmente incontinencia fecal y de flatos, 16,3 % (7/43) y 13,9 % (6/43) respectivamente. Conclusiones: la incidencia de DPS y de complicaciones del posparto inmediato en la institución fueron poco frecuentes. Se deben mejorar las estrategias de seguimiento posparto mediante protocolos institucionales, con el fin de identificar y brindar un manejo oportuno de las complicaciones a mediano plazo.
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Cheng W, English E, Horner W, Swenson CW, Chen L, Pipitone F, Ashton-Miller JA, DeLancey JOL. Hiatal failure: effects of pregnancy, delivery, and pelvic floor disorders on level III factors. Int Urogynecol J 2023; 34:327-343. [PMID: 36129480 PMCID: PMC10171831 DOI: 10.1007/s00192-022-05354-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 08/28/2022] [Indexed: 01/26/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The failure of the levator hiatus (LH) and urogenital hiatus (UGH) to remain closed is not only associated with pelvic floor disorders, but also contributes to recurrence after surgical repair. Pregnancy and vaginal birth are key events affecting this closure. An understanding of normal and failed hiatal closure is necessary to understand, manage, and prevent pelvic floor disorders. METHODS This narrative review was conducted by applying the keywords "levator hiatus" OR "genital hiatus" OR "urogenital hiatus" in PubMed. Articles that reported hiatal size related to pelvic floor disorders and pregnancy were chosen. Weighted averages for hiatal size were calculated for each clinical situation. RESULTS Women with prolapse have a 22% and 30% larger LH area measured by ultrasound at rest and during Valsalva than parous women with normal support. Women with persistently enlarged UGH have 2-3 times higher postoperative failure rates after surgery for prolapse. During pregnancy, the LH area at Valsalva increases by 29% from the first to the third trimester in preparation for childbirth. The enlarged postpartum hiatus recovers over time, but does not return to nulliparous size after vaginal birth. Levator muscle injury during vaginal birth, especially forceps-assisted, is associated with increases in hiatal size; however, it only explains a portion of hiatus variation-the rest can be explained by pelvic muscle function and possibly injury to other level III structures. CONCLUSIONS Failed hiatal closure is strongly related to pelvic floor disorders. Vaginal birth and levator injury are primary factors affecting this important mechanism.
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Affiliation(s)
- Wenjin Cheng
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.
- Beaumont Hospital Dearborn, Department of Obstetrics and Gynecology, 18101 Oakwood Blvd, Dearborn, MI, 48124, USA.
| | - Emily English
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Michigan Medicine, University of Michigan Health-West, Grand Rapids, MI, USA
| | - Whitney Horner
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Carolyn W Swenson
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Division of Urogynecology and Pelvic Reconstructive, University of Utah, Salt Lake City, UT, USA
| | - Luyun Chen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Fernanda Pipitone
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - James A Ashton-Miller
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - John O L DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
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Chi X, Yu S, Zhu K, Chen Y, Chu Y, Chen X. Influence of Different Obstetric Factors on Early Postpartum Pelvic Floor Function in Primiparas After Vaginal Delivery. Int J Womens Health 2023; 15:81-90. [PMID: 36713132 PMCID: PMC9879044 DOI: 10.2147/ijwh.s390626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/18/2023] [Indexed: 01/23/2023] Open
Abstract
Purpose This study sought to explore the obstetric factors affecting early postpartum pelvic floor function of primiparas after vaginal delivery. Patients and Methods We included 3362 primiparas who underwent postpartum re-examination in International Peace Maternity and Child Health Hospital at 42-60 days after delivery. The Glazer Protocol was used to evaluate their pelvic floor function, and univariate and multivariate logistic regression analyses were performed to identify obstetric factors that might affect it. Results Forceps-assisted delivery significantly increased the risk of the decline in fast- and slow-twitch muscle strength in the early postpartum period when compared with natural vaginal delivery (P < 0.05). Women with a pre-pregnancy body mass index (BMI) of ≥18.5 kg/m2 had a decreased risk of decline in fast-twitch muscle strength than those with a pre-pregnancy BMI of <18.5 kg/m2 (P < 0.05). Women who had a pre-pregnancy BMI of 24.0 to <28.0 kg/m2 bore a decreased risk of decline in slow-twitch muscle strength than those with a pre-pregnancy BMI of <18.5 kg/m2 (P < 0.05). The risk of decline in fast-twitch muscle strength and slow-twitch muscle in women with anemia during pregnancy was significantly increased (P < 0.05); women with second-stage labors of >2 h had an increased risk of fast-twitch and slow-twitch muscle strength decline than those with <2 h (P < 0.05). Conclusion Both pre-pregnancy underweight and obesity may cause impairment of early postpartum pelvic floor function. Forceps delivery, anemia during pregnancy, and the length of second stage of labor are independent factors leading to pelvic floor function impairment.
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Affiliation(s)
- Xiaolei Chi
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China,Shanghai Key Laboratory of Embryo Original Disease, Shanghai, People’s Republic of China
| | - Shushu Yu
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China,Shanghai Key Laboratory of Embryo Original Disease, Shanghai, People’s Republic of China
| | - Kun Zhu
- Department of Pathology, Tenth People’s Hospital of Tongji University, Shanghai, People’s Republic of China
| | - Yiyao Chen
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China,Shanghai Key Laboratory of Embryo Original Disease, Shanghai, People’s Republic of China
| | - Yi Chu
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China,Shanghai Key Laboratory of Embryo Original Disease, Shanghai, People’s Republic of China
| | - Xinliang Chen
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China,Shanghai Key Laboratory of Embryo Original Disease, Shanghai, People’s Republic of China,Correspondence: Xinliang Chen, Tel +8618017316169, Fax +86(21)64071243, Email
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Doumouchtsis SK, de Tayrac R, Lee J, Daly O, Melendez-Munoz J, Lindo FM, Cross A, White A, Cichowski S, Falconi G, Haylen B. An International Continence Society (ICS)/ International Urogynecological Association (IUGA) joint report on the terminology for the assessment and management of obstetric pelvic floor disorders. Int Urogynecol J 2023; 34:1-42. [PMID: 36443462 PMCID: PMC9834366 DOI: 10.1007/s00192-022-05397-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2022] [Indexed: 11/30/2022]
Abstract
AIMS The terminology of obstetric pelvic floor disorders should be defined and reported as part of a wider clinically oriented consensus. METHODS This Report combines the input of members of two International Organizations, the International Continence Society (ICS) and the International Urogynecological Association (IUGA). The process was supported by external referees. Appropriate clinical categories and a sub-classification were developed to give coding to definitions. An extensive process of 12 main rounds of internal and 2 rounds of external review was involved to exhaustively examine each definition, with decision-making by consensus. RESULTS A terminology report for obstetric pelvic floor disorders, encompassing 357 separate definitions, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it usable by different specialty groups and disciplines involved in the study and management of pregnancy, childbirth and female pelvic floor disorders. Clinical assessment, investigations, diagnosis, conservative and surgical treatments are major components. Illustrations have been included to supplement and clarify the text. Emerging concepts, in use in the literature and offering further research potential but requiring further validation, have been included as an Appendix. As with similar reports, interval (5-10 year) review is anticipated to maintain relevance of the document and ensure it remains as widely applicable as possible. CONCLUSION A consensus-based Terminology Report for obstetric pelvic floor disorders has been produced to support clinical practice and research.
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Affiliation(s)
- Stergios K. Doumouchtsis
- grid.419496.7Department of Obstetrics and Gynaecology, Epsom and St. Helier University Hospitals NHS Trust, Epsom, UK
- grid.264200.20000 0000 8546 682XSt. George’s University of London, London, UK
- grid.5216.00000 0001 2155 0800Laboratory of Experimental Surgery and Surgical Research “N.S. Christeas”, National and Kapodistrian University of Athens, Medical School, Athens, Greece
- grid.464520.10000 0004 0614 2595School of Medicine, American University of the Caribbean, Cupecoy, Sint Maarten
- School of Medicine, Ross University, Miramar, FL USA
| | - Renaud de Tayrac
- grid.411165.60000 0004 0593 8241Nimes University Hospital, Nimes, France
| | - Joseph Lee
- grid.1005.40000 0004 4902 0432University New South Wales, Sydney, Australia
| | - Oliver Daly
- grid.417072.70000 0004 0645 2884Western Health, Melbourne, Australia
| | - Joan Melendez-Munoz
- grid.411295.a0000 0001 1837 4818Hospital Universitari Dr. Josep Trueta, Girona, Spain
| | - Fiona M. Lindo
- grid.63368.380000 0004 0445 0041Houston Methodist Hospital, Texas A&M University College of Medicine, Houston Methodist Hospital, Houston, TX USA
| | - Angela Cross
- grid.415534.20000 0004 0372 0644Middlemore Hospital, Auckland, New Zealand
| | - Amanda White
- grid.89336.370000 0004 1936 9924University of Texas at Austin, Austin, TX USA
| | - Sara Cichowski
- grid.5288.70000 0000 9758 5690Oregon Health & Sciences University, Portland, OR USA
| | - Gabriele Falconi
- grid.413009.fComplex Operative Unit of Gynecology, Fondazione Policlinico Tor Vergata University Hospital, Rome, Italy
| | - Bernard Haylen
- grid.1005.40000 0004 4902 0432University New South Wales, Sydney, Australia
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Tecson-Lim M, Pacquee S, Gillor M, Shek KL, Dietz HP. Is age at menarche a predictor of maternal birth trauma? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:677-681. [PMID: 34580956 DOI: 10.1002/uog.24785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/12/2021] [Accepted: 09/16/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Age at menarche and the interval between menarche and age at first vaginal birth have been shown to be associated with reproductive performance; however, their association with maternal birth trauma has not been studied. We aimed to determine whether age at menarche, age at first vaginal birth and their interval are associated independently with levator ani muscle (LAM) avulsion and external anal sphincter (EAS) defect. METHODS This was a retrospective analysis of the ultrasound volume datasets of 466 vaginally parous patients attending one of two tertiary urogynecological units in Australia. All patients had undergone a standardized interview and clinical examination using the pelvic organ prolapse quantification staging system, followed by four-dimensional translabial ultrasound. Tomographic ultrasound imaging was used to evaluate the LAM for avulsion and the EAS for significant defect. RESULTS Of the 466 women analyzed, LAM avulsion was diagnosed in 121 (26.0%) and significant EAS defect in 55 (11.8%). Logistic regression analysis showed no association between age at menarche and LAM avulsion (P = 0.67). Weak but significant associations were noted between LAM avulsion and age at first vaginal birth (odds ratio (OR), 1.070 (95% CI, 1.03-1.11); P = 0.0007) and between LAM avulsion and menarche-to-first-vaginal-birth interval (OR, 1.064 (95% CI, 1.02-1.11); P = 0.0018). No significant associations were noted between significant EAS defect and any of the evaluated variables (all P ≥ 0.49). CONCLUSIONS Age at menarche is not predictive of maternal birth trauma i.e. LAM avulsion and EAS residual defect. There was a statistically significant association between LAM avulsion and menarche-to-first-vaginal-birth interval; however, this was not stronger than the previously established association between LAM avulsion and age at first vaginal birth, arguing against any distinct effect of prolonged prepregnancy hormonal stimulation on the biomechanical properties of the pelvic floor. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- M Tecson-Lim
- Ultrasound Center for Women, Department of Obstetrics and Gynecology, Southern Philippines Medical Center, Davao City, Philippines
| | - S Pacquee
- Sydney Medical School Nepean, University of Sydney, Penrith, NSW, Australia
| | - M Gillor
- Kaplan Medical Centre, Rehovot, affiliated to the Hebrew University and Hadassah School of Medicine, Jerusalem, Israel
| | - K L Shek
- Sydney Medical School Nepean, University of Sydney, Penrith, NSW, Australia
- Obstetrics and Gynaecology, Western Sydney University, Liverpool, NSW, Australia
| | - H P Dietz
- Sydney Medical School Nepean, University of Sydney, Penrith, NSW, Australia
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Wu S, Ren Y, Lin X, Huang Z, Zheng Z, Zhang X. Development and validation of a composite AI model for the diagnosis of levator ani muscle avulsion. Eur Radiol 2022; 32:5898-5906. [PMID: 35362748 DOI: 10.1007/s00330-022-08754-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: 11/06/2021] [Revised: 02/08/2022] [Accepted: 03/18/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the feasibility and reliability of a composite AI model for the diagnosis of levator ani muscle (LAM) avulsion of tomographic ultrasound imaging (TUI). METHODS Ultrasonic images of the pelvic floor from a total of 304 patients taken from January 2018 to October 2020 were included. All patients included underwent standardized interviews and transperineal ultrasound (TPUS). Transfer-learning and ensemble-learning methods were adopted to develop the proposed model on the basis of three classic convolutional neural networks (CNN). Confusion matrix (CM) and the ROC statistic were used to assess the effectiveness of the proposed model. Gradient-weighted class activation mappings (Grad-CAMs) were used to help enhance the interpretability of the proposed model. RESULTS Of the 304 patients included, 208 were in the derivation cohort (108 LAM avulsion and 100 normal) and 96 (39 LAM avulsion and 57 normal) were in the validation cohort. The proposed model in LAM avulsion diagnosis outperformed other models and a junior clinician in both the test set of derivation cohort and the validation cohort, with accuracies of 0.95 and 0.81, and AUCs of 0.98 and 0.86, respectively. According to the heatmap of Grad-CAMs, the proposed model mainly localizes areas between the pubic symphysis and the bilateral insertion point of LAM when making a diagnosis, which is exactly the region of interest in clinical practice. CONCLUSION The proposed model using ultrasonic images of the pelvic floor may be a promising tool in assisting the diagnosis of LAM avulsion in clinical practice. KEY POINTS • First AI-assisted model for levator ani muscle avulsion diagnosis • Diagnosis accuracy of less-experienced clinicians could be improved using the proposed model.
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Affiliation(s)
- Shuangyu Wu
- Department of Ultrasound, The Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou, Guangdong Province, China
| | - Yong Ren
- Guangdong Provincial Key Laboratory of Digestive Cancer Research, The Seventh Affiliated Hospital of Sun Yat-Sen University, Shenzhen, Guangdong Province, China.,Artificial Intelligence Innovation Center, Research Institute of Tsinghua, Pearl River Delta, Guangzhou, Guangdong Province, China
| | - Xin Lin
- Department of Ultrasound, The Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou, Guangdong Province, China
| | - Zeping Huang
- Department of Ultrasound, The Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou, Guangdong Province, China
| | - Zhijuan Zheng
- Department of Ultrasound, The Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou, Guangdong Province, China
| | - Xinling Zhang
- Department of Ultrasound, The Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou, Guangdong Province, China.
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Yao L, Li F, Wang D, Sheng S. Evaluation of acupuncture treatments of postpartum female pelvic floor dysfunction by four-dimensional transperineal pelvic floor ultrasound. Medicine (Baltimore) 2021; 100:e27236. [PMID: 34678860 PMCID: PMC8542121 DOI: 10.1097/md.0000000000027236] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 08/26/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION In the present investigation, a systematic evaluation of the clinical treatment performance of diagnosed with pelvic floor dysfunction is explored. By comparing the 4Dtransperineal pelvic floor ultrasound images with the acupuncture treatment performance of the patients, an evaluation system with various parameters is established to provide critical information to guide the clinical treatment fpostpartum female pelvic floor dysfunction (FPFD). METHODS Eighty patients diagnosed with FPFD are divided into 2 groups. After the designated treatment to the patients, they are carefully examined using transperineal pelvic floor ultrasound. The shape and activity of bladder neck, cervix and rectum anal canal under resting, anal sphincter and Valsalva movements are observed and recorded. The morphology and continuous shape of levator ani muscle in different states after 4D image reconstruction are obtained. RESULTS After the acupuncture treatment, the bladder neck descent is decreased by 3.8 cm and the anal levator muscle area is decreased by 3.4 cm2 comparing with the control group. The anal levator muscle hole diameter is decreased by 0.3 cm, while the anterior and posterior diameter is reduced by 0.5 cm. Reduced possibility of cystocele and uterine prolapse is demonstrated by X2 test. These changes upon acupuncture therapy are in line with the improved conditions of the patients, indicating these parameters can help evaluate the therapy performance. CONCLUSION 4D pelvic floor ultrasound imaging provides objective and quantified information for the clinical diagnosis and treatment of FPFD and the assessment of therapy efficacy, making it a promising novel method in practical applications.
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12
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Yune Y, Jeong HY, Park DH, Lee JK. Three-Dimensional Pelvic Floor Ultrasound Assessment of Pelvic Organ Prolapse: Minimal Levator Hiatus and Levator Ani Deficiency Score. Ann Coloproctol 2021; 37:291-297. [PMID: 34376023 PMCID: PMC8566146 DOI: 10.3393/ac.2020.01095.0156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/16/2021] [Indexed: 11/17/2022] Open
Abstract
Purpose The purpose of this study was to determine whether levator ani deficiency (LAD) scores and minimal levator hiatus (MLH) areas affect Pelvic Organ Prolapse Quantification (POP-Q) stage. Methods This study was a retrospective chart review of patients with pelvic organ prolapse (POP) at Seoul Songdo Hospital between August 2019 and August 2020. Three-dimensional (3D) pelvic floor ultrasound, preoperative anal manometry, and other physiological tests were performed in 78 patients with POP symptoms. We divided the patients into mild prolapse and severe prolapse groups based on the POP-Q. We examined the LAD and MLH areas. LAD scores were categorized as mild, moderate, or severe. Results There were 32 patients (41.0%) in the mild prolapse group (POP-Q stage I and II) and 46 (59.0%) in the severe prolapse group (POP-Q stage III and IV). The mean LAD score was significantly higher in severe prolapse group (13.33±2.49 vs. 8.19±2.92, P<0.001), and the rate of severe deficiency was also significantly higher in the severe prolapse group (29 [63.0%] vs. 2 [6.3%], P<0.001). The mean MLH was also significantly larger in the severe prolapse group (17.91±2.74 cm2 vs. 14.95±2.60 cm2, P<0.001). In addition, both MLH and LAD scores tended to increase at each stage. Conclusion There is a strong positive correlation between the POP-Q stage and the MLH and LAD scores that can be seen on 3D pelvic floor ultrasound. The findings of this study, by objectively demonstrating LAD and MLH in women with POP, are an important contribution to POP.
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Affiliation(s)
- Yongwoo Yune
- Department of Surgery, Seoul Songdo Hospital, Seoul, Korea
| | | | - Duk Hoon Park
- Department of Surgery, Seoul Songdo Hospital, Seoul, Korea
| | - Jong Kyun Lee
- Department of Surgery, Seoul Songdo Hospital, Seoul, Korea
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13
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Rusavy Z, Paymova L, Kozerovsky M, Veverkova A, Kalis V, Kamel RA, Ismail KM. Levator ani avulsion: a Systematic evidence review (LASER). BJOG 2021; 129:517-528. [PMID: 34245656 DOI: 10.1111/1471-0528.16837] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is variation in the reported incidence rates of levator avulsion (LA) and paucity of research into its risk factors. OBJECTIVE To explore the incidence rate of LA by mode of birth, imaging modality, timing of diagnosis and laterality of avulsion. SEARCH STRATEGY We searched MEDLINE, EMBASE, CINAHL, AMED and MIDIRS with no language restriction from inception to April 2019. STUDY ELIGIBILITY CRITERIA A study was included if LA was assessed by an imaging modality after the first vaginal birth or caesarean section. Case series and reports were not included. DATA COLLECTION AND ANALYSIS RevMan v5.3 was used for the meta-analyses and SW SAS and STATISTICA packages were used for type and timing of imaging analyses. RESULTS We included 37 primary non-randomised studies from 17 countries and involving 5594 women. Incidence rates of LA were 1, 15, 21, 38.5 and 52% following caesarean, spontaneous, vacuum, spatula and forceps births, respectively, with no differences by imaging modality. Odds ratio of LA following spontaneous birth versus caesarean section was 10.69. The odds ratios for LA following vacuum and forceps compared with spontaneous birth were 1.66 and 6.32, respectively. LA was more likely to occur unilaterally than bilaterally following spontaneous (P < 0.0001) and vacuum-assisted (P = 0.0103) births but not forceps. Incidence was higher if assessment was performed in the first 4 weeks postpartum. CONCLUSIONS LA incidence rates following caesarean, spontaneous, vacuum and forceps deliveries were 1, 15, 21 and 52%, respectively. Ultrasound and magnetic resonance imaging were comparable tools for LA diagnosis. TWEETABLE ABSTRACT Levator avulsion incidence rates after caesarean, spontaneous, vacuum and forceps deliveries were 1, 15, 21 and 52%, respectively.
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Affiliation(s)
- Z Rusavy
- Department of Obstetrics and Gynaecology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Obstetrics and Gynaecology, University Hospital, Pilsen, Czech Republic
| | - L Paymova
- Department of Obstetrics and Gynaecology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Obstetrics and Gynaecology, University Hospital, Pilsen, Czech Republic
| | - M Kozerovsky
- Department of Obstetrics and Gynaecology, University Hospital, Pilsen, Czech Republic
| | - A Veverkova
- Department of Obstetrics and Gynaecology, University Hospital, Pilsen, Czech Republic
| | - V Kalis
- Department of Obstetrics and Gynaecology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Obstetrics and Gynaecology, University Hospital, Pilsen, Czech Republic
| | - R A Kamel
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Cairo University, Cairo, Egypt
| | - K M Ismail
- Department of Obstetrics and Gynaecology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
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Levator Morphology and Strength After Obstetric Avulsion of the Levator Ani Muscle. Female Pelvic Med Reconstr Surg 2021; 26:56-60. [PMID: 30272594 DOI: 10.1097/spv.0000000000000641] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Obstetric levator avulsion may be an important risk factor for prolapse. This study compares the size of the levator hiatus, the width of the genital hiatus, and pelvic muscle strength between vaginally parous women with or without levator avulsion, 5 to 15 years after delivery. METHODS Parous women were assessed for levator ani avulsion, using 3-dimensional transperineal ultrasound. Women with and without levator ani avulsion were compared with respect to levator hiatus areas (measured on ultrasound), genital hiatus (measured on examination), and pelvic muscle strength (measured with perineometry). Further analysis also considered the association of forceps-assisted birth. RESULTS At a median interval of 11 years from first delivery, levator avulsion was identified in 15% (66/453). A history of forceps-assisted delivery was strongly associated with levator avulsion (45% vs 8%; P < 0.001). Levator avulsion was also associated with a larger levator hiatus area (+7.3 cm; 95% confidence interval [CI], 4.1-10.4, with Valsalva), wider genital hiatus (+0.6 cm; 95% CI, 0.3-0.9, with Valsalva), and poorer muscle strength (-14.5 cm H2O; 95% CI, -20.4 to -8.7, peak pressure). Among those with levator avulsion, forceps-assisted birth was associated with a marginal increase in levator hiatus size but not genital hiatus size or muscle strength. CONCLUSIONS Obstetric levator avulsion is associated with a larger levator hiatus, wider genital hiatus, and poorer pelvic muscle strength. Forceps-assisted birth is an important marker for levator avulsion but may not be an independent risk factor for the development of pelvic muscle weakness or changes in hiatus size in the absence of levator avulsion.
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15
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Dietz HP. Ultrasound imaging of maternal birth trauma. Int Urogynecol J 2021; 32:1953-1962. [PMID: 33595672 DOI: 10.1007/s00192-020-04669-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/28/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The term 'maternal birth trauma' has undergone substantial changes in meaning over the last 2 decades. Leaving aside psychological morbidity, somatic trauma is now understood to encompass not just episiotomy, perineal tears and obstetric anal sphincter injuries (OASI), but also trauma to the levator ani muscle. This review covers diagnosis of maternal birth trauma by translabial ultrasound imaging. METHODS Narrative review. RESULTS Tomographic imaging of pelvic structures with the help of 4D ultrasound, used since 2007, has allowed international standardization and seems to be highly reproducible and valid for the diagnosis of OASI and levator avulsion. CONCLUSIONS Translabial and exo-anal ultrasound allows the assessment of maternal birth trauma in routine clinical practice and the utilization of avulsion and sphincter trauma as key performance indicators of maternity services. It is hoped that this will lead to a greater awareness of maternal birth trauma among maternity caregivers and improved outcomes for patients, both in the short term and in the decades to come.
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Affiliation(s)
- Hans Peter Dietz
- Department of Obstetrics, Gynecology & Neonatology, Sydney Medical School Nepean, The University of Sydney, 62 Derby Street, Kingswood, NSW, 2747, Australia.
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16
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Early postpartum physical activity and pelvic floor support and symptoms 1 year postpartum. Am J Obstet Gynecol 2021; 224:193.e1-193.e19. [PMID: 32798462 DOI: 10.1016/j.ajog.2020.08.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/27/2020] [Accepted: 08/11/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Risks of pelvic organ prolapse and urinary incontinence increase after the first vaginal delivery. During the early postpartum period, a time of active regeneration and healing of the pelvic floor, women may be particularly vulnerable to greater pelvic floor loading. OBJECTIVE This prospective cohort study aimed to determine whether objectively measured moderate to vigorous physical activity in the early postpartum period predicts pelvic floor support and symptoms 1 year after the first vaginal birth. STUDY DESIGN We enrolled nulliparous women in the third trimester, later excluding those who had a cesarean or preterm delivery. Participants wore triaxial wrist accelerometers at 2 to 3 weeks and 5 to 6 weeks postpartum for ≥4 days. Primary outcomes, assessed 1 year postpartum, included (1) pelvic floor support on Pelvic Organ Prolapse Quantification examination, dichotomized as maximal vaginal descent of <0 cm (better support) vs ≥0 cm (worse support); and (2) pelvic floor symptom burden, considered positive with report of ≥1 bothersome symptom in ≥2 of 6 domains, assessed using the Epidemiology of Prolapse and Incontinence Questionnaire. The primary predictor was average daily moderate to vigorous physical activity. Because we could not eliminate women with pelvic floor changes before pregnancy, we modeled prevalence, rather than risk, ratios for each outcome using modified Poisson regression. RESULTS Of 825 participants eligible after delivery, 611 completed accelerometry and 1-year follow-up; 562 completed in-person visits, and 609 completed questionnaires. The mean age was 28.9 years (standard deviation, 5.01). The mean for moderate to vigorous physical activity measured in minutes per day was 57.3 (standard deviation, 25.4) and 68.1 (standard deviation, 28.9) at 2 to 3 weeks and 5 to 6 weeks, respectively. One year postpartum, 53 of 562 participants (9.4%) demonstrated worse vaginal support and 330 of 609 participants (54.2%) met criteria for pelvic floor symptom burden. In addition, 324 (53.1%), 284 (46.6%), 144 (23.6%), and 25 (4.1%) reported secondary outcomes of stress urinary incontinence, overactive bladder, anal incontinence, and constipation, respectively, and 264 (43.4%), 250 (41.0%), and 89 (14.6%) reported no, mild, or moderate to severe urinary incontinence, respectively. The relationship between moderate to vigorous physical activity and outcomes was not linear. On the basis of plots, we grouped quintiles of moderate to vigorous physical activity into 3 categories: first and second quintiles combined, third and fourth quintiles combined, and fifth quintile. In final multivariable models, compared with women in moderate to vigorous physical activity quintiles 3 and 4, those in the lower 2 (prevalence ratio, 0.55; 95% confidence interval, 0.31-1.00) and upper quintile (prevalence ratio, 0.70; 95% confidence interval, 0.35-1.38)) trended toward lower prevalence of worse support. However, we observed the reverse for symptom burden: compared with women in quintiles 3 and 4, those in the lower 2 (prevalence ratio, 1.20; 95% confidence interval, 1.02-1.41) and upper quintile prevalence ratio 1.34 (95% confidence interval, 1.11-1.61) demonstrated higher prevalence of symptom burden. Moderate to vigorous physical activity did not predict any of the secondary outcomes. The presence of a delivery factor with potential to increase risk for levator ani muscle injury did not modify the effect of moderate to vigorous physical activity on outcomes. CONCLUSION Except for support, which was worse in women with moderately high levels of activity, early postpartum moderate to vigorous physical activity was either protective or had no effect on other parameters of pelvic floor health. Few women performed substantial vigorous activity, and thus, these results do not apply to women performing strenuous exercise shortly after delivery.
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Jansson MH, Franzén K, Hiyoshi A, Tegerstedt G, Dahlgren H, Nilsson K. Risk factors for perineal and vaginal tears in primiparous women - the prospective POPRACT-cohort study. BMC Pregnancy Childbirth 2020; 20:749. [PMID: 33267813 PMCID: PMC7709229 DOI: 10.1186/s12884-020-03447-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 11/20/2020] [Indexed: 01/15/2023] Open
Abstract
Background The aim of this study was to estimate the incidence of second-degree perineal tears, obstetric anal sphincter injuries (OASI), and high vaginal tears in primiparous women, and to examine how sociodemographic and pregnancy characteristics, hereditary factors, obstetric management and the delivery process are associated with the incidence of these tears. Methods All nulliparous women registering at the maternity health care in Region Örebro County, Sweden, in early pregnancy between 1 October 2014 and 1 October 2017 were invited to participate in a prospective cohort study. Data on maternal and obstetric characteristics were extracted from questionnaires completed in early and late pregnancy, from a study-specific delivery protocol, and from the obstetric record system. These data were analyzed using unadjusted and adjusted multinomial and logistic regression models. Results A total of 644 women were included in the study sample. Fetal weight exceeding 4000 g and vacuum extraction were found to be independent risk factors for both second-degree perineal tears (aOR 2.22 (95% CI: 1.17, 4.22) and 2.41 (95% CI: 1.24, 4.68) respectively) and OASI (aOR 6.02 (95% CI: 2.32, 15.6) and 3.91 (95% CI: 1.32, 11.6) respectively). Post-term delivery significantly increased the risk for second-degree perineal tear (aOR 2.44 (95% CI: 1.03, 5.77), whereas, maternal birth positions with reduced sacrum flexibility significantly decreased the risk of second-degree perineal tear (aOR 0.53 (95% CI 0.32, 0.90)). Heredity of pelvic floor dysfunction and/or connective tissue deficiency, induced labor, vacuum extraction and fetal head circumference exceeding 35 cm were independent risk factors for high vaginal tears (aOR 2.32 (95% CI 1.09, 4.97), 3.16 (95% CI 1.31, 7.62), 2.53 (95% CI: 1.07, 5.98) and 3.07 (95% CI 1.5, 6.3) respectively). Conclusion The present study corroborates previous findings of vacuum extraction and fetal weight exceeding 4000 g as risk factors of OASI. We found that vacuum extraction is a risk factor for second-degree tear, and vacuum extraction, fetal head circumference exceeding 35 cm and heredity of pelvic floor dysfunction and/or connective tissue deficiency were associated with increased risk of high vaginal tears. These findings have not been documented previously and should be confirmed by additional studies.
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Affiliation(s)
- Markus Harry Jansson
- Department of Obstetrics and Gynecology, Örebro University Hospital, Örebro, Sweden. .,School of Medical Sciences, Faculty of Health and Medicine, Örebro University, SE-701 82, Örebro, Sweden.
| | - Karin Franzén
- Department of Obstetrics and Gynecology, Örebro University Hospital, Örebro, Sweden.,School of Medical Sciences, Faculty of Health and Medicine, Örebro University, SE-701 82, Örebro, Sweden
| | - Ayako Hiyoshi
- School of Medical Sciences, Faculty of Health and Medicine, Örebro University, SE-701 82, Örebro, Sweden
| | - Gunilla Tegerstedt
- Unit of Obstetrics and Gynecology, CLINTEC, Karolinska University Hospital at Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Hedda Dahlgren
- Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - Kerstin Nilsson
- School of Medical Sciences, Faculty of Health and Medicine, Örebro University, SE-701 82, Örebro, Sweden
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Lin W, Lin L, Dong B, Chen L, Lei H, Gao Y, Chen Y, Sun P. The Role of Obstetric Factors, miRNA-30d and miRNA-181a in Postpartum Women with Pelvic Organ Prolapse. Risk Manag Healthc Policy 2020; 13:2309-2316. [PMID: 33149711 PMCID: PMC7604264 DOI: 10.2147/rmhp.s268235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/15/2020] [Indexed: 01/06/2023] Open
Abstract
Background The diagnosis of postpartum pelvic organ prolapse (POP) relies on symptoms combined with pelvic organ prolapse-quantification (POP-Q) and lacks serological indicators. The objective of this study was to assess serum elastin, type I collagen, miRNA-30d, and miRNA-181a in the early postpartum period to identify hematologic predictors of POP. Material and Methods The study included 1013 42- to 60-day-postpartum women who had delivered at Quanzhou Women's and Children's Hospital from October 1, 2016, to October 31, 2017. This study was performed in accordance with the Declaration of Helsinki. The pregnancy and childbirth characteristics and pelvic floor function were evaluated. Forty cases with and without POP were matched, and serum elastin and type I collagen were determined by enzyme-linked immunosorbent assay (ELISA). Reverse-transcription polymerase chain reaction (RT-PCR) was used to detect miRNA-30d and miRNA-181a in 15 pairs. Results Of the 1013 women recruited, 699 (69.00%) were diagnosed with POP. The mean age was 29.00 years old, and the mean body mass index (BMI) was 22.6 kg/m2. In the univariate analysis, age ≥35 years (OR, 1.449; 95% CI, 0.965, 2.298), postpartum BMI ≥ 24 (OR, 4.402; 95% CI, 2.657, 6.148), neonatal weight ≥4 kg (OR, 4.832; 95% CI, 1.373, 17.290) and vaginal delivery (OR, 2.751; 95% CI, 1.855, 4.081) were risk factors for postpartum POP. There were no significant differences in the concentrations of serum elastin and type I collagen between the groups (P=0.52; P=0.26). There were significant differences in the concentrations of miRNA-30d and miRNA-181a between the groups (P=0.004; P=0.003). Conclusion miRNA-30d and miRNA-181a tended to be increased in women with POP and could be potential clinical predictors.
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Affiliation(s)
- Wenyu Lin
- Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Liqing Lin
- Department of Women's Health Care, Quanzhou Women's and Children's Hospital, Quanzhou, 362000, People's Republic of China
| | - Binhua Dong
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China.,Laboratory of Gynecologic Oncology, Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Lihua Chen
- Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China
| | - Huifang Lei
- Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Yuqin Gao
- Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Yaojia Chen
- Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Pengming Sun
- Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China.,Laboratory of Gynecologic Oncology, Department of Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, 350001, People's Republic of China
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Lima CTS, Brito GA, Karbage SAL, Bilhar APM, Grande AJ, Carvalho FHC, Bezerra LRPS, Nascimento SL. Pelvic floor ultrasound finds after episiotomy and severe perineal tear: systematic review and meta-analysis. J Matern Fetal Neonatal Med 2020; 35:2375-2386. [PMID: 32660290 DOI: 10.1080/14767058.2020.1786049] [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] [Indexed: 10/23/2022]
Abstract
AIM Vaginal delivery is a well-known risk factor for pelvic floor muscle (PFM) injuries, mainly when associated to prolonged labor, instrumental birth and perineal trauma such as episiotomy and perineal tears. The purpose of this meta-analysis was to test the hypothesis that episiotomy and severe perineal tear may increase the risk of pelvic floor damage. METHODS We performed a systematic literature search through electronic databases including MEDLINE via PubMed, LILACS via BVS, Embase via Elsevier and Cochrane Library up to January 2019. We included articles that reported as outcome one or more morphological aspects of the PFM evaluated by ultrasonography in primiparous women three to 24 months postpartum. This review is registered in the PROSPERO database (registration number: CRD42017075750). RESULTS the final selection was composed of 18 articles for the systematic review, and 10 for the meta-analysis. Women with levator ani muscle (LAM) avulsion were 1.77 times more likely to have undergone episiotomy (OR = 1.77, CI 95% 1.25-2.51, five trials), 4.31 times more likely to have severe perineal tear (OR = 4.31, CI 95% 2.34-7.91, two trials). Women with defects in the anal sphincters were 2.82 times more likely to have suffered severe perineal tear (OR = 2.82, 95% CI 1.71-4.67, three trials). CONCLUSIONS Both episiotomy and severe perineal tear are risk factors for LAM avulsion and anal sphincter injury, and this can be useful for identifying women who are at greater risk of developing PFM dysfunctions.
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Affiliation(s)
- Clara Taína Silva Lima
- Department of Women's, Child and Adolescent Health, Federal University of Ceara, Fortaleza, Brazil
| | | | | | - Andreisa Paiva Monteiro Bilhar
- Department of Women's, Child and Adolescent Health, Federal University of Ceara, Fortaleza, Brazil.,Maternity School Assis Chateaubriand, Fortaleza, Brazil
| | - Antônio José Grande
- Medicine and Sciences Department, State University of Mato Grosso do Sul, Brazil
| | - Francisco Herlânio Costa Carvalho
- Department of Women's, Child and Adolescent Health, Federal University of Ceara, Fortaleza, Brazil.,Maternity School Assis Chateaubriand, Fortaleza, Brazil
| | | | - Simony Lira Nascimento
- Department of Women's, Child and Adolescent Health, Federal University of Ceara, Fortaleza, Brazil.,Department of Physical Therapy, Federal University of Ceara, Fortaleza, Brazil.,Maternity School Assis Chateaubriand, Fortaleza, Brazil
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Abstract
OBJECTIVE The goal of this study was to evaluate differences in levator ani hematoma formation within 3 days of delivery between adult women after their first vaginal delivery and adult women who have had multiple vaginal deliveries. METHODS This was a cross-sectional study at a single institution from 2013 to 2015 using a high-resolution endovaginal ultrasound transducer to identify postvaginal delivery hematoma formation. Logistic regression was used to examine the association between hematoma formation and vaginal parity while considering potential confounders including induction, vaginal operative delivery, vaginal birth after cesarean, fetal weight, fetal head circumference, race and ethnicity, body mass index, age at delivery, gestational age, and length of second-stage labor. RESULTS Ninety women (46 vaginal-primiparous; 44 vaginal-multiparous) were included in this study. After adjusting for oxytocin use, length of second-stage labor, and body mass index, the odds of pelvic floor hematoma of 1000 mm3 or greater were 2.93 (95% confidence interval, 0.78-10.91) times greater in women after their first vaginal delivery compared with women with a history of multiple vaginal deliveries. The adjusted odds of pelvic floor hematoma of 1500 mm3 or greater were 6.02 (95% confidence interval, 1.09-33.24) times greater in vaginal-primiparous compared with vaginal-multiparous women. CONCLUSIONS Although the prevalence of pelvic floor hematoma was higher in vaginal-primiparous women than vaginal-multiparous women after vaginal delivery, hematomas were present in both groups. Future prospective studies are needed to evaluate the additive effect of multiple vaginal deliveries on the pelvic floor.
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The effect of replacing vacuum with forceps in operative vaginal delivery: an observational study. Int Urogynecol J 2020; 31:1771-1776. [PMID: 32535687 DOI: 10.1007/s00192-020-04352-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: 02/11/2020] [Accepted: 05/20/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS An increase in vaginal delivery with forceps may increase rates of pelvic floor trauma. This study was designed to predict trauma rates resulting from policies preferencing forceps. METHODS This is an observational cohort study utilizing data from 660 primiparae enrolled in an RCT in two tertiary obstetric units in Sydney, Australia. Participants were assessed clinically and with 4D translabial ultrasound in the late third trimester and again at 3-6 months postpartum. Incidence of trauma associated with mode of delivery was adjusted to reflect change associated with a conversion of vacuum to forceps delivery. Primary outcome measures were third-/fourth-degree tear, levator avulsion (LA) and external anal sphincter (EAS) trauma diagnosed sonographically. RESULTS Five hundred four women were seen at a mean of 5.1 (2.3-24.3) months postpartum. After exclusion of 21 because of missing data, 483 women were analysed: 112 (23%) had a CS, 268 (55%) a normal vaginal delivery (NVD), 69 (14%) a vacuum (VD) and 34 (7%) a forceps (FD). One hundred fifty-two women had EAS trauma and/or LA; 17 sustained both. After VD, 32/69 (46%) women suffered LA and/or EAS trauma; after FD, it was 33/34 (97%). Converting VD to FD was estimated to result in an increase in trauma from 152/483 (31%) to 187/483 (39%). A formula can be generated based on local obstetric and ultrasound data to estimate trauma incidence. CONCLUSIONS A change in obstetric practice resulting in the conversion of primary VD to primary FD would be expected to substantially increase the likelihood of pelvic floor trauma.
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Cassadó J, Simó M, Rodríguez N, Porta O, Huguet E, Mora I, Girvent M, Fernández R, Gich I. Prevalence of levator ani avulsion in a multicenter study (PAMELA study). Arch Gynecol Obstet 2020; 302:273-280. [PMID: 32449062 DOI: 10.1007/s00404-020-05585-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 05/05/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE The objective is to determine the prevalence of levator ani muscle (LAM) avulsion using four-dimensional ultrasound in primiparous women after vaginal delivery and according to delivery mode. METHODS This prospective, multicenter study included 322 women evaluated at 6-12 months postpartum by four-dimensional transperineal ultrasound to identify levator ani muscle avulsion. The researcher who performed the ultrasound was blinded to all clinical data. Meaningful data about the birth were also recorded: mode of delivery, mother's age and body mass index, duration of second stage, episiotomy, perineal tearing, anesthesia, assistant, head circumference and fetal weight. RESULTS 303 volumes were valid for evaluation. The overall prevalence of levator ani muscle avulsion was 18.8% (95% CI 14.4-23.2%). In our multivariate analysis, only mode of delivery reached statistical significance as a risk factor for levator ani muscle avulsion (p < 0.001). The prevalence according to the different modes of delivery was 7.8% in spontaneous delivery, 28.8% in vacuum-assisted and 51.1% in forceps-assisted delivery. Compared with spontaneous delivery, the OR for LAM avulsion was 12.31 with forceps (CI 95% 5.65-26.80) and 4.78 with vacuum-assisted delivery (CI 95% 2.15-10.63). CONCLUSIONS Levator ani avulsion during vaginal delivery in primiparous women occurs in nearly one in every five deliveries. Delivery mode is a significant and modifiable intrapartum risk factor for this lesion. The incidence is lower in spontaneous delivery and significantly increases when an instrument is used to assist delivery, especially forceps.
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Affiliation(s)
- Jordi Cassadó
- Obstetrics and Gynecology Department, Hospital Universitari Mútua de Terrassa, Plaça Dr. Robert, 4, 08221, Terrassa, Spain.
| | - Marta Simó
- Obstetrics and Gynecology Department, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Nuria Rodríguez
- Obstetrics and Gynecology Department, Hospital Universitari de la Vall d'Hebrón, Barcelona, Spain
| | - Oriol Porta
- Obstetrics and Gynecology Department, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Eva Huguet
- Obstetrics and Gynecology Department, Hospital Universitari Mútua de Terrassa, Plaça Dr. Robert, 4, 08221, Terrassa, Spain
| | - Irene Mora
- Obstetrics and Gynecology Department, Consorci Sanitari d'Igualada, Igualada, Spain
| | - Marta Girvent
- Obstetrics and Gynecology Department, Hospital General de Granollers, Granollers, Spain
| | - Rebeca Fernández
- Obstetrics and Gynecology Department, Hospital Universitari Dexeus, Barcelona, Spain
| | - Ignasi Gich
- Sant Pau Biomedical Research Institute (IIB Sant Pau) and CIBER Epidemiology and Public Health (CIBERESP), Barcelona, Spain
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Kimmich N, Birri J, Zimmermann R, Kreft M. Association between the side of levator Ani muscle trauma and fetal position at birth - a prospective observational study. Z Geburtshilfe Neonatol 2020; 225:134-139. [PMID: 32380559 DOI: 10.1055/a-1153-9387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Trauma of the levator ani muscle (LAM) is common after vaginal birth and can most reliably be diagnosed by 3-dimensional (3D) translabial ultrasound (TLUS). Multiple risk factors are known in general, but not in association to a specific side of the body. Therefore, our aim was to evaluate different impact factors which cause LAM trauma on either side of the body or bilateral by focusing on the fetal position at birth. MATERIAL AND METHODS As part of a prospective cohort study between 3/2017 and 4/2019, we analyzed vaginal births of nulliparous women with singletons in vertex presentation≥36+0 gestational weeks. We evaluated their pelvic floor for hematomas, partial and complete LAM avulsions by 3D TLUS 2-4 days postpartum and searched for an association between the affected body side and different fetal, maternal and obstetrical factors. RESULTS 71 out of 213 women (33.3%) suffered from LAM trauma - 17 (23.9%) on the right side, 20 (28.2%) on the left side and 34 (47.9%) bilateral. No association between the different evaluated factors and the affected body side could be identified, except for the quality of fetal heart rate tracing. CONCLUSIONS No significant impact factors of LAM trauma could be associated with a specific side of the body. Other possible mechanisms need investigation in the future, such as the time of the birth canal and the fetus to adapt to each other, including adequate time for the tissue to stretch and the fetus to rotate into the ideal position within the LAM hiatus. EINLEITUNG Levatormuskelverletzungen sind häufig nach Vaginalgeburten und können zuverlässig mittels translabialem 3D-Ultraschall diagnostiziert werden. Diverse Risikofaktoren sind hierfür bekannt, allerdings keine hinsichtlich der Assoziation zu einer der beiden Körperseiten. Daher war das Ziel dieser Arbeit, verschiedene Einflussfaktoren im Rahmen vaginaler Geburten zu evaluieren, welche eine Levatorverletzung auf einer der beiden Körperseiten bzw. beidseitig begünstigen, v. a. hinsichtlich der Kindsposition im Geburtskanal. MATERIAL UND METHODIK In einer prospektiven Kohortenstudie analysierten wir von 3/2017-4/2019 Erstgebärende mit vaginalen Einlingsgeburten aus Schädellage≥36+0 SSW. Wir evaluierten 2-4 Tage postpartal ihren Beckenboden mittels 3D-Ultraschall hinsichtlich Hämatomen sowie partiellen und kompletten Levatoravulsionen und suchten nach Assoziationen zwischen der betroffenen Körperseite und fetalen, maternalen und geburtshilflichen Einflussfaktoren. ERGEBNISSE Von 213 Frauen erlitten 71 (33.3%) eine Levatorverletzung - 17 (23.9%) rechtsseitig, 20 (28.2%) linksseitig und 34 (47.9%) beidseitig. Es wurden keine Assoziationen zwischen den untersuchten Einflussfaktoren und der betroffenen Körperseite gefunden, bis auf die Qualität der fetalen Herzfrequenz. DISKUSSION Es konnten keine signifikanten Einflussfaktoren für das Auftreten einer Levatorverletzung einer spezifischen Körperseite eruiert werden. Daher bedarf es in Zukunft der Untersuchung weiterer Mechanismen, wie der Adaptationsvorgänge von Geburtskanal und Fet und der adäquaten Zeit für das Gewebe zur notwendigen Dehnung, v. a. im Bereich der Levatoröffnung.
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Affiliation(s)
- Nina Kimmich
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Jana Birri
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Roland Zimmermann
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Martina Kreft
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland.,Sydney Ultrasound for Women, Sydney, Australia
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Urinary Incontinence in Women: Modern Methods of Physiotherapy as a Support for Surgical Treatment or Independent Therapy. J Clin Med 2020; 9:jcm9041211. [PMID: 32340194 PMCID: PMC7230757 DOI: 10.3390/jcm9041211] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/20/2020] [Accepted: 04/20/2020] [Indexed: 12/12/2022] Open
Abstract
Urinary incontinence (UI) is a common health problem affecting quality of life of nearly 420 million people, both women and men. Pelvic floor muscle (PFM) training and other physiotherapy techniques play an important role in non-surgical UI treatment, but their therapeutic effectiveness is limited to slight or moderate severity of UI. Higher UI severity requires surgical procedures with pre- and post-operative physiotherapy. Given that nearly 30%–40% of women without dysfunction and about 70% with pelvic floor dysfunction are unable to perform a correct PFM contraction, therefore, it is particularly important to implement physiotherapeutic techniques aimed at early activation of PFM. Presently, UI physiotherapy focuses primarily on PFM therapy and its proper cooperation with synergistic muscles, the respiratory diaphragm, and correction of improper everyday habits for better pelvic organ support and continence. The purpose of this work is a systematic review showing the possibilities of using physiotherapeutic techniques in the treatment of UI in women with attention to the techniques of PFM activation. Evidence of the effectiveness of well-known (e.g., PFM training, biofeedback, and electrostimulation) and less-known (e.g., magnetostimulation, vibration training) techniques will be presented here regarding the treatment of symptoms of urinary incontinence in women.
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New concepts in regenerative medicine approaches to the treatment of female stress urinary incontinence. Curr Opin Urol 2020; 29:380-384. [PMID: 30855380 DOI: 10.1097/mou.0000000000000617] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Update on recent regenerative medicine approaches to the treatment of stress urinary incontinence (SUI) caused by intrinsic sphincter deficiency (ISD). RECENT FINDINGS In the treatment of female SUI/ISD, results using different types of cellular therapy have been disappointing, and new approaches are desirable. To advance our regenerative medicine approaches to SUI/ISD, it is critical to utilize animal models that best parallel the pathophysiology of this disease in women. Many current animal models mimic acute SUI/ISD. However, SUI/ISD in women is usually a chronic condition resulting from previous muscle and nerve sphincter damage during parturition or muscle loss during aging. Similar to women, a nonhuman primate (NHP) model of chronic SUI/ISD has demonstrated only modest response to cell therapy. However, treatment with stromal cell-derived factor 1 (SDF1), also known as C-X-C motif chemokine 12 (CXCL12) restored continence in this model. SUMMARY As a potential therapeutic approach, the use of a well characterized chemokine, such as CXCL12, may by-pass the lengthy and expensive process of cell isolation, expansion, and injection. Recent findings in this new NHP model of chronic SUI/ISD may open up the field for noncell-based treatments.
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García-Mejido JA, Martín-Martínez A, González-Diaz E, Fernández-Fernández C, Ortega I, Medina M, Fernández-Corona A, Fernández-Palacín A, Sainz JA. Malmström vacuum or Kielland forceps: which causes more damage to pelvic floor? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:257-263. [PMID: 31332857 DOI: 10.1002/uog.20404] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 07/01/2019] [Accepted: 07/03/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To determine whether differences exist in the rate of levator ani muscle (LAM) avulsion between women who had undergone either Malmström vacuum delivery (MVD) or Kielland forceps delivery (KFD), allowing for potential confounding factors. METHODS This was a prospective observational study of nulliparous women undergoing instrumental delivery using Malmström vacuum extractor or Kielland forceps, at two hospital centers in Spain. Fetal head position (anterior, posterior or transverse) and fetal head station (low or mid) were assessed by ultrasound and digital examination, respectively. Avulsion was defined on tomographic ultrasound imaging as an abnormal insertion of the LAM in the three central slices from the plane of minimal hiatal dimensions. RESULTS In total, 414 patients were included in the study (212 MVD and 202 KFD). We observed a higher rate of LAM avulsion in the KFD group (KFD 49.5% vs MVD 32.5%; P = 0.001). When the results were evaluated according to fetal head position and station, we observed no differences in LAM avulsion. The crude odds ratio (OR) for the difference in avulsion between women in the KFD and MVD groups was 2.03 (95% CI, 1.36-3.03). However, when adjusted for duration of second stage of labor, fetal head circumference and fetal head station, the OR was no longer statistically significant (OR, 2.14 (95% CI, 0.95-4.85); P = 0.068). CONCLUSION When potential confounding factors are taken into account, the rate of LAM avulsion does not differ between women according to whether they have undergone KFD or MVD. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- J A García-Mejido
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
- Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
| | - A Martín-Martínez
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Gran Canarias, Gran Canarias, Spain
| | - E González-Diaz
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Leon (CAULE), Leon, Spain
| | - C Fernández-Fernández
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Leon (CAULE), Leon, Spain
| | - I Ortega
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Gran Canarias, Gran Canarias, Spain
| | - M Medina
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Gran Canarias, Gran Canarias, Spain
| | - A Fernández-Corona
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Leon (CAULE), Leon, Spain
| | - A Fernández-Palacín
- Biostatistics Unit, Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain
| | - J A Sainz
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
- Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
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Sainz JA, González-Diaz E, Martínez AM, Ortega I, Fernández-Fernández C, Palacín AF, García-Mejido JA. Prevalence of levator hiatal overdistension after vacuum and forceps deliveries. Neurourol Urodyn 2020; 39:841-846. [PMID: 31977114 DOI: 10.1002/nau.24294] [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: 10/18/2019] [Accepted: 01/08/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Levator ani avulsion rates after assisted vaginal delivery have been reported in the literature. However, there are no definitive data regarding the association between overdistention and assisted vaginal delivery. Therefore, our aim is to report overdistention rates after assisted vaginal delivery with a postpartum ultrasound examination. MATERIALS AND METHODS This multicenter study involved a retrospective analysis of data from primiparous women (n = 602) who had previously been recruited at three tertiary hospitals between January 2015 and January 2017. Overdistention was assessed at 6 months postpartum using three-/four-dimensional transperineal ultrasound. Patients with levator ani muscle avulsion were excluded. Overdistention was defined as a levator hiatal area ≥ 25 cm2 on Valsalva. RESULTS Of the 602 primiparous patients, 250 patients who satisfied the inclusion criteria (139 patients who underwent forceps delivery and 111 patients who underwent vacuum delivery) were evaluated. Overdistention occurred in 20% (50 of 250) of these patients. Overdistention was observed for 1% (1/111) of vacuum deliveries and 35.3% (49 of 139) of forceps deliveries. We found an increased risk of overdistention following forceps delivery compared to vacuum delivery, with a crude odds ratio (OR) of 59.9 (95% confidence interval [CI]: 8.1, 442.2) and an adjusted OR (adjusted for maternal age, second-stage duration, and head circumference) of 17.6 (95% CI: 2.3, 136.7). CONCLUSIONS Postpartum overdistention occurred for 20% of assisted vaginal deliveries, with an increased risk of overdistention following forceps delivery compared to vacuum delivery.
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Affiliation(s)
- José A Sainz
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain.,Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
| | - Enrique González-Diaz
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Gran Canarias, Gran Canarias, Spain
| | - Alicia M Martínez
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Leon (CAULE), Leon, Spain
| | - Ismael Ortega
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Gran Canarias, Gran Canarias, Spain
| | - Camino Fernández-Fernández
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Leon (CAULE), Leon, Spain
| | - Ana F Palacín
- Biostatistics Unit, Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain
| | - José A García-Mejido
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain.,Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
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Pelvic organ prolapse as a function of levator ani avulsion, hiatus size, and strength. Am J Obstet Gynecol 2019; 221:41.e1-41.e7. [PMID: 30885773 DOI: 10.1016/j.ajog.2019.03.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/22/2019] [Accepted: 03/11/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND Obstetrical levator ani muscle avulsion is detected after 10%-30% of vaginal deliveries and is associated with pelvic organ prolapse later in life. However, the mechanism by which levator avulsion may contribute to prolapse is unknown. OBJECTIVES This study investigated the extent by which size of the levator hiatus and pelvic muscle weakness may explain the association between levator avulsion and pelvic organ prolapse. STUDY DESIGN This was a supplementary study of a longitudinal cohort of parous women enrolled 5-10 years after first delivery and assessed annually for prolapse (defined as descent beyond the hymen) for up to 9 annual visits. For this substudy, vaginally parous participants were assessed for levator avulsion using 3-dimensional transperineal ultrasound. Ultrasound was performed at a median interval of 11 years from delivery. Ultrasound volumes also were used to measure levator hiatus area with Valsalva. Pelvic muscle strength was measured with perineometry. Women with and without pelvic organ prolapse were compared for levator avulsion, levator hiatus area, and pelvic muscle strength, using multivariable logistic regression yielding a measure of mediation. Bootstrap methods were used to calculate the confidence interval corresponding to the measure of mediation by hiatus area and pelvic muscle strength. RESULTS Prolapse was identified in 109 of 429 (25%) and was significantly associated with levator avulsion (odds ratio, 4.17; 95% confidence interval, 2.28-7.31). Prolapse also was associated with levator hiatus area (odds ratio, 1.52 per 5 cm2; 95% confidence interval, 1.34-1.73) and inversely with muscle strength (odds ratio, 0.87 per 5 cm H2O; 95% confidence interval, 0.81-0.94). In a multivariable logistic model including levator avulsion, levator hiatus area, and strength, the association between levator avulsion and prolapse was substantially attenuated and indeed was no longer statistically significant (odds ratio, 1.75; 95% confidence interval, 0.91-3.39). Hiatus area and strength mediated 61% (95% confidence interval, 34%-106%) of the association between avulsion and prolapse. Furthermore, since the 95% confidence interval for this estimate contained 100%, it cannot be ruled out that the 2 markers fully mediate the effect of avulsion on prolapse. CONCLUSIONS The strong association between pelvic organ prolapse and levator avulsion can be explained to a large extent by a larger levator hiatus and weaker pelvic muscles after levator avulsion.
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Sveinsdottir E, Gottfredsdottir H, Vernhardsdottir AS, Tryggvadottir GB, Geirsson RT. Effects of an intervention program for reducing severe perineal trauma during the second stage of labor. Birth 2019; 46:371-378. [PMID: 30444289 DOI: 10.1111/birt.12409] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 10/20/2018] [Accepted: 10/20/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Obstetric anal sphincter injuries lead frequently to short- and long-term consequences for the mother, including perineal pain, genital prolapse, and sexual problems. The aim of the study was to evaluate whether the implementation of an intervention program in the second stage of labor involving altered perineal support techniques reduced severe perineal trauma. METHODS All women reaching the second stage of labor and giving birth vaginally to singleton babies at Landspítali University Hospital (comprising 76% of births in Iceland in 2013) were enrolled in a cohort study. Data were recorded retrospectively for 2008-2010 and prospectively in 2012-2014, for a total of 16 336 births. During 2011, an intervention program was implemented, involving all midwives and obstetricians working in the labor wards. Two professionals assessed and agreed on classification of every perineal tear. RESULTS The prevalence of obstetric anal sphincter injuries decreased from 5.9% to 3.7% after the implementation (P < 0.001). Third-degree tears decreased by 40%, and fourth-degree tears decreased by 56% (P < 0.001). The prevalence of first-degree tears increased from 25.8% to 33.1%, whereas second-degree tears decreased from 44.7% to 36.6% between the before and after study periods. Severe perineal trauma was linked to birthweight, and this did not change despite the new intervention. CONCLUSIONS Active intervention to reduce perineal trauma was associated with an overall significant decrease in obstetric anal sphincter injuries. Good perineal visualization, manual perineal support, and controlled delivery of the fetal head were essential components for reducing perineal trauma.
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Affiliation(s)
- Edda Sveinsdottir
- Midwifery Division, Faculty of Nursing, University of Iceland, Reykjavik, Iceland.,Department of Obstetrics and Gynecology, Women's Clinic, Landspítali University Hospital, Reykjavik, Iceland
| | - Helga Gottfredsdottir
- Midwifery Division, Faculty of Nursing, University of Iceland, Reykjavik, Iceland.,Department of Obstetrics and Gynecology, Women's Clinic, Landspítali University Hospital, Reykjavik, Iceland
| | - Anna S Vernhardsdottir
- Midwifery Division, Faculty of Nursing, University of Iceland, Reykjavik, Iceland.,Department of Obstetrics and Gynecology, Women's Clinic, Landspítali University Hospital, Reykjavik, Iceland
| | | | - Reynir T Geirsson
- Department of Obstetrics and Gynecology, Women's Clinic, Landspítali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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Abstract
OBJECTIVES With vaginal childbirth, 10% to 30% of women sustain levator ani muscle avulsion. The objective of this study was to estimate the cumulative incidence of prolapse and other pelvic floor disorders (PFDs), comparing vaginally parous women with and without levator avulsion. METHODS Parous women enrolled in a longitudinal study were assessed annually for PFDs with the Pelvic Organ Prolapse Quantification Examination (for prolapse) and the Epidemiology of Prolapse and Incontinence Questionnaire (for stress incontinence, overactive bladder, and anal incontinence). Three-dimensional transperineal ultrasound was used to identify levator avulsion. Women with and without levator avulsion after vaginal delivery were compared for the cumulative incidence of PFDs. Further analysis also stratified by forceps delivery. RESULTS At the time of assessment, 453 participants were 6 to 17 years from first delivery (median, 11 years). Levator avulsion was identified in 15% (66/453) and was more common among those who had undergone forceps-assisted delivery (P < 0.001). Levator avulsion was strongly associated with prolapse beyond the hymen (odds ratio, 2.7; 95% confidence interval, 1.3-5.7) and with symptoms of prolapse (odds ratio, 3.0; 95% confidence interval-1.2, 7.3). These associations persisted after controlling for forceps-assisted delivery. In contrast, the odds of stress incontinence, overactive bladder, and anal incontinence were marginally (but not significantly) increased among women with levator avulsion in this cohort. CONCLUSIONS Obstetric levator avulsion is strongly associated with pelvic organ prolapse. The relationship between levator avulsion and other PFDs may not be significant.
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Volløyhaug I, Taithongchai A, Van Gruting I, Sultan A, Thakar R. Levator ani muscle morphology and function in women with obstetric anal sphincter injury. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:410-416. [PMID: 30207014 DOI: 10.1002/uog.20115] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/19/2018] [Accepted: 08/28/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To estimate the prevalence of, and explore the risk factors for, levator ani muscle (LAM) injury in women with clinically diagnosed obstetric anal sphincter injury (OASI). The secondary aim was to assess the association between LAM injury and pelvic floor muscle contraction, anal incontinence (AI) and urinary incontinence (UI) in women with OASI. METHODS This was a cross-sectional study of 250 women with OASI, recruited between 2013 and 2015 from a tertiary referral center at Croydon University Hospital, UK. AI symptoms were assessed using the modified St Mark's incontinence score and UI was assessed using the International Consultation on Incontinence modular Questionnaire for Urinary Incontinence - Short Form. All participants underwent three/four-dimensional transperineal ultrasound at rest and on maximum pelvic floor muscle contraction. Major LAM injury was defined as a unilateral or bilateral defect in all three central slices on tomographic ultrasound imaging. Muscle contraction was assessed using the modified Oxford scale (MOS) and measured on ultrasound as the proportional change in the anteroposterior (AP) levator hiatal diameter between rest and contraction. Multivariable logistic regression analysis was used to study risk factors for LAM injury. Differences in contraction and AI and UI symptoms between women with intact and those with injured LAM were studied using multivariable ANCOVA and the Mann-Whitney U-test. RESULTS Of the 248 women with OASI for whom ultrasound volumes of adequate quality were available, 29.4% were found to have major LAM injury. The prevalence of LAM injury was 23.6% after normal vaginal delivery and 40.2% after operative vaginal delivery (adjusted odds ratio, 4.1 (95% CI, 1.4-11.9); P = 0.01). LAM injury was associated with weaker pelvic floor muscle contraction, with an adjusted mean difference for proportional change in AP diameter of 5.0 (95% CI, 3.0-6.9) and MOS of 0.6 (95% CI, 0.3-0.9) (P < 0.001 for both). AI and UI symptom scores were similar between women with intact and those with injured LAM. CONCLUSIONS Operative vaginal delivery was a risk factor for LAM injury in women with OASI. LAM injury was associated with weaker pelvic floor muscle contraction. Special attention is recommended for women with OASI and LAM injury, as they are at high risk for future pelvic floor disorders. The benefits of implementation of an intensive, focused and structured pelvic floor rehabilitation program need to be evaluated in these women. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- I Volløyhaug
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Obstetrics and Gynaecology, Trondheim University Hospital, Trondheim, Norway
| | - A Taithongchai
- Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
| | - I Van Gruting
- Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
| | - A Sultan
- Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
| | - R Thakar
- Obstetrics and Gynaecology, Croydon University Hospital, Croydon, UK
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García-Mejido JA, Fernández-Palacín A, Bonomi Barby MJ, Castro L, Aquise A, Sainz JA. A comparable rate of levator ani muscle injury in operative vaginal delivery (forceps and vacuum) according to the characteristics of the instrumentation. Acta Obstet Gynecol Scand 2019; 98:729-736. [PMID: 30681721 DOI: 10.1111/aogs.13544] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 01/17/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Forceps delivery is associated with a high rate of levator ani muscle (LAM) trauma (avulsion) at 35%-65% whereas data on avulsion rates after vacuum delivery vary greatly. Nevertheless, a common characteristic of all previous studies carried out to evaluate the association between instrumental deliveries (forceps and vacuum) and LAM avulsion, is the fact that characteristics of the instrumentation have not been described or evaluated. The objective of this study is to compare the rate of LAM avulsion between forceps and vacuum deliveries according to the characteristics of the instrumentation. MATERIAL AND METHODS Prospective, observational study, including 263 nulliparous women, who underwent an instrumental delivery with either Malmström vacuum or Kielland forceps. The characteristics of the instrumentation, position (anterior position and other position) and height of the fetal head at the moment of instrumentation (low instrumentation [vertex at +2 station] and mid-instrumentation [head is involved but leading part above +2 station]) were assessed. Evaluation of LAM avulsion was performed at 6 months postpartum by three-/four-dimensional transperineal ultrasound. Using the multi-view mode, a complete avulsion was diagnosed when the abnormal muscle insertion was identified in all three central slices, that is, in the plane of minimal hiatal dimensions and the 2.5-mm and 5.0-mm slices cranial to this one. To detect a 30% or 15% difference in the LAM injury rate, with 80% power and 5% α-error, we needed, respectively 42 and 99 women per study group. RESULTS In all, 263 nulliparous individuals have been evaluated (162 vacuum deliveries, 101 forceps deliveries). Instrumentation in an occipito-anterior position was more frequent in vacuum deliveries (75.3% vs 56.4%, P = .002), whereas other positions were more frequent in the forceps deliveries group (24.7% vs 43.6%). No statistically significant differences were noted regarding the height of the fetal head at the moment of instrumentation. No statistically significant differences were found in the presence of LAM avulsion (41.4% vs 38.6%) between vacuum and forceps deliveries. The univariate analysis of the crude odds ratio was 1.17, 95% CI 0.67-1.98, P = .70 for the avulsion of the LAM and the multivariate of the adjusted OR 0.90, 95% CI; 0.53-1.55, P = .71. CONCLUSIONS We consider that, in our population, LAM avulsion rate should not be a factor taken into account when choosing the type of instrumentation (Malmström vacuum or Kielland forceps) in an operative delivery.
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Affiliation(s)
- José A García-Mejido
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain.,Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
| | - Ana Fernández-Palacín
- Biostatistics Unit, Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain
| | - María J Bonomi Barby
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
| | - Laura Castro
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
| | - Adriana Aquise
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain.,Harris Birthright Research Center for Fetal Medicine, King's College Hospital, London, UK
| | - José A Sainz
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain.,Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
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Contributing factors in forceps associated pelvic floor trauma. Int Urogynecol J 2019; 31:167-171. [PMID: 30666429 DOI: 10.1007/s00192-019-03869-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/02/2019] [Indexed: 12/28/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Levator avulsion occurs in 10-35% of women after a first vaginal delivery, with forceps being the main risk factor. Three mechanisms have been proposed to account for the high risk of trauma: the additional space requirement, increased speed of distension, and/ or greater force. This study examines the additional space requirements associated with forceps to determine any associated increase in avulsion risk. METHODS This was an in vitro simulation study of spatial requirements for delivery of a fetal head by forceps, with mathematical modelling of spatial requirements using data from a local observational study. A balloon device was used to model head circumferences through the range of expected measurements at term, with measurements taken after application of three different types of forceps. Each measurement was performed in triplicate. RESULTS On average, forceps increased the circumference of the fetal head by 1.01 cm for Wrigley's, 1.04 cm for Kielland's, and 1.64 cm for Neville-Barnes forceps, resulting in an estimated increase in the diameter of the fetal head by 0.32 cm, 0.33 cm, and 0.52 cm, respectively. This increase was linear throughout the tested range. In 534 singleton pregnancies at term, we determined an odds ratio (OR) of 1.11 per centimeter head circumference for avulsion. Hence, the additional space requirement due to forceps explains ORs of 1.11, 1.12, and 1.19 for avulsion, depending on forceps type. CONCLUSIONS The effect of forceps on avulsion risk is not fully explained by the increase in space requirement alone. Other factors, such as shortened time to maximum distension and/or increased peak force applied may contribute to the excess risk.
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O'Brien S, Jordan S, Siassakos D. The role of manual rotation in avoiding and managing OVD. Best Pract Res Clin Obstet Gynaecol 2018; 56:69-80. [PMID: 30670334 DOI: 10.1016/j.bpobgyn.2018.12.001] [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: 07/20/2018] [Revised: 11/08/2018] [Accepted: 12/03/2018] [Indexed: 11/16/2022]
Abstract
Manual rotation (MR) is the most common technique used by accoucheurs who wish to correct malposition of the foetal head to either avoid or facilitate an operative vaginal delivery (OVD). MR can be performed using either a whole-hand or a digital approach. MR should be formally taught and trainees should be assessed for competence, and later, performance should ideally be tracked with statistical control charts. There is paucity of robust evidence evaluating MR relative to the other methods of rotational OVD: rotational forceps (RF) and rotational ventouse (RV). Furthermore, there is little evidence concerning long-term maternal outcomes of rotational OVD. A prospective randomised trial of MR versus either RF or RV is clearly needed, along with a core outcome set for OVD to facilitate comprehensive evaluation programmes that focus on aspects pertaining to women.
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Affiliation(s)
- Stephen O'Brien
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Dept of Women's Health, The Chilterns, Southmead Hospital, Bristol, BS10 5NB, UK. stephen.o'
| | - Sharon Jordan
- Dept of Women's Health, The Chilterns, Southmead Hospital, Bristol, BS10 5NB, UK.
| | - Dimitrios Siassakos
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Dept of Women's Health, The Chilterns, Southmead Hospital, Bristol, BS10 5NB, UK.
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Dietz HP, Callaghan S. We need to treat pregnant women as adults. Aust N Z J Obstet Gynaecol 2018; 58:701-703. [DOI: 10.1111/ajo.12885] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 07/25/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Hans P. Dietz
- Obstetrics and GynaecologySydney Medical School NepeanUniversity of Sydney Penrith Australia
| | - Sascha Callaghan
- Sydney Law SchoolUniversity of Sydney Sydney New South Wales Australia
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Turel F, Caagbay D, Dietz HP. Prevalence of Maternal Birth Trauma in Nepali Women. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:2803-2809. [PMID: 29676809 DOI: 10.1002/jum.14637] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/28/2018] [Accepted: 02/26/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Pelvic organ prolapse is very common among women in Nepal, especially uterine prolapse. This would suggest a high rate of levator trauma, which is a strong predictor of such prolapse in the Western world. Hence, we decided to study the prevalence of maternal birth trauma in Nepali women. METHODS In November 2016, we offered an interview, clinical examination, and 4-dimensional translabial sonography to women attending a gynecology clinic. Of 129 women seen, 5 were excluded due to previous pelvic surgery. Translabial sonography volume data sets were obtained and analyzed by tomographic imaging for levator ani and anal sphincter trauma at a later date, blinded against all clinical data. RESULTS Mean age was 39 (21-74) years, median vaginal parity was 2 (0-9), mean age at first delivery 21 (14-40). Seventeen (14%) had not given birth vaginally; of these, 14 (11%) delivered by cesarean only, and 3 (2%) were nulliparous. Tomographic assessment for levator avulsion and anal sphincter trauma was possible in 124 women and performed as previously described. We found 2 (2%) unilateral avulsions and significant external anal sphincter defects in another 2 women. CONCLUSIONS Levator and anal sphincter trauma are significantly less prevalent in Nepali women in comparison to Western populations. This is intriguing, especially in view of the high prevalence of prolapse in Nepali women.
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Affiliation(s)
- Friyan Turel
- Department of Obstetrics, Gynaecology & Neonatology, Sydney Medical School Nepean, Australia
| | - Delena Caagbay
- Department of Physiotherapy, University of Sydney, Australia
| | - Hans Peter Dietz
- Department of Obstetrics, Gynaecology & Neonatology, Sydney Medical School Nepean, Australia
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Patton V, Kumar S, Parkin K, Karantanis E, Dinning P. The relationship between residual sphincter damage after primary repair, faecal incontinence, and anal sphincter function in primiparous women with an obstetric anal sphincter injury. Neurourol Urodyn 2018; 38:193-199. [PMID: 30387531 DOI: 10.1002/nau.23826] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/31/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS Anal sphincter injury has been identified as a primary cause of post-partum fecal incontinence in women with obstetric anal sphincter injury. However, women without obstetric anal sphincter injury may also develop fecal incontinence. The aim is to determine the relationship between fecal incontinence severity; and i) residual anal sphincter injury, quantified by the Starck score, and ii) anal sphincter tone. METHODS Consecutive case series of prospectively collected data set in a Pelvic Floor Unit within a tertiary teaching hospital in Australia. Population 181 primiparous women with Sultan classification Grade 3 and 4 sphincter injuries. MAIN OUTCOME MEASURES Sultan classification, anal manometry, pudendal nerve terminal motor latency, St Mark's fecal incontinence score, and Starck ultrasound score. RESULTS 45% of women reported some degree of fecal incontinence. One third of women with normal external sphincter tone were incontinent. Those with higher Starck score had higher St Mark's scores. A higher Sultan classification correlated with more severe incontinence regardless if the repair was complete. Forceps delivery had a twofold risk of incontinence when compared to non-forceps delivery. CONCLUSION The importance of an effective anal sphincter repair is confirmed. However, overall there is no direct relationship between residual sphincter damage, anal sphincter tone, and fecal incontinence severity. These data indicate that anal sphincter integrity alone is not the sole mechanism for maintaining fecal continence. Rectal and colonic motor function may also play a role and investigation into these components may provide greater insight into the effect of vaginal delivery upon fecal continence mechanisms.
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Affiliation(s)
- Vicki Patton
- Centre for Nursing Research, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Swetha Kumar
- Nepean Hospital Sydney, Department of Women and Children's Health, Sydney, New South Wales, Australia
| | - Katrina Parkin
- Department of Women and Children's Health St George Public Hospital, University of NSW St George Clinical School, Kogarah, New South Wales, Australia
| | - Emmanuel Karantanis
- Department of Women and Children's Health St George Public Hospital, University of NSW St George Clinical School, Kogarah, New South Wales, Australia
| | - Phil Dinning
- College of Medicine and Public Health and Centre for Neuroscience, Flinders University, Bedford Park, South Australia, Australia.,Department of Surgery and Gastroenterology, Flinders Medical Centre, Bedford Park, South Australia, Australia
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Caudwell-Hall J, Kamisan Atan I, Guzman Rojas R, Langer S, Shek KL, Dietz HP. Atraumatic normal vaginal delivery: how many women get what they want? Am J Obstet Gynecol 2018; 219:379.e1-379.e8. [PMID: 30063899 DOI: 10.1016/j.ajog.2018.07.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 07/04/2018] [Accepted: 07/24/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Trauma to the perineum, levator ani complex, and anal sphincter is common during vaginal childbirth, but often clinically underdiagnosed, and many women are unaware of the potential for long-term damage. OBJECTIVE In this study we use transperineal ultrasound to identify how many women will achieve a normal vaginal delivery without substantial damage to the levator ani or anal sphincter muscles, and to create a model to predict patient characteristics associated with successful atraumatic normal vaginal delivery. STUDY DESIGN This is a retrospective, secondary analysis of data sets gathered in the context of an interventional perinatal imaging study. A total of 660 primiparas, carrying an uncomplicated singleton pregnancy, underwent an antepartum and postpartum interview, vaginal exam (Pelvic Organ Prolapse Quantification), and 4-dimensional translabial ultrasound. Ultrasound data were analyzed for levator trauma and/or overdistention and residual sphincter defects. Postprocessing analysis of ultrasound volumes was performed blinded against clinical data and analyzed against obstetric data retrieved from the local maternity database. Levator avulsion was diagnosed if the muscle insertion at the inferior pubic ramus at the plane of minimal hiatal dimensions and within 5 mm above this plane on tomographic ultrasound imaging was abnormal, ie the muscle was disconnected from the inferior pubic ramus. Hiatal overdistensibility (microtrauma) was diagnosed if there was a peripartum increase in hiatal area on Valsalva by >20% with the resultant area ≥25 cm2. A sphincter defect was diagnosed if a gap of >30 degrees was seen in ≥4 of 6 tomographic ultrasound imaging slices bracketing the external anal sphincter. Two models were tested: a first model that defines severe pelvic floor trauma as either obstetric anal sphincter injury or levator avulsion, and a second, more conservative model, that also included microtrauma. RESULTS A total of 504/660 women (76%) returned for postpartum follow-up as described previously. In all, 21 patients were excluded due to inadequate data or intercurrent pregnancy, leaving 483 women for analysis. Model 1 defined nontraumatic vaginal delivery as excluding operative delivery, obstetric anal sphincter injuries, and sonographic evidence of levator avulsion or residual sphincter defect. Model 2 also excluded microtrauma. Of 483 women, 112 (23%) had a cesarean delivery, 103 (21%) had an operative vaginal delivery, and 17 (4%) had a third-/fourth-degree tear, leaving 251 women who could be said to have had a normal vaginal delivery. On ultrasound, in model 1, 27 women (6%) had an avulsion and 31 (6%) had a residual defect, leaving 193/483 (40%) who met the criteria for atraumatic normal vaginal delivery. In model 2, an additional 33 women (7%) had microtrauma, leaving only 160/483 (33%) women who met the criteria for atraumatic normal vaginal delivery. On multivariate analysis, younger age and earlier gestation at time of delivery remained highly significant as predictors of atraumatic normal vaginal delivery in both models, with increased hiatal area on Valsalva also significant in model 2 (all P ≤ .035). CONCLUSION The prevalence of significant pelvic floor trauma after vaginal child birth is much higher than generally assumed. Rates of obstetric anal sphincter injury are often underestimated and levator avulsion is not included as a consequence of vaginal birth in most obstetric text books. In this study less than half (33-40%) of primiparous women achieved an atraumatic normal vaginal delivery.
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Affiliation(s)
- Jessica Caudwell-Hall
- Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, Liverpool, Australia
| | - Ixora Kamisan Atan
- Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, Liverpool, Australia; Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Rodrigo Guzman Rojas
- Departamento de Ginecología y Obstetricia, Clínica Alemana de Santiago-Universidad del Desarrollo, Chile; Departamento de Ginecología y Obstetricia, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Susanne Langer
- Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, Liverpool, Australia
| | - Ka Lai Shek
- Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, Liverpool, Australia; Liverpool Clinical School, Western Sydney University, Australia
| | - Hans Peter Dietz
- Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, Liverpool, Australia.
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Martín Del Olmo JC, Toledano M, Martín Esteban ML, Montenegro MA, Gómez JR, Concejo P, Rodríguez de Castro M, Del Rio F. Outcomes of laparoscopic management of multicompartmental pelvic organ prolapse. Surg Endosc 2018; 33:1075-1079. [PMID: 29998390 DOI: 10.1007/s00464-018-6357-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 07/06/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Pelvic organ prolapse (POP) is an increasing medical problem with complex diagnostics and controversial surgical management. It causes a series of dysfunctions in the gynecological, urinary, and anorectal organs. Numerous procedures have been proposed to treat these conditions, but in recent years, ventral mesh rectocolposacropexy (VMRCS) has emerged as the procedure of choice for the surgical treatment of POP, especially by a laparoscopic approach. This surgical technique limits the risk of autonomic nerve damage, and the colpopexy allows the correction of concomitant prolapse of the middle compartment. However, symptoms derived from anterior compartment prolapse remain a major morbidity and sometimes require an additional procedure. The aim of this study is to evaluate the results of laparoscopic prosthetic rectocolposacropexy (LRCS) and colposacropexy (LCS) procedures performed to manage combined multicompartmental POP. METHODS Between November 2008 and December 2017, 38 patients with symptomatic POP underwent rectocolposacropexy (RCS) or colposacropexy (CS) by a laparoscopic approach. Demographics, mortality, morbidity, hospital stay, and functional outcomes were retrospectively analyzed. RESULTS The median operating time was 200 min (IQR 160-220). Additional simultaneous surgery for POP was performed in nine cases: five suburethral slings and four hysterectomies were performed. No mortality was recorded. The conversion rate was 7.89%. There were two intraoperative complications (5.26%): one enterotomy and one urinary bladder tear. Late complications occurred in 5.26% of cases. After a mean follow-up of 20 months, constipation was completely resolved or improved in 83.33% of patients, urinary stress incontinence was resolved or improved in 52.94%, and gynecological symptomatology was resolved or improved in 93.75%. The recurrence rate was 5.26%. CONCLUSIONS Laparoscopic mesh rectocolposacropexy and colposacropexy are safe and effective techniques associated with very low morbidity. In the medium term, they provide good results for POP and associated symptoms, but urinary symptomology has a worse outcome.
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Affiliation(s)
- J C Martín Del Olmo
- Department of General Surgery, Medina del Campo Hospital, Valladolid, Spain. .,, Madrid, Spain.
| | - M Toledano
- Department of General Surgery, Medina del Campo Hospital, Valladolid, Spain
| | - M L Martín Esteban
- Department of General Surgery, Medina del Campo Hospital, Valladolid, Spain
| | - M A Montenegro
- Department of General Surgery, Medina del Campo Hospital, Valladolid, Spain
| | - J R Gómez
- Department of General Surgery, Medina del Campo Hospital, Valladolid, Spain
| | - P Concejo
- Department of General Surgery, Medina del Campo Hospital, Valladolid, Spain
| | - M Rodríguez de Castro
- Department of Obstetrics and Gynecology, Medina del Campo Hospital, Valladolid, Spain
| | - F Del Rio
- Department of Urology, Medina del Campo Hospital, Valladolid, Spain
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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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Caudwell-Hall J, Kamisan Atan I, Brown C, Guzman Rojas R, Langer S, Shek KL, Dietz HP. Can pelvic floor trauma be predicted antenatally? Acta Obstet Gynecol Scand 2018; 97:751-757. [DOI: 10.1111/aogs.13315] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 01/25/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Jessica Caudwell-Hall
- Sydney Medical School Nepean; University of Sydney; Nepean Hospital; Penrith NSW Australia
| | - Ixora Kamisan Atan
- Sydney Medical School Nepean; University of Sydney; Nepean Hospital; Penrith NSW Australia
- Universiti Kebangsaan Malaysia Medical Center; Kuala Lumpur Malaysia
| | - Chris Brown
- NHMRC Clinical Trials Center; University of Sydney; Sydney NSW Australia
| | - Rodrigo Guzman Rojas
- Department of Gynecology and Obstetrics; Clínica Alemana de Santiago-Universidad del Desarrollo; Santiago Chile
- Department of Obstetrics and Gynecology; Hospital Clínico de la Universidad de Chile; Santiago Chile
| | - Susanne Langer
- Sydney Medical School Nepean; University of Sydney; Nepean Hospital; Penrith NSW Australia
| | - Ka L. Shek
- Sydney Medical School Nepean; University of Sydney; Nepean Hospital; Penrith NSW Australia
- Liverpool Clinical School; Western Sydney University; Sydney NSW Australia
| | - Hans P. Dietz
- Sydney Medical School Nepean; University of Sydney; Nepean Hospital; Penrith NSW Australia
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Orejuela FJ, Gandhi R, Mack L, Lee W, Sangi-Haghpeykar H, Dietz HP, Ramin SM. Prospective evaluation of the safety and feasibility of a pelvic floor dilator during active labor. Int Urogynecol J 2018; 29:1485-1492. [PMID: 29411072 DOI: 10.1007/s00192-018-3555-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 01/04/2018] [Indexed: 12/31/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to assess the safety and feasibility of using a pelvic floor dilator during active labor to prevent injuries to the levator ani muscle (LAM) and perineum. METHODS In a prospective pilot study, a pelvic floor dilator using soft pads was introduced into the vaginal canal to gradually expand the vagina, in 30 nulliparous women and in 10 controls. The primary outcomes were adverse events related to the device. Secondary outcomes were perineal lacerations after delivery, sonographically defined levator ani injury, hiatal area dimensions, and anal sphincter disruption, all at 12-20 weeks postpartum, and maximum pelvic floor dilation, time to achieve maximum dilation, and device retention rate. RESULTS From October 2014 through November 2016, a total of 494 women were screened, and 61 consented to the study. Thirty women used the device and 27 returned for follow-up. No maternal or neonatal injuries were related to use of the dilator. The average maximum dilation of the vaginal canal was 7.4 cm (SD 0.7, range 5.5-8.0). Dilation time averaged 27 min (SD 13, range 5-60). Device insertion adjustment was needed in 13 out of 30 cases (43%). Similar rates of 3th-4th degree perineal lacerations were seen in both groups. Levator ani avulsion was diagnosed in 2 out of 27 (7%) in the device group and in 1 out of 9 (11%) in the control group (p = 0.2). The rate of partial injury in the device group was 2 out of 27 (7%) vs 2 out of 9 (22%) in the comparison group (p = 0.2). CONCLUSION The use of the pelvic floor dilator during active labor is feasible. No safety issues were identified.
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Affiliation(s)
- Francisco J Orejuela
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, 6651 Main Street, Houston, TX, 77030, USA.
| | - Rajshi Gandhi
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, 6651 Main Street, Houston, TX, 77030, USA
| | - Lauren Mack
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, 6651 Main Street, Houston, TX, 77030, USA
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, 6651 Main Street, Houston, TX, 77030, USA
| | - Haleh Sangi-Haghpeykar
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, 6651 Main Street, Houston, TX, 77030, USA
| | - Hans P Dietz
- Department of Obstetrics and Gynecology, Sydney Medical School Nepean, The University of Sydney, Sydney, NSW, Australia
| | - Susan M Ramin
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, 6651 Main Street, Houston, TX, 77030, USA
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