Echogenicity of puborectalis muscle, cervix and vastus lateralis muscle in pregnancy in relation to mode of delivery

OBJECTIVES

To confirm our previous observation that levator hiatal dimensions and mean echogenicity of the puborectalis muscle (MEP) are significantly different at 12 weeks' gestation in women who delivered by Cesarean section due to failure to progress compared with those who delivered vaginally. The secondary objective was to assess the association between the echogenicity of the cervix and vastus lateralis muscle and mode of delivery.

METHODS

In this prospective multicenter study, 306 nulliparous women with a singleton pregnancy underwent ultrasound assessments of the pelvic floor at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver, of the cervix and of the vastus lateralis muscle at 12 weeks' gestation. Dimensions of the levator hiatus, MEP and mean echogenicity of the cervix and vastus lateralis muscle were measured and compared according to mode of delivery.

RESULTS

Two hundred and forty-nine women were included in the analyses. We were unable to confirm our previous finding that MEP and levator hiatal transverse diameter and area at 12 weeks' gestation are associated significantly with mode of delivery. In addition, we could not demonstrate a significant association between echogenicity of the cervix or vastus lateralis muscle and mode of delivery. Overall, MEP was a mean of 20 points lower in women in the new database as compared with the previous study, despite the use of the same ultrasound equipment.

CONCLUSION

In a second, independent multicenter dataset, we were unable to confirm our previous finding that levator hiatal dimensions and MEP on pelvic floor muscle contraction are associated significantly with mode of delivery. We also found no association between echogenicity of the cervix or vastus lateralis and mode of delivery. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Structural changes in puborectalis muscle after vaginal delivery

OBJECTIVE

To evaluate the structural composition of the puborectalis muscle before and at several timepoints after first vaginal delivery, by the use of echogenicity and area measurements, in order to explore its recovery.

METHODS

Twenty nulliparous women with a singleton pregnancy underwent 3D/4D transperineal ultrasound assessments at rest, on pelvic floor muscle contraction and on Valsalva maneuver at 12 weeks' gestation and at 1 day and 1, 2, 3, 4, 6, 12, 18 and 24 weeks after vaginal delivery. The puborectalis muscle was delineated for measurements of mean echogenicity (MEP) and area (PMA). To assess changes in MEP and PMA over time, linear mixed model analysis was used. The exact number of days after delivery at each ultrasound examination was used as a covariate.

RESULTS

For all timepoints after delivery, MEP was significantly decreased compared with that at 12 weeks' gestation. MEP values increased significantly over time from 1 day to 24 weeks after delivery. Although not statistically significant, a decrease in MEP was observed between 3 and 4 weeks after delivery for all maneuvers. PMA at rest and on Valsalva maneuver remained constant after delivery.

CONCLUSION

When compared with measurements taken during pregnancy, a sharp decrease in MEP was observed soon after vaginal delivery, which was most likely caused by stretch trauma to the puborectalis muscle and subsequent formation of (micro) hematoma and edema. Subsequent increases in MEP may reflect the disappearance of hematoma and edema, and also the formation of connective and scar tissue. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Recovery of puborectalis muscle after vaginal delivery: an ultrasound study

OBJECTIVES

To assess change in levator hiatal dimensions between pregnancy and different timepoints after vaginal delivery, and map recovery of the hiatus in order to contribute to secondary prevention of symptoms of pelvic floor disorders.

METHODS

Twenty nulliparous women with a singleton pregnancy underwent ultrasound assessment of the pelvic floor at rest, on maximum pelvic floor muscle contraction (PFMC) and on Valsalva maneuver at 12 weeks' gestation and at 1 day and 1, 2, 3, 4, 6, 12, 18 and 24 weeks after vaginal delivery. Dimensions of the levator hiatus were measured and contractility and distensibility were calculated. The Wilcoxon signed rank test was used to compare each postpartum value with that at 12 weeks' gestation.

RESULTS

Levator hiatal area at rest, on PFMC and on Valsalva maneuver was significantly increased at 1 day and at 1 and 2 weeks after vaginal delivery compared with measurements at 12 weeks' gestation. Hiatal area at rest and on PFMC from 3 weeks postpartum onward, as well as contractility from 6 weeks onward, were comparable to values at 12 weeks' gestation, whereas, a significant difference remained on Valsalva maneuver until 24 weeks after delivery. Moreover, distensibility was still increased at 24 weeks postpartum compared with measurements at 12 weeks' gestation.

CONCLUSION

The puborectalis muscle has the ability to recover anatomically from a first vaginal delivery, and recovery occurs mainly during the first 3 weeks after delivery. Stretching of the puborectalis muscle, as reflected by distensibility, persisted 24 weeks after the first vaginal delivery. The data provide a better understanding of the early 'normal' regeneration process and we hypothesize that the first 3 weeks postpartum is the best window in which to start secondary prevention. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Changes in global strain of puborectalis muscle during pregnancy and postpartum

OBJECTIVE

One of the functional parameters that can be assessed by ultrasound is muscle strain, which represents the extent of deformation of the muscle from its original shape when forces are applied to the tissue under study. The aim of this study was to evaluate the effect of pregnancy and delivery on the puborectalis muscle, by assessing changes in global strain of the muscle during and after pregnancy.

METHODS

This was a secondary analysis of a prospective observational study on the association between stress urinary incontinence and levator ani muscle avulsion after delivery. Two-hundred and eighty nulliparous pregnant women underwent four-dimensional transperineal ultrasound assessments at 12 and 36  weeks of gestation, and 6 months postpartum. Tomographic ultrasound images were constructed and the puborectalis muscle was delineated by hand using programming software. After delineation, the length of the midline of the puborectalis muscle was measured at rest and during maximum pelvic floor muscle contraction, and global strain was expressed as percentile difference. Postpartum results were analyzed separately for vaginal, operative (vacuum) vaginal and Cesarean delivery. Differences in global strain of the puborectalis muscle according to mode of delivery were compared using a paired-sample t-test. The effect of partial or complete avulsion of the puborectalis muscle on postpartum strain was evaluated by ANOVA.

RESULTS

In total, 254 datasets were analyzed. Global strain of the puborectalis muscle did not change during pregnancy, but after spontaneous or operative vaginal delivery the global strain diminished significantly. No significant change was observed in strain of the puborectalis muscle after Cesarean delivery. Women who suffered complete bilateral avulsion had significantly lower strain compared with women with an intact puborectalis muscle.

CONCLUSION

Spontaneous or operative vacuum vaginal birth and complete bilateral avulsion of the puborectalis muscle influence negatively the strain of the puborectalis muscle. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Quality of reporting of diagnostic accuracy studies on pelvic floor three-dimensional transperineal ultrasound: a systematic review

OBJECTIVE

In recent years, a large number of studies have been published on the clinical relevance of pelvic floor three-dimensional (3D) transperineal ultrasound. Several studies compare sonography with other imaging modalities or clinical examination. The quality of reporting in these studies is not known. The objective of this systematic review was to determine the compliance of diagnostic accuracy studies investigating pelvic floor 3D ultrasound with the Standards for Reporting of Diagnostic Accuracy (STARD) guidelines.

METHODS

Published articles on pelvic floor 3D ultrasound were identified by a systematic literature search of MEDLINE, Web of Science and Scopus databases. Prospective and retrospective studies that compared pelvic floor 3D ultrasound with other clinical and imaging diagnostics were included in the analysis. STARD compliance was assessed and quantified by two independent investigators, using 22 of the original 25 STARD checklist items. Items with the qualifier 'if done' (Items 13, 23 and 24) were excluded because they were not applicable to all papers. Each item was scored as reported (score = 1) or not reported (score = 0). Observer variability, the total number of reported STARD items per article and summary scores for each item were calculated. The difference in total score between STARD-adopting and non-adopting journals was tested statistically, as was the effect of year of publication.

RESULTS

Forty studies published in 13 scientific journals were included in the analysis. Mean ± SD STARD checklist score of the included articles was 16.0 ± 2.5 out of a maximum of 22 points. The lowest scores (< 50%) were found for reporting of handling of indeterminate results or missing responses, adverse events and the time interval between tests. Interobserver agreement for rating the STARD items was excellent (intraclass correlation coefficient, 0.77). An independent t-test showed no significant mean difference ± SD in total STARD checklist score between STARD-adopting and non-adopting journals (16.4 ± 2.2 vs 15.9 ± 2.6, respectively). Mean ± SD STARD checklist score for articles published in 2003-2009 was lower, but not statistically different, compared with those published in 2010-2015 (15.2 ± 2.5 vs 16.6 ± 2.4, respectively).

CONCLUSION

The overall compliance with reporting guidelines of diagnostic accuracy studies on pelvic floor 3D transperineal ultrasound is relatively good compared with other fields of medicine. However, specific checklist items require more attention when reported. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Measuring echogenicity and area of the puborectalis muscle: method and reliability

OBJECTIVES

To develop a semi-automated method to assess puborectalis muscle echogenicity on three-dimensional/four-dimensional (3D/4D) volume transperineal ultrasound images using 4D View and Matlab® software and evaluate its intra- and interobserver reliability.

METHOD

The data of 23 women in their first trimester were included. 3D/4D volume datasets were obtained at rest. Two inexperienced observers were trained by an experienced observer to construct tomographic ultrasound images (TUI) from the original data and to delineate all structures. Puborectalis muscle area (PMA) and the mean echogenicity of the puborectalis muscle (MEP) were calculated offline. Intra- and interobserver reliability were determined by intraclass correlation coefficients (ICC) and their 95% CIs.

RESULTS

The development of a semi-automated method to calculate puborectalis area and echogenicity is described in detail. PMA and MEP measurements in pregnant women demonstrated almost perfect intraobserver reliability for both inexperienced observers, with ICC values ranging from 0.88 to 0.99. The interobserver reliability showed ICCs of 0.63 for PMA and almost perfect ICC values, of 0.96-0.98, for echogenicity. The majority of intraobserver mismatch between two delineations of PMA occurred near the borders.

CONCLUSIONS

Matlab software can be used to provide reliable measurements of the area and echogenicity of the puborectalis muscle. As the latter can be used to assess structural changes in the puborectalis muscle, it appears a promising new tool for studying pelvic floor structural anatomy.

[Anorectal injury after a fall from a jet ski]

A 28-year-old female sustained an anorectal rupture after a fall from a jet ski. The rupture was sutured and a double-loop colostomy was created. Three months later, following a test of functional continence, the colostomy was removed. The patient recovered without complications and with preservation of faecal continence. During a fall from a jet ski at high speeds, the water behaves as a solid object that penetrates the body. The choice oftreatment depends on the anatomical location and extent of the injury, on the comorbidity, and on a possible delay in the presentation of the symptoms. Wearing ofwetsuits is proposed as a possible preventive measure.

Which factors influenced the result of a tension free vaginal tape operation in a single teaching hospital?

BACKGROUND

Tension free vaginal tape (TVT) has proven to be successful. Nevertheless, complications of the TVT have been reported. The aim of this study was to describe factors that might influence the efficacy and safety of the TVT procedure in our clinic.

METHODS

Medical records of all patients who underwent TVT surgery between 1 January 2001 and 1 May 2004 were reviewed. To achieve subjective follow-up, in 2004 and 2005, we sent all patients standardised validated questionnaires. Data were analysed with SPSS.

RESULTS

A total of 198 TVT procedures were performed. In 75 cases (37.9%), the procedure was combined with vaginal prolapse surgery. Complications were found in 19.7% of all TVT procedures. Most patients (71%) returned the questionnaire. Median follow-up was 27 months (range: 9-49). Subjective success rate was 73%. Logistic regression analysis showed that success rate of the TVT procedure was not influenced by any of the factors we studied. Complications were not more common in patients who had undergone prior incontinence or prolapse surgery. Concomitant prolapse surgery with the TVT, however, was found to be the only risk factor for complications, mainly prolonged catheterisation.

CONCLUSIONS

In this study, we found no factor that influenced the success rate of the TVT. In the literature, the experience of the surgeon is marked as a factor influencing the success rate. We, therefore, gradually reduced the number of gynecologists who perform TVT. Concomitant prolapse surgery, however, was shown to be an independent risk factor for complications. Therefore, we prefer to 'separate' prolapse and incontinence surgery.

Morbidity and development in childhood of infants born after temporising treatment of early onset pre-eclampsia

OBJECTIVE

To assess morbidity and development in childhood of infants born after temporising management of severe early onset pre-eclampsia.

DESIGN

Cohort study with matched controls.

SETTING

University centre for high risk obstetrics.

SAMPLES

Three groups of neonates matched for gender and year of birth: one born after temporising treatment of severe early onset (<32 weeks) pre-eclampsia with an average delay of delivery of two weeks (n= 193); one born at the duration of pregnancy [1 week] of the pre-eclamptic mother on admission (control group I, n = 192); and one born at the same gestational age [1 week] as the infant of the pre-eclamptic mother (control group II, n= 189).

METHOD

Follow up at four years of age or more using medical records and questionnaires.

MAIN OUTCOME MEASURES

The presence of various morbidities including mental retardation, cerebral palsy, motor skill problems, visual handicap, hearing loss, speech and language problems, education level and acute or chronic respiratory problems.

RESULTS

Median follow up of seven years (range 4-12) was achieved in 159 infants in the study group (83%), 122 in control group I (64%) and 110 in control group II (58%). Missing data analysis showed no differences in neonatal characteristics and morbidity between infants with and without follow up in the study group. All major and minor handicaps were less frequent in the study group than in control group I but statistical significance was reached only for acute and chronic respiratory disorders in the study group (13.8%) compared with control group I (27%).

CONCLUSION

Average delay of delivery of two weeks with temporising management in severe early onset pre-eclampsia is associated with a reduced risk of respiratory disorders in childhood.

A new device for bone anchor fixation in laparoscopic sacrocolpopexy: the Franciscan laparoscopic bone anchor inserter

BACKGROUND

A laparoscopic modification of the sacrocolpopexy procedure with mesh and bone anchor fixation with the Franciscan laparoscopic bone anchor inserter was developed.

METHODS

We developed a laparoscopic bone anchor inserter for the placement of a titanium bone anchor in sacral segment 3 as fixation for the mesh in laparoscopic sacrocolpopexy procedures performed in women with posthysterectomy vault prolapse.

RESULTS

Surgery successfully corrected vaginal vault prolapse. Laparoscopic bone anchor insertion with this new and simple device took 2 minutes and provided a firm anchor for mesh fixation. MRI demonstrated an anatomically preferable vaginal axis toward the hollow of the sacrum.

CONCLUSION

Application of the newly developed Franciscan laparoscopic bone anchor inserter in laparoscopic sacrocolpopexy is an easy and safe procedure that provides firm fixation and excellent anatomical results.

Surgical treatment of vaginal vault prolapse

Vaginal vault prolapse can cause limitations in physical and social functioning. This problem will enhance with the increasing age in women. New surgical techniques, like tension free vaginal mesh and laparoscopic sacrocolpopexy reduce surgical strain in patients and make prolapse surgery achievable in elderly women. doi:10.3126/njog.v2i2.1446 N. J. Obstet. Gynaecol 2007 Nov-Dec; 2 (2): 3 - 8