Prevalence of levator ani muscle injury in Chinese women after first delivery

Obstetric risk factors for levator ani muscle avulsion: A systematic review and meta-analysis

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.

Assisted vaginal birth in 21st century: current practice and new innovations

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.

The use of bubble charts in analyzing second stage cesarean delivery rates

BACKGROUND

The incidence of second stage cesarean delivery has been rising globally because of the failure or the anticipated difficulty of performing instrumental delivery. Yet, the best way to interpret the figure and its optimal rate remain to be determined. This is because it is strongly influenced by the practice of other 2 modes of birth, namely cesarean delivery performed before reaching the second stage and assisted vaginal birth during the second stage. In this regard, a bubble chart that can display 3-dimensional data through its x-axis, y-axis, and the size of each plot (presented as a bubble) may be a suitable method to evaluate the relationship between the rates of these 3 modes of births.

OBJECTIVE

This study aimed to conduct an epidemiologic study on the incidence of second stage cesarean deliveries rates among >300,000 singleton term births in 10 years from 8 obstetrical units and to compare their second stage cesarean delivery rates in relation to their pre-second stage cesarean delivery rates and assisted vaginal birth rates using a bubble chart.

STUDY DESIGN

The territory-wide birth data collected between 2009 and 2018 from all 8 public obstetrical units (labelled as A to H) were reviewed. The inclusion criteria were all singleton pregnancies with cephalic presentation that were delivered at term (≥37 weeks' gestation). Pre-second stage cesarean delivery rate was defined as all elective cesarean deliveries and those emergency cesarean deliveries that occurred before full cervical dilatation was achieved as a proportion of the total number of births. The second stage cesarean delivery rate and assisted vaginal birth rate were calculated according to the respective mode of delivery as a proportion of the number of cases that reached full cervical dilatation. The rates of these 3 modes of births were compared among the parity groups and among the 8 units. Using a bubble chart, each unit's second stage cesarean delivery rate (y-axis) was plotted against its pre-second stage cesarean delivery rate (x-axis) as a bubble. Each unit's second stage cesarean delivery to assisted vaginal birth ratio was represented by the size of the bubble.

RESULTS

During the study period, a total of 353,434 singleton cephalic presenting term pregnancies were delivered in the 8 units, and 180,496 (51.1%) were from nulliparous mothers. When compared with the multiparous group, the nulliparous group had a significantly lower pre-second stage cesarean delivery rate (18.58% vs 21.26%; P<.001) but a higher second stage cesarean delivery rate (0.79% vs 0.22%; P<.001) and a higher assisted vaginal birth rate (17.61% vs 3.58%; P<.001). Using the bubble of their averages as a reference point in the bubble chart, the 8 units' bubbles were clustered into 5 regions indicating their differences in practice: unit B and unit H were close to the average in the center. Unit A and unit F were at the upper right corner with a higher pre-second stage cesarean delivery rate and second stage cesarean delivery rate. Unit D and unit E were at the opposite end. Unit C was at the upper left corner with a low pre-second stage cesarean delivery rate but a high second stage cesarean delivery rate, whereas unit G was at the opposite end. Unit C and unit G were also in the extremes in terms of pre-second stage cesarean delivery to assisted vaginal birth ratio (0.09 and 0.01, respectively). Although some units seemed to have very similar second stage cesarean delivery rates, their obstetrical practices were differentiated by the bubble chart.

CONCLUSION

The second stage cesarean delivery rate must be evaluated in the context of the rates of pre-second stage cesarean delivery and assisted vaginal birth. A bubble chart is a useful method for analyzing the relationship among these 3 variables to differentiate the obstetrical practice between different units.

The use of bubble charts in analyzing the global second-stage cesarean delivery rates: a systematic review

OBJECTIVE

This study aimed to systematically review the worldwide second-stage cesarean delivery rate concerning pre-second-stage cesarean delivery and assisted vaginal birth rates.

DATA SOURCES

PubMed, Medline Ovid, EBSCOhost, Embase, Scopus, and Google Scholar were queried from inception to February 2023, with the following terms: "full dilatation," "second stage," and "cesarean," with their word variations. Furthermore, an additional cohort of 353,434 cases from our recently published study was included.

STUDY ELIGIBILITY CRITERIA

Only original studies that provided sufficient information on the number of pre-second-stage cesarean deliveries, second-stage cesarean deliveries, and vaginal births were included for the calculation of different modes of delivery. Systemic reviews, meta-analyses, or case reports were excluded.

METHODS

Study identification and data extraction were independently performed by 2 authors. Selected studies were categorized on the basis of parity, study period, and geographic regions for comparison.

RESULTS

A total of 25 studies were included. The overall pre-second-stage cesarean delivery rate, the second-stage cesarean delivery rate, and the second-stage cesarean delivery-to-assisted vaginal birth ratio were 17.94%, 2.65%, and 0.19, respectively. Only 5 studies described singleton, term, cephalic presenting pregnancies of nulliparous women, and their second-stage cesarean delivery rates were significantly higher than those studies with cohorts of all parity groups (4.50% vs 0.83%; P<.05). In addition, the second-stage cesarean delivery rate showed a secular increase across 2009 (0.70% vs 1.05%; P<.05). Moreover, it was the highest among African studies (5.14%) but the lowest among studies from East Asia and South Asia (0.94%). The distributions of second-stage cesarean delivery rates of individual studies and subgroups were shown with that of pre-second-stage cesarean delivery and assisted vaginal birth using the bubble chart.

CONCLUSION

The overall worldwide pre-second-stage cesarean delivery rate was 17.94%, the second-stage cesarean delivery rate was 2.65%, and the second-stage cesarean delivery-to-assisted vaginal birth ratio was 0.19. The African studies had the highest second-stage cesarean delivery rate (5.14%) and second-stage cesarean delivery-to-assisted vaginal birth ratio (1.88), whereas the studies from East Asia and South Asia were opposite (0.94% and 0.11, respectively).

Management of levator ani avulsion: a systematic review and narrative synthesis

PURPOSE

Levator ani muscle (LAM) avulsion affects up to 35% of women. Unlike obstetric anal sphincter injury, LAM avulsion is not diagnosed immediately after vaginal delivery, however, has a profound impact on quality of life. The management of pelvic floor disorders is in growing demand yet the significance of LAM avulsion in the context of pelvic floor dysfunction (PFD) is poorly understood. This study collates information on success of treatment for LAM avulsion to establish the best options for management of women.

METHODS

MEDLINE®, MEDLINE® In-Process, EMBASE, PubMed, CINAHL and The Cochrane Library were searched for articles that evaluated the management techniques used to treat LAM avulsion. The protocol was registered with PROSPERO (CRD42021206427).

RESULTS

Natural healing of LAM avulsion occurs in 50% of women. Conservative measures, including pelvic floor exercises and pessary use are poorly studied. Pelvic floor muscle training for major LAM avulsions was of no benefit. Post-partum pessary use was only of benefit in the first three months for women. Surgeries for LAM avulsion are poorly researched but studies suggest they may provide benefit for 76-97% of patients.

CONCLUSIONS

Whilst some women with PFD secondary to LAM avulsion improve spontaneously, 50% continue to have pelvic floor symptoms 1 year following delivery. These symptoms result in a significant negative impact on quality of life, however, it is not clear whether conservative or surgical methods are helpful. There is a pressing need for research to find effective treatments and explore appropriate surgical repair techniques for women with LAM avulsion.

Ultrasound examination of the pelvic floor during active labor: A longitudinal cohort study

INTRODUCTION

There is limited evidence about changes in the pelvic floor during active labor. We aimed to investigate changes in hiatal dimensions during the active first stage of labor and associations with fetal descent and head position.

MATERIAL AND METHODS

We conducted a longitudinal, prospective cohort study at the National University Hospital of Iceland, from 2016 to 2018. Nulliparous women with spontaneous onset of labor, a single fetus in cephalic presentation, and gestational age ≥37 weeks were eligible. Fetal position was assessed with transabdominal ultrasound and fetal descent was measured with transperineal ultrasound. Three-dimensional volumes were acquired from transperineal scanning at the start of the active phase of labor and in late first stage or early second stage. The largest transverse hiatal diameter was measured in the plane of minimal hiatal dimensions. The levator urethral gap was measured as the distance between the center of the urethra and the levator insertion using tomographic ultrasound imaging. Measurements of the levator urethral gap were made in the plane of minimal hiatal dimensions and 2.5 and 5 mm cranial to this.

RESULTS

The final study population comprised 78 women. The mean transverse hiatal diameter increased 12.4% between the two examinations, from 39.4 ± 4.1 mm (±standard deviation) at the first examination to 44.3 ± 5.8 mm at the last examination (p < 0.01). We found a moderate correlation between the transverse hiatal diameter and fetal station at the last examination (r = 0.44, r2  = 0.19; p < 0.01; regression equation y = 2.71 + 0.014x), and a weak correlation between the change in transverse hiatal diameter and change in fetal station (r = 0.29; r2  = 0.08; p = 0.01; regression equation y = 0.24 + 0.012x). Levator urethral gap increased significantly in all three planes on both the left and right sides. Head position was not associated with hiatal measurements after adjusting for fetal station.

CONCLUSIONS

We found a significant, but only modest, increase of the hiatal dimensions during the first stage of labor. The risk of levator ani trauma will therefore be low during this stage. The change in transverse hiatal diameter was associated with fetal descent but not with head position.

Diagnosis of maternal birth trauma by pelvic floor ultrasound

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.

Association Between Urinary Stress Incontinence and Levator Avulsion Detected by 3D Transperineal Ultrasound

PURPOSE

 To determine the association between levator avulsion and urinary stress incontinence (USI) by 3/4D transperineal ultrasound.

MATERIALS AND METHODS

 842 patients who were admitted to our hospital from 2016 to 2019 were recruited for our study. 3D/4D transperineal ultrasound was performed. After standard interview and clinical evaluation, general conditions and levator hiatus data were collected and measured to compare with each group. The odds ratio (OR) of USI symptoms or ultrasound features with levator avulsion were calculated.

RESULTS

 A total of 593 women were studied: 204 suffered from levator avulsion (96 cases of left-side avulsion, 80 cases of right-side avulsion and 28 cases of bilateral avulsion) and 389 women had no avulsion. The gravidity and episiotomy conditions of the avulsion groups were significantly different from the no-avulsion group. Significant differences were found in the transverse diameters and anteroposterior diameters between the levator avulsion group and the no-avulsion group, but there was no difference among the avulsion groups, regardless of whether the patient was at rest or performing the Valsalva maneuver. Interestingly, a significant difference was found in the presence of USI symptoms between the uni-avulsion group and the no-avulsion group. The odds ratio (OR) of USI symptoms in the uni-avulsion group is 2.786 (95 %CI, 1.663-4.669), but 0.939 (95 %CI, 0.276-3.199) for the bilateral avulsion and no-avulsion groups.

CONCLUSION

 Unilateral levator avulsion may be a risk factor for urinary stress incontinence.

Transvaginal Two-Dimensional Ultrasound Evaluation as a Screening Tool for Levator ani Muscle Avulsion in Postpartum Women

OBJECTIVES

To evaluate the agreement between two-dimensional transvaginal ultrasound (2D-TVUS) and transperineal tomographic ultrasound imaging on three-dimensional (3D) volume in diagnosing levator ani muscle (LAM) avulsion of postpartum women. Furthermore, we tested the repeatability of the 2D-TVUS in measuring the LAM thickness.

METHODS

A retrospective study was performed using the data sets from postpartum women. One doctor measured the thickness of the LAM on the images at the attachment to the arcus tendinous levator ani and the middle part using the 2D-TVUS ultrasound data sets of postpartum women. These women were examined twice, at 42-56 days and 3-6 months postpartum. Intra-observer repeatability was expressed using intraclass correlation coefficients (ICCs). The other doctor judged whether there was avulsion in the LAM on the 2D-TVUS and transperineal tomography imaging on the 3D volume. The inter-method agreement was determined using Cohen's kappa coefficient (k).

RESULTS

Thickness measurements of the middle part and attachment of the LAM by 2D-TVUS showed excellent and good intra-observer repeatability (ICC 0.84; 95% CI, 0.76-0.88, and ICC 0.74; 95% CI, 0.67-0.84, respectively). The overall agreement was 92% (Cohen's kappa was 0.79) between 2D-TVUS and transperineal tomographic imaging. Compared to transperineal tomographic imaging in the diagnosis of LAM avulsion, the diagnostic sensitivity of 2D-TVUS was 91.7%, the specificity was 92.1%.

CONCLUSIONS

The 2D-TVUS technique, a simple and reproducible method for assessing LAM avulsion, may be helpful as a screening tool for LAM avulsion of postpartum women.

Perineal stress as a predictor of performing episiotomy in primiparous women: a prospective observational study

Background

Episiotomy is a surgical solution to relieve perineal stress, resulting in an easily repairable incision, in comparison to the risks of serious vaginal trauma during delivery. The midwife typically adopts such a clinical decision, on experience and subjective judgment. However, the association between perineal stress and episiotomy is poorly characterized. Our aim was to identify a threshold value for perineal stress leading to episiotomy, which eventually may be employed as a clinical tool for assessing whether an episiotomy is required or not.

Methods

In total, 245 nulliparous women were investigated for perineal stress during non-instrumental vaginal delivery in Ningbo Women & Children’s Hospital. During the second stage of labor, a flexible membrane stress sensor was placed between the fetal head and perineal wall above the anal fissure. Once the entire fetal head pressed against the sensor, real-time perineal stress was measured, and the peak value was recorded. Cases were divided into non-episiotomy group (n = 173) and episiotomy group (n = 72). The correlations between perineal stress and episiotomy was assessed through logistic regression with adjustment for maternal age, estimated birthweight, duration of second stage of labor, maternal body mass index, and presence of analgesia. Midwives were blinded to all stress measurement values. The predictive value of perineal stress on performing episiotomy was evaluated, together with the ideal cut-off perineal stress value for performing episiotomy. A ROC analysis was also performed.

Results

The episiotomy group had significantly higher levels of perineal stress in comparison to the non-episiotomy group (140.50 ± 16.03 N versus 118.37 ± 19.21 N, p < 0.01). The episiotomy group was linked to significantly higher perineal stress in comparison to the non-episiotomy group (140.50 ± 16.03 VS 118.37 ± 19.21 N, p < 0.01). ROC analysis between perineal stress and episiotomy revealed a high area under the curve (AUC 0.81, 95% CI 0.75–0.86) and a cut-off value for perineal stress of 124.49 N was identified for episiotomy decision.

Conclusion

The level of perineal stress was an independent predictor of performing episiotomy in nulliparous women during non-instrumental vaginal delivery. Perineal stress exceeding 124.49 N was identified as the cut-off prompting midwives to perform episiotomy.

A review of levator ani avulsion after childbirth: Incidence, imaging and management

Key Content • Levator ani muscle (LAM) avulsion injury occurs occultly during childbirth, most commonly during operative vaginal deliveries. • Injuries of levator ani have long term sequelae for pelvic floor health. As life expectancy increases the burden of disease upon urogynaecology services will need to be considered. • Diagnosis of this condition can be difficult as there is no agreed 'gold standard' imaging modality. • There is no consensus regarding surgical management of LAM avulsion. Learning objectives • Review anatomy and function of levator ani muscle • Identify the risk factors for levator ani avulsion injury • Role of imaging to appropriately identify LAM injury and current management options including appropriate follow up • Management of subsequent pregnancy following LAM avulsion Ethical issues • Is there value to the patient in diagnosing levator ani avulsion when there is no recommended treatment for these injuries?

On the management of maternal pushing during the second stage of labor: a biomechanical study considering passive tissue fatigue damage accumulation

BACKGROUND

During the second stage of labor, the maternal pelvic floor muscles undergo repetitive stretch loading as uterine contractions and strenuous maternal pushes combined to expel the fetus, and it is not uncommon that these muscles sustain a partial or complete rupture. It has recently been demonstrated that soft tissues, including the anterior cruciate ligament and connective tissue in sheep pelvic floor muscle, can accumulate damage under repetitive physiological (submaximal) loads. It is well known to material scientists that this damage accumulation can not only decrease tissue resistance to stretch but also result in a partial or complete structural failure. Thus, we wondered whether certain maternal pushing patterns (in terms of frequency and duration of each push) could increase the risk of excessive damage accumulation in the pelvic floor tissue, thereby inadvertently contributing to the development of pelvic floor muscle injury.

OBJECTIVE

This study aimed to determine which labor management practices (spontaneous vs directed pushing) are less prone to accumulate damage in the pelvic floor muscles during the second stage of labor and find the optimum approach in terms of minimizing the risk of pelvic floor muscle injury.

STUDY DESIGN

We developed a biomechanical model for the expulsive phase of the second stage of labor that includes the ability to measure the damage accumulation because of repetitive physiological submaximal loads. We performed 4 simulations of the second stage of labor, reflecting a directed pushing technique and 3 alternatives for spontaneous pushing.

RESULTS

The finite element model predicted that the origin of the pubovisceral muscle accumulates the most damage and so it is the most likely place for a tear to develop. This result was independent of the pushing pattern. Performing 3 maternal pushes per contraction, with each push lasting 5 seconds, caused less damage and seemed the best approach. The directed pushing technique (3 pushes per contraction, with each push lasting 10 seconds) did not reduce the duration of the second stage of labor and caused higher damage accumulation.

CONCLUSION

The frequency and duration of the maternal pushes influenced the damage accumulation in the passive tissues of the pelvic floor muscles, indicating that it can influence the prevalence of pelvic floor muscle injuries. Our results suggested that the maternal pushes should not last longer than 5 seconds and that the duration of active pushing is a better measurement than the total duration of the second stage of labor. Hopefully, this research will help to shed new light on the best practices needed to improve the experience of labor for women.

The evolution of levator ani muscle trauma over the first 9 months after vaginal birth

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the evolution of levator ani muscle (LAM) trauma over the first 9 months after birth and to evaluate their agreement between different assessment periods.

METHODS

From March 2017 to April 2019 we prospectively evaluated LAM states (intact, hematoma, partial or complete avulsion) of primiparous women after vaginal birth by using 4D translabial ultrasound (TLUS) at three different assessment periods. All women were examined 1-4 days (A1) and 6-10 weeks (A2) postpartum, and women with a trauma additionally 6-9 months postpartum (A3). Cohen's Kappa analysis was performed to evaluate the test agreement between the assessment periods.

RESULTS

Thirty-two percent of the women at A1 had a LAM trauma and 24% at A2. The higher number of LAM injuries at A1 can be explained by hematomas (14%), of which 51% spontaneously resolved at A2, 35% revealed themselves as partial, and 12% as complete avulsions. At A3, we observed anatomical improvement from complete to partial avulsions (23%) and few partial avulsions changed into an intact LAM (3%); none of the complete avulsions changed into an intact LAM. The agreement of 4D TLUS between A1 and A2 was moderate to good (0.64 for the right-sided LAM/0.60 for the left-sided LAM) and between A2 and A3 good to very good (0.76 right-sided/0.84 left-sided).

CONCLUSIONS

Levator ani muscle trauma can reliably be diagnosed during all assessment periods. However, the agreement between A1 and A2 was only moderate to good. This can be explained by hematomas inside the LAM that were only observed early postpartum. We observed some anatomical improvement at A3, but no complete avulsion improved to an intact LAM.

A predictive model of choosing pessary type for women with symptomatic pelvic organ prolapse

OBJECTIVE

To investigate clinical factors including translabial ultrasound parameters, which are predictive for choosing pessary type (Ring or Gellhorn) in the fitting trial, and to establish a predictive model.

METHODS

A retrospective study was conducted on symptomatic women with pelvic organ prolapse (POP) at the Pelvic Floor Disease Diagnosis and Treatment Center (Liaoning Province, China) between May 2018 and December 2020 who were successfully fitted with pessaries. This retrospective study was supplemented with a prospective cohort study on women seeking pessary for first-line treatment of POP at the above tertiary center between December 2020 and April 2021 for validation. Enrolled participants were grouped by their fitted type of pessary. Demographic and clinical parameters between groups, including pelvic organ prolapse quantification and translabial ultrasound, were analyzed using logistic regression. A receiver operating characteristic curve was calculated using predictive values obtained by regression as the predictor for choosing pessary type in the pessary fitting trial.

RESULTS

The 181 participants included in the retrospective analysis were randomly divided into the "Development" and "Validation" datasets. In the "Development" set, multivariable logistic regression analyses showed that a younger age (odds ratio [OR]: 0.950; 95% confidence interval [CI]: 0.908-0.995; P = 0.026), a larger hiatal circumference on Valsalva (OR: 1.348; 95% CI: 1.103-1.647; P = 0.004), and a higher POP-Q stage (OR: 2.963; 95% CI: 1.210-7.255; P = 0.017) were independent predictors for successful fitting with the Gellhorn pessary. The predictive model was P = exp(Z)/[1 + exp(Z)], Z = -0.051 × Age (y) + 0.298 × hiatal circumference on Valsalva (cm) + 1.086 × pelvic organ prolapse stage (2, 3, or 4) - 5.490. The area under the receiver operating characteristic curves (AUC) was 0.776 (P < 0.001) and 0.705 (P < 0.001) based on the "Development" dataset and "Validation" datasets, respectively. The AUC was 0.815 (P < 0.001) based on the prospective cohort validation.

CONCLUSIONS

For severe POP, women with younger age and larger hiatal circumference, Gellhorn pessaries should be their first choice instead of ring ones in pessary fitting trials.

Levator ani avulsion: a Systematic evidence review (LASER)

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.

Surface electromyography of the pelvic floor at 6-8 weeks following delivery: a comparison of different modes of delivery

INTRODUCTION AND HYPOTHESIS

The objective of this study was to compare the impact of different modes of delivery, especially forceps delivery (FD), on pelvic floor muscles (PFMs) through vaginal surface electromyography (sEMG) in primiparous women at early (6-8 weeks) postpartum.

METHODS

A total of 1259 primiparous women with full-term singleton births were included in this cross-sectional study. Of these, 98 were delivered by forceps, 865 underwent spontaneous vaginal delivery (SD) and 296 underwent elective cesarean delivery (CD). Clinical demographic characteristics and vaginal sEMG variables of parturients 6-8 weeks after birth were collected and analyzed using SPSS software. One-way ANOVA with Bonferroni correction, Chi-square test or Student's t-test was used according to the variable type. Spearman correlation and binary logistic regression analyses were also used. P/α ≤ 0.05 was considered statistically significant.

RESULTS

Amplitude of fast and sustained contractions on sEMG in the FD group was significantly lower compared with the CD and SD groups. The sEMG amplitude of all contractions was significantly higher in the CD group compared with the FD and SD groups (P < 0.01). According to binary logistic regression analysis, mode of delivery was a major influencing factor in sEMG.

CONCLUSIONS

An early postpartum sEMG test appears to be helpful for the assessment of PFM activity. Mode of delivery was a major influencing factor on sEMG. Forceps delivery significantly inversely influenced PFM activity.

Women with advanced pelvic organ prolapse and levator ani muscle avulsion would significantly benefit from mesh repair surgery

OBJECTIVES

Mesh repair surgery for pelvic organ prolapse (POP) has been suspended in some countries owing to concerns about its associated complications. However, mesh repair has been shown to reduce the risk of prolapse recurrence after surgery. In view of this controversy, our aim was to assess the incidence of subjective and objective recurrence of POP following mesh repair surgery vs native-tissue repair in women with Stage-III or Stage-IV POP.

METHODS

This was a prospective observational study of women who presented with Stage-III or Stage-IV POP and received primary prolapse surgery between 2013 and 2018. Transperineal ultrasound was performed before the operation and volumes were analyzed offline to assess the presence of levator ani muscle (LAM) avulsion. All women were counseled on either mesh repair or native-tissue reconstruction. The mesh-repair group was followed up for up to 5 years and the native-tissue-repair group for up to 2 years after the operation. Prolapse symptoms and POP quantification (POP-Q) staging were assessed at follow-up. Subjective recurrence of POP was defined as symptoms of prolapse (vaginal bulge sensation or dragging sensation) reported by the patient. Objective recurrence was defined as POP-Q ≥ Stage II. The subjective and objective recurrences of prolapse were compared between women with and those without mesh use. Multivariate regression analysis was used to identify risk factors for the recurrence of POP.

RESULTS

A total of 154 Chinese women with Stage-III or Stage-IV prolapse were recruited. Of these, 104 (67.5%) underwent mesh repair (transabdominal in 57 women and transvaginal in 47 women) and 50 (32.5%) had native-tissue repair surgery. Ninety-five (61.7%) women had LAM avulsion. Both the subjective POP recurrence rate (4.8% vs 20.0%; P = 0.003) and the objective recurrence rate (20.2% vs 46.0%; P = 0.001) were significantly lower in the mesh-repair group than in the native-tissue-repair group. On multivariate logistic regression analysis, mesh repair was associated significantly with a reduced risk of subjective recurrence (odds ratio (OR), 0.20 (95% CI, 0.07-0.63)) and of objective recurrence (OR, 0.16 (95% CI, 0.07-0.55)) of prolapse. On subgroup analysis of women with LAM avulsion, mesh repair significantly reduced the risk of subjective recurrence (OR, 0.24 (95% CI, 0.07-0.87)) and objective recurrence (OR, 0.23 (95% CI, 0.09-0.57)) of POP. The incidence of mesh-related complications was low, and mesh exposure could be treated conservatively or by minor surgery.

CONCLUSIONS

Mesh repair surgery, compared with native-tissue repair, was associated with a 5-fold reduction in the risk of subjective recurrence and a 6-fold reduction in the risk of objective recurrence of prolapse in women with Stage-III or Stage-IV POP. In women with concomitant LAM avulsion, mesh repair surgery was associated with a 4-fold reduction in both objective and subjective recurrence of POP. The rate of mesh-related complications was low, and mesh exposure could be treated conservatively or by minor surgery. The benefit of mesh surgery for these high-risk women appears to outweigh the risks of mesh complications, and it could be a treatment option for this group of women. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasound imaging of maternal birth trauma

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.

Association between levator ani avulsion and urinary incontinence in women: A systematic review and meta-analysis

Background

Urinary incontinence is a bothersome symptom. Although the relationship between stress urinary incontinence (SUI) and vaginal delivery is established, the pathology underlying SUI after vaginal birth remains to be elucidated.

Objectives

To determine whether levator ani muscle avulsion predisposes for SUI in women.

Search strategy

Pubmed and Embase were searched for terms and their variations “levator ani muscle avulsion” and “urinary incontinence”, from inception until 5 November 2019.

Selection criteria

Inclusion criterion: studies describing the relationship between urinary incontinence and levator ani muscle avulsion in women at least 1 year after delivery. Exclusion criterion: studies only analyzing the urethral sphincter or hiatus dimensions.

Data collection and analysis

Odds ratios were used and if not available, were calculated as means of data synthesis, adjusted odds ratios if presented by the study, random‐effects model to compute a pooled estimate.

Results

Seven studies were included, accounting for 2388 women. Comparing women with and without levator ani muscle avulsion, the overall odds ratio for SUI is 0.87 (95% confidence interval 0.56–1.34), and after adjustment for possible confounders was 0.72 (95% confidence interval 0.40–1.30).

Conclusion

There is no relationship between levator ani muscle avulsion and SUI in women.

A systematic review and meta‐analysis was conducted to evaluate the relationship between levator ani muscle avulsion and stress urinary incontinence, which could not be supported.

Change in prevalence of major levator ani muscle defects from 6 weeks to 1 year postpartum, and maternal and obstetric risk factors: A longitudinal ultrasound study

INTRODUCTION

The present study aimed first to investigate the change in prevalence of major levator ani muscle (LAM) defects, also called avulsions, from 6 weeks to 1 year postpartum, and second to assess maternal and obstetric risk factors for having persistent major LAM defects/avulsions at 1 year postpartum.

MATERIAL AND METHODS

This is a secondary analysis of data from a prospective cohort study including 300 nulliparous women at 17-19 weeks of gestation. Major LAM defects were diagnosed at 6 weeks and 1 year postpartum using transperineal ultrasonography. We defined persistent major LAM defects as a defect diagnosed both at 6 weeks and 1 year postpartum. Maternal and obstetric data were obtained from the hospital's electronic birth records. Pelvic floor muscle function was measured vaginally by manometer at 21 weeks of gestation. The main outcome measurement was change in prevalence of major LAM defects. Maternal and obstetric risk factors for having persistent major LAM defect were also assessed.

RESULTS

Prevalence of major LAM defects was 19.4% at 6 weeks and 10.4% at 1 year postpartum. No new major LAM defects were diagnosed at 1 year postpartum. Persisting major LAM defects were associated with longer second stage of labor (median 74.5 minutes vs median 48.0 minutes, P = .012) and higher neonatal birthweight (mean difference of 232.3 g, 95% confidence interval [CI] 21.5-443.1). Vacuum delivery was independently associated with persistent major LAM defects, adjusted OR 3.0 (95% CI 1.0-9.0).

CONCLUSIONS

There was a 50% reduction of sonographically diagnosed major LAM defects from 6 weeks to 1 year postpartum. This finding suggests that assessment of the major LAM 6 weeks postpartum may be too early to diagnose defects/avulsions. Long second stage of labor, high neonatal birthweight and vacuum delivery were associated with persistent major LAM defects/avulsions.

Effect of perineum protection cooperated by two operators in the forceps-assisted vaginal delivery: a case-control study

Objective: To investigate the effect of unique skill of perineum protection in forceps delivery on the maternal and neonatal morbidity.Methods: A case-control study was conducted. Singleton pregnancies with forceps-assisted and normal vaginal deliveries were recruited. The maternal and neonatal complications were compared between forceps and normal deliveries.Results: Five hundred forty participants were included. The prevalence of maternal anal sphincter injury, postpartum hemorrhage, vaginal hematoma, cervical laceration, perineal wound infection, perineal wound dehiscence, dyspareunia, urinary incontinence, and anal incontinence were not significantly different between forceps and normal deliveries (p > .05). However, the rate of neonatal facial injury was higher in the forceps group (2.9% versus 0, p = .004).Conclusions: Cooperation according to the tension of perineum and labor process between obstetrician and midwife is important for perineum protection. Forceps-assisted delivery concentrating on perineum protection is an effective alternative in decreasing maternal morbidity.

The correlation between the type of forceps application and the rate of levator ani muscle avulsion: A prospective cohort study

OBJECTIVES

The association between the use of forceps and levator ani muscle (LAM) avulsion seems to be clear-cut. However, whether the lesion is due to the mechanical trauma yielded by the instrument or to the intrinsic complexity of this type of delivery, is yet to be determined. This study aims at determining the difference in LAM avulsion rate between Kielland rotational forceps and non-rotational forceps.

STUDY DESIGN

Prospective observational study with 94 nulliparous women with forceps-assisted deliveries (FD) between July 2015 and January 2016. 3D-TpUS was performed 6 months after every patient's delivery, during which LAM avulsion, and levator hiatus area and anteroposterior and transverse diameters were assessed.

RESULTS

A total of 89 nulliparous were studied, comprising 27 rotational-FD, and 62 non-rotational-FD. No differences in obstetric, intrapartum, or neonatal characteristics were observed between study groups. There were no statistically significant differences in the presence of avulsion between cases of rotational forceps (44.4% vs 35.5%, OR: 1.5 [0.6-3.6]), correction of asinclitism of the fetal head (34.4% vs. 40.4% OR: 0.8 [0.3-1.9]) or station (midforceps: 32.8% vs low forceps: 50.0% OR: 2.0 [0.8-5.1]).

CONCLUSIONS

We have not observed differences in the LAM-avulsion rate between rotational forceps and non-rotational forceps performed by highly experienced personnel in instrumental deliveries.

Influence of the disengagement of the forceps on levator ani muscle injuries in instrumental delivery: A multicenter study

INTRODUCTION

Forceps use is the main risk factor for levator ani muscle (LAM) injuries. We believe that the disengagement of the forceps branches before delivery of the fetal head could influence LAM injuries, so we aimed to determine the influence of the disengagement of the forceps on the occurrence of LAM avulsion during forceps delivery.

MATERIAL AND METHODS

A prospective, observational, multicenter study was conducted with 261 women who underwent forceps delivery. The women were classified according to whether the branches of the forceps had been disengaged before delivery of the fetal head. LAM avulsion was defined using a multislice mode (3 central slices).

RESULTS

In all, 255 women completed the study (160 without disengagement and 95 with disengagement). LAM avulsions were observed in 37.9% of women in the group with disengagement and in 41.9% of women in the group without disengagement. The crude OR (without disengagement vs with disengagement) for avulsion was 0.90 (95% CI 0.49-1.67, P = 0.757) and an adjusted OR of 0.82 (95% CI 0.40-1.69, P = 0.603).

CONCLUSIONS

We did not observe a statistically significant reduction in the LAM avulsion rate with disengagement of the forceps branches before delivery of the fetal head.

Pelvic organ prolapse in Caucasian and East Asian women: a comparative study

OBJECTIVE

Ethnicity has been suggested to be a significant risk factor for pelvic organ prolapse (POP); yet, pelvic organ descent in different ethnic groups, especially in Asian populations, is not well studied. The aim of this study was to compare prolapse stages, pelvic organ descent and hiatal dimensions between East Asian and Caucasian women presenting with symptoms of POP.

METHODS

This was a prospective observational study of East Asian and Caucasian women presenting with symptoms of POP to a tertiary urogynecology clinic in, respectively, Hong Kong and Sydney. Demographic data, prolapse symptoms and prolapse stage were assessed. Physical examination was performed using the pelvic organ prolapse quantification (POP-Q) system. All women underwent transperineal ultrasound using Voluson systems. Offline analysis of four-dimensional ultrasound volume data was performed at a later date, by one operator blinded to all clinical data, to ascertain pelvic organ descent and hiatal dimensions on Valsalva maneuver. Levator muscle avulsion was assessed in volumes obtained on pelvic floor muscle contraction. Multiple logistic regression analysis was performed to assess factors associated with prolapse on clinical and ultrasound examinations.

RESULTS

A total of 225 East Asian women were included between July 2012 and February 2014 from the Hong Kong clinic and 206 Caucasian women between January 2015 and July 2016 from the Sydney clinic. There was no significant difference in the overall staging of prolapse. However, in East Asian women, compared with Caucasians, apical compartment prolapse was more common (99.6% vs 71.8%, P < 0.001) and posterior compartment prolapse less common (16.9% vs 48.5%, P < 0.001) on POP-Q examination. On Valsalva maneuver, the position of the uterus was lower in East Asian than in Caucasian women (-11.3 vs 1.35 mm, P < 0.001), while the rectal ampulla position was lower in Caucasians than in East Asians (-10.6 vs - 4.1 mm, P < 0.001). On multiple regression analysis, Caucasian ethnicity was a significant factor for lower risk of apical compartment prolapse on clinical assessment (odds ratio (OR), 0.01; P < 0.001) and on ultrasound (OR, 0.13; P < 0.001), and for a higher risk of posterior compartment prolapse on clinical assessment (OR, 4.36; P < 0.001) and of true rectocele on ultrasound (OR, 8.14; P < 0.001).

CONCLUSIONS

East Asian women present more commonly with uterine prolapse while Caucasians show more often posterior compartment prolapse. Ethnicity was a significant predictor of type of prolapse on multivariate analysis. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Association between pelvic floor muscle trauma and contraction in parous women from a general population

OBJECTIVE

To study possible associations between pelvic floor muscle contraction, levator ani muscle (LAM) trauma and/or pelvic organ prolapse (POP) ≥ Stage 2 in parous women recruited from a general population.

METHODS

This was a secondary analysis of data from a cross-sectional study of 608 parous women from a general population examined using the POP quantification system (POP-Q) and three-dimensional/four-dimensional transperineal ultrasound for identification of LAM macrotrauma (avulsion) and microtrauma (distension of levator hiatal area > 75^th percentile on Valsalva maneuver). Muscle contraction was assessed using the modified Oxford scale (MOS), perineometry and ultrasound measurement of proportional change of anteroposterior hiatal diameter and levator hiatal area at rest and on pelvic floor muscle contraction. The Mann-Whitney U-test was used to study associations between pelvic floor muscle contraction, LAM trauma and POP.

RESULTS

Women with macrotrauma (n = 113) had significantly weaker median pelvic floor muscle contraction, as measured using MOS and perineometry, than did women with an intact LAM (n = 493) (contraction strength was 1.5 (range, 0.0-5.0) vs 3.5 (range, 0.0-5.0) on MOS, and vaginal squeeze pressure was 15.0 (range, 0.0-78.0) cmH₂ O vs 28.0 (range, 0.0-129.0) cmH₂ O on perineometry; P < 0.001). This was also demonstrated by ultrasound measurement, with a proportional change in hiatal area of 19.9% (range, 4.1-48.0%) vs 34.0% (range, 0.0-64.0%) (P < 0.001) and proportional change in anteroposterior diameter of 16.2% (range, -5.7 to 42.6%) vs 26.0% (range, -3.4 to 49.4%) (P < 0.001). No statistically significant difference between women with (n = 65), and those without (n = 378), microtrauma was found after excluding women with macrotrauma. Women with POP had weaker muscle contraction than those without; in those with POP-Q ≥ 2 (n = 275) compared with those with POP-Q < 2 (n = 333), muscle contraction strength was 3.0 (range, 0.0-5.0) vs 3.5 (range, 0.0-5.0) on MOS, vaginal squeeze pressure was 21.0 (range, 0.0-98.0) cmH₂ O vs 28.0 (range, 3.0-129.0) cmH₂ O on perineometry, proportional change in hiatal area was 29.6% (range, 0.0-60.9%) vs 33.8% (range, 0.0-64.4%) and proportional change in anteroposterior diameter was 22.8% (range, -5.7 to 49.4%) vs 25.7% (range, -3.4 to 49.4%) (P < 0.001 for all).

CONCLUSIONS

LAM macrotrauma was associated with weaker pelvic floor muscle contraction measured using palpation, perineometry and ultrasound. Women with POP had weaker contraction than did women without POP. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Delivery mode and the risk of levator muscle avulsion: a meta-analysis

INTRODUCTION AND HYPOTHESIS

Female pelvic organ prolapse (POP) is a common condition, with a lifetime risk for surgery of 10-20%. Pregnancy and childbirth are the commonest modifiable risk factors for POP, and avulsion of the levator ani muscle is likely to be an etiological factor. Avulsion is more common in instrumental delivery. However, we were unable to identify a meta-analysis on this issue. Our aim was to perform a systemic review and quantitative meta-analysis of the prevalence of avulsion relative to delivery mode.

METHODS

Four electronic databases (MEDLINE, PubMed, Embase, and Google Scholar) were searched for studies published between 1991 and 1 October 2018 without language restrictions.

RESULTS

Twenty studies met inclusion criteria, and 14 were prospective. Seventeen used sonographic techniques; three were magnetic resonance (MR) studies. For this review, three comparisons were performed: forceps vs. vacuum (9 studies), forceps vs. normal vaginal delivery (NVD) (12 studies), and vacuum vs. NVD (12 studies). The first meta-analysis showed an increased risk for avulsion following forceps compared with vacuum, with an odds ratio (OR) of 4.57 and confidence interval (CI) 3.21-6.51, p < 0.001. The second showed an increased risk for avulsion following forceps compared with NVD, with an OR of 6.94 (4.93-9.78), p < 0.001. The third showed no significant increased risk for avulsion following vacuum compared with NVD, with an OR of 1.31 (1.00-1.72), p = 0.051.

CONCLUSIONS

Forceps is a strong risk factor for avulsion, with an OR of 6.94 (4.93-9.78) compared with NVD and an OR of 4.57 (3.21-6.51) compared with vacuum birth.

Levator Ani avulsion: The histological composition of this site. A cadaveric study

INTRODUCTION

The sonographic appearance of a levator muscle "avulsion" representing the literal detachment of the pubovisceral muscle (PVM) enthesis has been contested. The nature of the levator ani "avulsion" is still not fully understood. It is known, that the tensile strength of a tendon is dependent on collagen with increased synthesis of collagen occurring in tissue with increased mechanical load levels. This study aims to perform a quantitative histological evaluation of the PVM enthesis with or without the imaging finding of levator ani "avulsion" to determine if there is a difference in the proportion of muscle and collagen.

METHOD

Three-dimensional translabial ultrasound for PVM "avulsion" was performed on cadavers using a GE Voluson I with a 5-9 MHz electronic probe. Cadavers were meticulously dissected to identify the presence or absence of an anatomical avulsion. The PVM enthesis was excised for further histopathological processing and treated with three different colorations. Quantitative analysis using ImageJ software was conducted to compare tissue composition in samples with or without sonographic "avulsion." All stages were performed by two separate investigators blinded to each other's results. The results were analyzed using SPSS v24, IBM.

RESULTS

Twenty-three PVM enthesis with histological staining were procured. Ultrasonographic "avulsions" were seen in 5/23 PVM enthesis. No anatomical avulsions were seen. There was no difference in the overall muscle or collagen content (Kruskal-Wallis, P = 0.864). The mean organized skeletal muscle content was 23% in the sonographic "avulsion" group versus 62% in the no "avulsion" group (Kruskall-Walis, P = 0.02). "Avulsions" were associated with a disorganized appearance at histology.

CONCLUSION

The tissue composition relating to the proportion of muscle and collagen was not significantly different in specimens with or without sonographic "avulsions." However, morphological differences were observed in the organization of the muscle fibres, which requires further evaluation.

Concordance of tomographic ultrasound and multiplanar ultrasound in detecting levator ani muscle injury in patients with pelvic organ prolapse

Aim

To compare the evaluations of evaluate levator ani muscle injury (LAMI) by tomographic ultrasound imaging (TUI) and multiplanar (MP) ultrasound in patients with pelvic organ prolapse (POP).

Method

This retrospective analysis studied women who underwent International Continence Society POP quantification examination between October 2015 and June 2016. LAMI was assessed by both TUI and MP ultrasounds. Concordance of these two testing results was analyzed. Their correlations with clinical symptoms were also studied.

Results

A total of 135 women were included. All the patients with POP had a minimal LAMI depth ≥ 7 mm. Two examinations, TUI and MP, had satisfactory concordance (k = 0.71, P < 0.01). Depth of LAMI in the coronal plane demonstrated good agreement with TUI scores (r = 0.84; P < 0.01). After controlling for age, BMI, and parity, to have clinically significant POP and POP symptoms, the odds ratios (ORs) for the depth of LAMI in the coronal plane were 1.31 (95% CI 1.19–1.44) and 1.25 (95% CI 1.14–1.36), and for TUI scores were 1.72 (95% CI 1.37–2.17) and 1.63 (95% CI 1.31–2.03). Receiver operating characteristic curve analyses showed a cutoff depth of 7 mm of LAMI yielded a sensitivity of 62% and specificity of 80% for POP symptoms.

Conclusions

TUI and MP had satisfactory concordance in detecting LAMI and correlated with clinical symptoms of POP.

Ultrasound in the assessment of pelvic organ prolapse

Imaging is increasingly being used in urogynaecology. Because of low cost and universal availability, ultrasound (US) is the most commonly used diagnostic modality, which allows the observation of manoeuvres such as Valsalva and pelvic floor muscle contraction in real time. The ability to see beyond surface anatomy is particularly important in the posterior compartment and in obstructed defecation where this method may replace defecation proctography. Imaging is especially useful in the form of 3D/4D multiplanar and tomographic translabial US, as these modalities give access to the axial plane and the levator ani. This allows assessment of both avulsion, i.e. major maternal birth trauma, and hiatal overdistension, i.e. ballooning. Both are major risk factors for both prolapse and prolapse recurrence. This review will outline current clinical utility, introduce recent research in the respective field and provide an overview of likely future utility of imaging in the investigation of pelvic organ prolapse.

Can We Evaluate Hiatal Ballooning by Measuring the Anteroposterior Diameter With 2-Dimensional Translabial Ultrasonography?

OBJECTIVES

To analyze the association between the anteroposterior hiatal diameter and pelvic organ prolapse and to determine whether 2-dimensional translabial ultrasonography can evaluate hiatal ballooning by measuring the anteroposterior diameter.

METHODS

This study was a retrospective analysis of 312 women seen for lower urinary tract symptoms or pelvic organ prolapse between December 2014 and July 2016. All women had an International Continence Society (ICS) Pelvic Organ Prolapse Quantification (POP-Q) system examination and 4-dimensional translabial ultrasonography. The anteroposterior hiatal diameter was measured in the midsagittal plane, and the hiatal area was measured in the minimal axial plane during the maximal Valsalva maneuver.

RESULTS

Valid data from 294 patients were analyzed. International Continence Society POP-Q stage 0 was found in 121 women, stage 1 in 49, stage 2 in 78, stage 3 in 42, and stage 4 in 4. The anteroposterior diameter had an excellent linear correlation (r = 0.814; P < .001) with the hiatal area during the Valsalva maneuver and was strongly related to ICS POP-Q stages (P < .01). A receiver operating characteristic curve analysis proposed a cutoff of 6.0 cm for the anteroposterior diameter against ICS POP-Q stage 2 and higher (sensitivity, 73%; specificity, 52%) and prolapse symptoms (sensitivity, 74%; specificity, 64%).

CONCLUSIONS

The anteroposterior hiatal diameter, which represents hiatal distensibility in the midsagittal plane, can be used to evaluate hiatal ballooning. "Mild" ballooning was defined as an anteroposterior diameter measurement of 6.0 to less than 6.5 cm, "moderate" ballooning as 6.5 to less than 7.0 cm, and "marked" ballooning as 7.0 cm or greater.

Longitudinal pelvic floor biometry: which factors affect it?

OBJECTIVES

To evaluate pelvic floor biometry of women 3-5 years after their first delivery. The effect of a subsequent delivery and the mode of delivery on pelvic floor biometry were also studied.

METHODS

Three-hundred and twenty-eight women who had been examined by translabial ultrasound during their first singleton pregnancy and at 8 weeks and 1 year postpartum, were invited for a follow-up 3-5 years later. The positions of the bladder neck, cervix, anorectal junction and hiatal area (HA) were evaluated using translabial ultrasound. The effects of parity, mode of delivery and levator ani muscle avulsion were studied.

RESULTS

A total of 240 women completed the study. Of these, 179 had one or more vaginal deliveries (VD) (VD-only group), 52 had one or more Cesarean sections (CS) (CS-only group) and nine had both VD and CS at follow-up. The mean interval between the first delivery and follow-up was 3.8 years. A significantly lower bladder neck and anorectal junction on Valsalva, a lower cervix at rest, on Valsalva and pelvic floor muscle contraction, and a greater HA were observed in the VD-only group at follow-up, compared with findings at 1 year of follow-up or in the first pregnancy. The findings were similar in the CS-only group, except without a lower anorectal junction on Valsalva. Compared with the primiparous VD-only group, a greater HA at rest was observed in the multiparous VD-only group (P = 0.027). The VD-only group had a greater HA than the CS-only group.

CONCLUSIONS

At 3-5 years after first delivery, a lower bladder neck, cervix and anorectal junction, and a greater HA were observed compared with findings in the first trimester and at 1 year of follow-up, regardless of parity or mode of delivery. Women with two or more VDs had a greater HA compared with those who had only one VD, and women with at least one VD had a greater HA compared with those who delivered by CS only. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Levator ani muscle avulsion is a risk factor for expulsion within 1 year of vaginal pessary placed for pelvic organ prolapse

OBJECTIVE

The aim of this study was to investigate whether the presence of levator ani muscle (LAM) avulsion is associated with expulsion within 1 year of a vaginal pessary placed for pelvic organ prolapse (POP).

METHODS

This was a prospective observational study of consecutive women with symptomatic POP, who had not received treatment for the condition before the consultation and opted for vaginal pessary placement in our center. Volume acquisition was performed before pessary insertion and offline analysis of the 3D/4D transperineal ultrasound volume data was performed. LAM was assessed on maximum pelvic floor muscle contraction (PFMC) and hiatal dimensions were assessed at rest, on PFMC and on maximum Valsalva. Results were compared between women in whom the pessary was retained for 1 year and those in whom the pessary was expelled within 1 year.

RESULTS

The datasets of 255 women were analyzed including 147 (57.6%) women who had a vaginal pessary continuously in place over 1 year and 108 (42.4%) with pessary expulsion. Mean age was 63.2 (SD, 9.9) years and median parity was 3 (2-4). Eighteen (7.1%) had Stage I, 164 (64.3%) Stage II, 67 (26.3%) Stage III and six (2.4%) Stage IV POP. Women with vaginal pessary expulsion within 1 year had significantly larger hiatal dimensions at rest and on Valsalva, larger hiatal area during rest, PFMC and Valsalva and higher rate of LAM avulsion (53.7% vs 27.2%, P < 0.01) compared with women in whom the pessary was retained for 1 year. After controlling for potential confounders, LAM avulsion remained a risk factor (OR, 3.18, P < 0.01) of vaginal pessary expulsion within 1 year.

CONCLUSIONS

Women in whom a vaginal pessary was expelled within 1 year of placement for POP had a larger hiatus. Presence of LAM avulsion was associated with a three-fold increase in the risk of expulsion of a vaginal pessary within 1 year. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Three-dimensional/four-dimensional transperineal ultrasound: clinical utility and future prospects

During the last decade, there has been a huge advancement in the use of transperineal ultrasound (TPU) in the field of obstetrics and gynecology. Its main applications in obstetrics include the monitoring of fetal progression in labor and recently the assessment of maternal pelvic dimensions, whereas in gynecology, TPU is at present widely used for the evaluation of the female pelvic floor, opening new boundaries for the assessment of pelvic floor disorders. The association of volumetric three-dimensional techniques has largely contributed to the remarkable progress that has occurred in the use of TPU. The aim of this paper is to offer an overview of the advantages, challenges and future perspectives of the use of TPU for women’s imaging.

Longitudinal follow-up of levator ani muscle avulsion: does a second delivery affect it?

OBJECTIVES

To evaluate the morphological outcome of levator ani muscle (LAM) avulsion 3-5 years after a first delivery and to assess the effect of a second delivery on this condition. The impact of LAM avulsion on pelvic floor disorders was also studied.

METHODS

Six hundred and sixty-six women who had been assessed for LAM avulsion 8 weeks after their first delivery were invited for a follow-up examination 3-5 years later. Women completed the Pelvic Floor Distress Inventory including the Urinary Distress Inventory (UDI) and Pelvic Organ Prolapse Distress Inventory (POPDI) questionnaires to explore symptoms of pelvic floor disorders, and the pelvic floor was examined using three-dimensional translabial ultrasound and assessed using the pelvic organ prolapse quantification system.

RESULTS

Three hundred and ninety-nine women completed the study, of whom 151 were multiparous. Mean interval between first delivery and follow-up was 42.3 ± 7.6 months. Among 69 women who had LAM avulsion 8 weeks after their first delivery, nine (13.0%) had no LAM avulsion at follow-up. One (0.9%) woman had a new LAM avulsion after her second vaginal delivery. A greater proportion of women with LAM avulsion reported symptoms of stress urinary incontinence (SUI) (adjusted odds ratio, 2.09 (95% CI, 1.18-3.70); P = 0.01) and symptoms of prolapse than did women without avulsion; however, this difference did not reach statistical significance (P = 0.61). Women with LAM avulsion had higher UDI and POPDI scores than did women without avulsion (median UDI score, 17.7 (interquartile range (IQR), 5.0-32.4) vs 9.2 (IQR, 0.0-22.1); P = 0.045 and median POPDI score, 20.8 (IQR, 8.8-40.5) vs 10.7 (IQR, 0.0-32.8); P = 0.021).

CONCLUSIONS

The risk of developing new LAM avulsion after a second vaginal delivery is low (0.9%). Healing of LAM avulsion was observed in 13% of women who had at least one vaginal delivery. At 3-5 years after delivery, women with LAM avulsion reported symptoms of SUI more often than did those without, and had higher UDI and POPDI scores, implying more bothersome symptoms. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Cell-based secondary prevention of childbirth-induced pelvic floor trauma

With advancing population age, pelvic-floor dysfunction (PFD) will affect an increasing number of women. Many of these women wish to maintain active lifestyles, indicating an urgent need for effective strategies to treat or, preferably, prevent the occurrence of PFD. Childbirth and pregnancy have both long been recognized as crucial contributing factors in the pathophysiology of PFD. Vaginal delivery of a child is a serious traumatic event, causing anatomical and functional changes in the pelvic floor. Similar changes to those experienced during childbirth can be found in symptomatic women, often many years after delivery. Thus, women with such PFD symptoms might have incompletely recovered from the trauma caused by vaginal delivery. This hypothesis creates the possibility that preventive measures can be initiated around the time of delivery. Secondary prevention has been shown to be beneficial in patients with many other chronic conditions. The current general consensus is that clinicians should aim to minimize the extent of damage during delivery, and aim to optimize healing processes after delivery, therefore preventing later dysfunction. A substantial amount of research investigating the potential of stem-cell injections as a therapeutic strategy for achieving this purpose is currently ongoing. Data from small animal models have demonstrated positive effects of mesenchymal stem-cell injections on the healing process following simulated vaginal birth injury.

Is obstetric anal sphincter injury a risk factor for levator ani muscle avulsion in vaginal delivery?

OBJECTIVE

To analyze whether women who sustain obstetric anal sphincter injury (OASI) in their first vaginal delivery have a higher incidence of levator ani muscle (LAM) avulsion than do women without OASI.

METHODS

We conducted a prospective observational cohort study of 80 primiparous women who gave birth at our tertiary obstetric unit between September 2011 and July 2013. The women were divided into two groups: women diagnosed with OASI during vaginal delivery (n = 40) and women without OASI (n = 40), matched by mode of delivery and newborn birth weight. Four-dimensional (4D) transperineal ultrasound was performed in all participants at 6-12 months after delivery to assess for integrity or avulsion of the LAM. Ultrasound images were evaluated by two observers who were blinded to group assignment and clinical data. Interobserver agreement was assessed to determine the reproducibility of 4D transperineal ultrasound for diagnosing LAM avulsion.

RESULTS

We found no statistically significant differences between the two groups. The incidence of LAM avulsion was 24.3% in the OASI group and 34.2% in the control group (P = 0.448). Interobserver agreement in the diagnosis of LAM avulsion in the study population using 4D transperineal ultrasound was 89.5%, with a kappa index of 0.76.

CONCLUSIONS

Our findings do not support OASI as a risk factor for LAM avulsion. Prospective studies in larger populations are needed to establish the biomechanical relationships of the pelvic floor structures involved in vaginal delivery. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Physical and cultural determinants of postpartum pelvic floor support and symptoms following vaginal delivery: a protocol for a mixed-methods prospective cohort study

INTRODUCTION

Pelvic floor disorders (PFDs), including pelvic organ prolapse (POP), stress and urgency urinary incontinence, and faecal incontinence, are common and arise from loss of pelvic support. Although severe disease often does not occur until women become older, pregnancy and childbirth are major risk factors for PFDs, especially POP. We understand little about modifiable factors that impact pelvic floor function recovery after vaginal birth. This National Institutes of Health (NIH)-funded Program Project, 'Bridging physical and cultural determinants of postpartum pelvic floor support and symptoms following vaginal delivery', uses mixed-methods research to study the influences of intra-abdominal pressure, physical activity, body habitus and muscle fitness on pelvic floor support and symptoms as well as the cultural context in which women experience those changes.

METHODS AND ANALYSIS

Using quantitative methods, we will evaluate whether pelvic floor support and symptoms 1 year after the first vaginal delivery are affected by biologically plausible factors that may impact muscle, nerve and connective tissue healing during recovery (first 8 weeks postpartum) and strengthening (remainder of the first postpartum year). Using qualitative methods, we will examine cultural aspects of perceptions, explanations of changes in pelvic floor support, and actions taken by Mexican-American and Euro-American primipara, emphasising early changes after childbirth. We will summarise project results in a resource toolkit that will enhance opportunities for dialogue between women, their families and providers, and across lay and medical discourses. We anticipate enrolling up to 1530 nulliparous women into the prospective cohort study during the third trimester, following those who deliver vaginally 1 year postpartum. Participants will be drawn from this cohort to meet the project's aims.

ETHICS AND DISSEMINATION

The University of Utah and Intermountain Healthcare Institutional Review Boards approved this study. Data are stored in a secure password-protected database. Papers summarising the primary results and ancillary analyses will be published in peer-reviewed journals.

Exercise and pregnancy in recreational and elite athletes: 2016 evidence summary from the IOC expert group meeting, Lausanne. Part 2-the effect of exercise on the fetus, labour and birth

This is Part 2 of 5 in the series of evidence statements from the IOC expert committee on exercise and pregnancy in recreational and elite athletes. Part 1 focused on the effects of training during pregnancy and on the management of common pregnancy-related symptoms experienced by athletes. In Part 2, we focus on maternal and fetal perinatal outcomes.

Antenatal pelvic floor biometry is related to levator ani muscle injury

OBJECTIVE

To evaluate the relationship between antenatal pelvic floor biometry and levator ani muscle (LAM) injury in Chinese women.

METHODS

Three-dimensional transperineal ultrasound was performed in nulliparous Chinese women with a singleton pregnancy at 9-12 weeks, 26-28 weeks and 36-38 weeks of gestation and again at 12 months after delivery. Hiatal anteroposterior (AP) diameter, transverse diameter and area were measured on the antenatal ultrasound volumes obtained at rest, on Valsalva maneuver and during pelvic floor muscle contraction (PFMC). LAM injury was evaluated using ultrasound volumes obtained during PFMC at 12 months after delivery.

RESULTS

In total, 328 women completed the study. At 12 months after delivery, 38 (14.8% of those who delivered vaginally) women had LAM injury; 28 were unilateral (14 right- and 14 left-sided) and 10 were bilateral. In all three trimesters there was smaller hiatal AP diameter and hiatal area in women with LAM injury when compared with women without injury. On multivariable analysis of the three factors, hiatal AP diameter at rest, hiatal area at rest and operative vaginal delivery, only hiatal AP diameter at rest in all three trimesters was an independent factor of LAM injury. A larger hiatal AP diameter at rest in the first, second and third trimesters reduced the likelihood of LAM injury with odds ratios of 0.21, 0.15 and 0.21, respectively.

CONCLUSIONS

A smaller antenatal hiatal AP diameter at rest is a risk factor for LAM injury. The hiatal AP diameter is relatively simple to measure and the error in measurement is relatively small. A prospective study to confirm this relationship and to explore whether this measurement, performed in the midsagittal plane, is repeatable should be performed. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

The impact of obstetric gel on the second stage of labor and perineal integrity: a randomized controlled trial

OBJECTIVE

Dianatal® is a bioadhesive gliding film which reduces the opposing force to vaginal childbirth. We aimed to investigate the safety, applicability, and impact of Dianatal® obstetric gel on second stage of labor and perineal integrity.

METHODS

Low-risk singleton pregnancies at term were prospectively enrolled. Eligible women were randomly assigned to either labor management without using obstetric gel, or labor management using intermittent application of obstetric gel into the birth canal during vaginal examinations, starting at active phase of labor (≥4 cm dilation). The primary measured outcome was the length of second stage of labor.

RESULTS

Overall, 200 cases were analyzed. Demographic, obstetrical, and labor characteristics were similar between the groups. Neither adverse events nor maternal or neonatal side effects were observed. The mean lengths of the active and second stages of labor were comparable between the obstetric gel-treated and the control groups (157 versus 219 min and 48 versus 56 min, respectively). None of the women had grade III/IV perineal tears. Maternal and neonatal outcomes were not negatively influenced by using obstetric gel. No difference was found after sub-group analysis for spontaneous vaginal delivery.

CONCLUSION

Dianatal® obstetric gel is safe in terms of maternal or neonatal use. Albeit a trend toward shorter labor stages using Dianatal® obstetric gel, no significant differences were noted among the groups. In order to further investigate the influence of the obstetric gel on labor stage interval, perineal integrity and maternal and neonatal outcomes, larger randomized clinical trials are needed to be carried out.