Can maternal hormones play a significant role in delivery mode?

The aim of this study was primarily to evaluate the levels of progesterone, oestradiol and relaxin during different delivery modes and secondarily to assess specific traits and changes in maternal pelvic dimensions during pregnancy and childbirth, in correlation with foetal size and maternal hormonal profile. Nulliparous women (n = 448) were evaluated at three different stages, during first trimester, at the time of admission for childbirth and finally just before childbirth. Each examination included clinical internal pelvimetry, blood sample collection for defining the hormones levels in peripheral maternal circulation and ultrasonographic measurements of specific variables of the pubic symphysis and the foetus. We included 304 nulliparous women divided in three groups. According to our results, there was statistically significant difference at the mean progesterone, oestradiol and relaxin range during different modes of childbirth (p-value < .01). We also found significant correlation between the newborn's weight and the changes in pubic symphysis dimensions. However, no significant association was noted between maternal hormones studied and the changes in pelvic dimensions.IMPACT STATEMENTWhat is already known on this subject? Mode of childbirth can be affected by various aspects, like maternal pelvic anatomy, foetal size and hormonal status at the time of labour. Hormonal fluctuations along with mechanical forces caused by the foetus are believed to lead to morphological alterations to promote natural vaginal childbirth.What do the results of this study add? Our results clearly showed that successful vaginal delivery is characterised by the prevalence of a hyperoestrogenic environment with higher values of intrapartum oestradiol range and significant increase in maternal serum relaxin levels. We also proved that progesterone levels do not decrease during vaginal childbirth, and we concluded that foetal size seems to be the most crucial factor causing alterations in maternal pelvis during parturition.What are the implications of these findings for clinical practice and further research? Our findings could form part of a set of key factors included in future algorithms or computerised biomechanical models for predicting potential childbirth mode. Larger multicenter studies should confirm our results and evaluate their clinical significance in the decision making to ensure safe childbirth and optimal maternal and perinatal outcomes.

Late-Onset Sacroiliac Osteoarthritis After Surgical Symphysiotomy: A Case Report

A 35-year-old female presented with right-sided gluteal pain and difficulty in walking 10 years after surgical symphysiotomy. Radiograph of the pelvis and bilateral hip joints showed osteoarthritis of the right sacroiliac joint with pubic diastasis of 1.5 cm. She was operated with pubis symphysis reduction and fixation using two orthogonal plates with one iliosacral screw. Postoperative period was uneventful. She was able to walk independently after three months of fixation. Follow-up at 18 months showed complete relief of symptoms with maintenance of reduction and no hardware breakage. The Lindahl score was 78, indicating an excellent outcome.

Evolution of the human pelvis and obstructed labor: new explanations of an old obstetrical dilemma

Without cesarean delivery, obstructed labor can result in maternal and fetal injuries or even death given a disproportion in size between the fetus and the maternal birth canal. The precise frequency of obstructed labor is difficult to estimate because of the widespread use of cesarean delivery for indications other than proven cephalopelvic disproportion, but it has been estimated that at least 1 million mothers per year are affected by this disorder worldwide. Why is the fit between the fetus and the maternal pelvis so tight? Why did evolution not lead to a greater safety margin, as in other primates? Here we review current research and suggest new hypotheses on the evolution of human childbirth and pelvic morphology. In 1960, Washburn suggested that this obstetrical dilemma arose because the human pelvis is an evolutionary compromise between two functions, bipedal gait and childbirth. However, recent biomechanical and kinematic studies indicate that pelvic width does not considerably affect the efficiency of bipedal gait and thus is unlikely to have constrained the evolution of a wider birth canal. Instead, bipedalism may have primarily constrained the flexibility of the pubic symphysis during pregnancy, which opens much wider in most mammals with large fetuses than in humans. We argue that the birth canal is mainly constrained by the trade-off between 2 pregnancy-related functions: while a narrow pelvis is disadvantageous for childbirth, it offers better support for the weight exerted by the viscera and the large human fetus during the long gestation period. We discuss the implications of this hypothesis for understanding pelvic floor dysfunction. Furthermore, we propose that selection for a narrow pelvis has also acted in males because of the role of pelvic floor musculature in erectile function. Finally, we review the cliff-edge model of obstetric selection to explain why evolution cannot completely eliminate cephalopelvic disproportion. This model also predicts that the regular application of life-saving cesarean delivery has evolutionarily increased rates of cephalopelvic disproportion already. We address how evolutionary models contribute to understanding and decision making in obstetrics and gynecology as well as in devising health care policies.

Radiographic Prevalence of Symphysis Pubis Abnormalities and Clinical Outcomes in Patients With Femoroacetabular Impingement Syndrome

BACKGROUND

The decreased hip range of motion seen in femoroacetabular impingement syndrome (FAIS) may lead to compensatory increased motion at the symphysis pubis (SP) with resultant increased stress on the joint, which can subsequently lead to osteitis pubis.

PURPOSE

To quantify the prevalence of SP abnormalities in patients with FAIS through the use of imaging modalities and to compare outcomes based on the presence of SP abnormalities.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Radiographs and magnetic resonance imaging (MRI) scans of 1009 consecutive patients who underwent primary hip arthroscopy for FAIS from January 2012 to January 2016 were identified. Exclusion criteria were patients undergoing revision or bilateral surgery, patients with dysplasia, and patients with less than 2-year follow-up. On radiographs, SP joints were reviewed for joint surface erosions, subchondral sclerosis and cysts, and ankylosis. MRI scans were reviewed for marrow edema in the subarticular pubic bone, subchondral sclerosis and cysts, joint surface erosions, and ankylosis. Patients with SP abnormalities were matched 1:2 to patients without SP abnormalities by age and body mass index. Outcomes included the Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool-12 (iHOT-12), and visual analog scales (VAS) for pain and satisfaction.

RESULTS

830 patients were included; 23 (2.8%) demonstrated SP abnormalities. Of the 726 (72%) MRI scans reviewed, 15 (1.8%) showed bone marrow edema, subchondral sclerosis, erosions, or ankylosis. After matching, patients without SP abnormalities had significantly greater HOS-ADL (95.7 vs 83.0; P = .008), HOS-SS (91.6 vs 61.9; P = .003), iHOT-12 (89.5 vs 74.6; P = .046), and VAS satisfaction (91.3 vs 58.8; P = .004) scores, in addition to less postoperative pain (6.3 vs 23.5; P < .001). No significant differences were found in the mHHS (92.5 vs 82.2; P = .08). Patients without SP abnormalities had higher odds of achieving the minimal clinically important difference for the HOS-ADL (odds ratio [OR], 4.5; 95% CI, 1.3-14.1; P = .010), the HOS-SS (OR, 7.2; 95% CI, 1.8-18.5; P = .006), and the mHHS (OR, 14.5; 95% CI, 1.8-24.7; P = .013).

CONCLUSION

A low prevalence (1.8%-2.6%) of SP joint abnormality is seen on imaging in patients with FAIS. These patients may demonstrate significantly inferior clinical outcomes and persistent postoperative pain after FAIS treatment.

Diastasis of symphysis pubis and labor: Systematic review

Symphysis pubis diastasis (SPD) is an infrequent complication of labor that can impair womens' general health through failure of the passive stability of the pelvic girdle. Although conservative approaches are often used to decrease symptoms and interpubic separation, notably few studies have analyzed the effect of these methods on managing the symptoms of women with SPD. The purpose of this study was to review the available literature on the conservative treatment of SPD during pregnancy and labor. A computer-based search using PubMed, PEDro, and CINAHL was performed up to November 2014. We selected all studies that considered women with SPD during pregnancy or labor and treated them with conservative methods and excluded those that included surgical intervention. Eighteen studies were selected, most of which were case reports. Although the overall results of conservative treatment were unclear because of the type and design of the obtained studies, most of the studies reported bed rest in the lateral decubitus position and a pelvic girdle as basic treatments. Additionally, the few clinical trials reported recommended additional physiotherapy, including strengthening and stabilizing exercises, to reduce SPD symptoms.

Chiropractic management of postpartum pubic symphysis diastasis: A case report

This case report describes the chiropractic management of a 30-year-old female patient with severe postpartum pelvic pain secondary to pubic symphysis diastasis. No literature was found on the chiropractic management of postpartum symphysis pubis diastasis. The existing literature concerning chiropractic care for symphysis pubis dysfunction during pregnancy is limited and indicates a potential benefit. Separation of the pubic symphysis may include ligamentous injury to the sacroiliac joints and may lead to chronic pain. Pubic symphysis separation of 17 millimeters was present on digital radiograph. Management consisted of chiropractic adjustments, trigger point release, electrical stimulation, moist heat, sacroiliac belt, and specific stabilizing exercises. The patient's pain improved immediately following treatment on the initial visit. Pain was reduced from 8/10 VAS at the first visit to 2/10 at the fourth visit. She was able to resume normal activities and reached a final pain level of 1/10. The diastasis was reduced by 7 millimeters at 14-weeks post radiograph for a final separation of just under 10 millimeters. Collaboration between obstetricians, midwives and chiropractors may be warranted.

Evaluation of established and new reference lines for the standardization of transperineal ultrasound

OBJECTIVES

To examine the performance of a new reference line for the assessment of pelvic organ descent by transperineal ultrasound.

METHODS

We compared our newly proposed reference line, between two hyperechoic contours of the symphysis pubis (Line 3), with the horizontal reference line proposed by Dietz and Wilson (Line 1) and the central pubic line proposed by Schaer et al. (Line 2). Ultrasound volumes of 94 women obtained in routine clinical practice were analyzed. The perpendicular distance from the reference lines to the internal sphincter and the most dependent part of the bladder base was measured for volumes obtained at rest, on pelvic floor muscle contraction, on Valsalva maneuver and during coughing. Measurements were repeated 4 months later by the same examiner. Rates of assessment were calculated, and intrarater reliability was evaluated using Bland-Altman plots and intraclass correlation coefficients.

RESULTS

Line 2 had to be excluded from reliability analysis because of an assessment rate of only 12%, whereas Lines 1 and 3 could be assessed in 100% of volumes. The intrarater repeatability of Lines 1 and 3 was shown to be very similar.

CONCLUSION

In this comparison of three potential reference lines for the assessment of pelvic organ descent by transperineal ultrasound, the central pubic line was shown to be inferior owing to poor visibility in our volumes. Inter-rater reliability analysis and validation studies are required to confirm our results.

Sonographic appearance of a cartilaginous cyst from the symphysis pubis mimicking a mass in the urinary bladder

A suprapubic cartilaginous cyst from the symphysis pubis is a rare lesion, which may be asymptomatic or cause symptoms such as urinary retention and pelvic pain. It is thought to be secondary to degenerative changes in the symphysis pubis and usually occurs in multiparous women. We report the case of a suprapubic cartilaginous cyst in a 76-year-old asymptomatic woman, which mimicked a bladder mass on ultrasonography.

Penile lengthening procedure with V-Y advancement flap and an interposing silicone sheath: A novel methodology

Surgery to augment penile length has become increasingly common. Lack of standardization of this controversial procedure has led to a wide variety of poorly documented surgical techniques, with unconvincing results. The most commonly used technique involves release of the suspensory ligament, with an advancement of an infrapubic skin flap onto the penis via a V-Y plasty. This technique has a major drawback of the possibility of reattachment of the penis to the pubis. We describe a new technique of interposing a silicone sheath along with V-Y advancement flap that overrides this drawback and minimizes the loss of the gained length.

Effects of zero reference position on bladder pressure measurements: an observational study

BACKGROUND

Although the World Society for Abdominal Compartment Syndrome in its guidelines recommends midaxillary line (MAL) as zero reference level in intra-abdominal pressure (IAP) measurements in aiming at standardizing the technique, evidence supporting this suggestion is scarce. The aim of this study is to study if the zero reference position influences bladder pressure measurements as estimate for IAP.

METHODS

The IAP of 100 surgical patients was measured during the first 24 h of admission to the surgical intensive care unit of General Calixto Garcia Hospital in Havana (Cuba) following laparotomy. The period was January 2009 to January 2010. The IAP was measured twice with a six-hour interval using the transurethral technique with a priming volume of 25 ml. IAP was first measured with the zero reference level placed at MAL (IAPMAL), followed by a second measurement at the level of the symphysis pubis (SP) after 3 minutes (IAPSP). Correlations were made between IAP and body mass index (BMI), type of surgery, gender, and age.

RESULTS

Mean IAPMAL was 8.5 ± 2.8 mmHg vs. IAPSP 6.5 ± 2.8 mmHg (p < 0.0001). The bias between measurements was 2.0 ± 1.5, 95% confidence interval of 1.4 to 3.0, upper limit of 4.9, lower limit of -0.9, and a percentage error of 35.1%. IAPMAL was consistently higher than IAPSP regardless of the type of surgery. The BMI correlated with IAP values regardless of the zero reference level (R2 = 0.4 and 0.3 with IAPMAL and IAPSP respectively, p < 0.0001).

CONCLUSIONS

The zero reference level has an important impact on IAP measurement in surgical patients after laparotomy and can potentially lead to over or underestimation. Further anthropometric studies are needed with regard to the relative MAL and SP zero reference position in relation to the theoretical ideal reference level at midpoint of the abdomen. Until better evidence is available, MAL remains the recommended zero reference position due to its best anatomical localization at iliac crest.

Locating the reference point of symphysis pubis in axial CT images

In this paper, we present an effective method to determine the reference point of symphysis pubis (SP) in an axial stack of CT images to facilitate image registration for pelvic cancer treatment. In order to reduce the computational time, the proposed method consists of two detection parts, the coarse detector, and the fine detector. The detectors check each image patch whether it contains the characteristic structure of SP. The coarse detector roughly determines the location of the reference point of SP using three types of information, which are the location and intensity of an image patch, the SP appearance, and the geometrical structure of SP. The fine detector examines around the location found by the coarse detection to refine the location of the reference point of SP. In the experiment, the average location error of the propose method was 2.23 mm, which was about the side length of two pixels. Considering that the average location error by a radiologist is 0.77 mm, the proposed method finds the reference point quite accurately. Since it takes about 10 s to locate the reference point from a stack of CT images, it is fast enough to use in real time to facilitate image registration of CT images for pelvic cancer treatment.