Choice of mode of delivery in a subsequent pregnancy after OASI: a survey among Dutch gynecologists

Local tissue response to a C-X-C motif chemokine ligand 12 therapy for fecal incontinence in a rabbit model

This study aimed to determine if local injection of C-X-C motif chemokine ligand 12 (CXCL12) reduces sphincter fibrosis, restores sphincter muscle content, vascularization, and innervation, and recruits progenitor cells in a rabbit model of anal sphincter injury and incontinence. Adult female rabbits were assigned to three groups: uninjured/no treatment (control), injured/treated (treated), and injured/no treatment (untreated) (n = 4 each). Injured groups were anesthetized, and a section of external anal sphincter was removed at the 9 o'clock position. The treated sphincters were injected with 200 ng of human recombinant CXCL12 6 wk after injury, and necropsy was performed 6-wk post-treatment. The external anal sphincter was removed, fixed, embedded in paraffin, sectioned, and mounted to slides for histologic analysis of collagen and muscle content and fiber characteristics: innervation, vascularization, and progenitor cell content. Compared with controls, untreated had significantly decreased total skeletal muscle, indistinct muscle layers, and disorganized circumferential and inner longitudinal layers at the injury site. Untreated also had significantly increased collagen fiber density at the injury site compared with treated and controls. Cells staining positive for CD34 within the skeletal muscle layer were increased in treated and untreated compared with controls. Staining density for markers of nerves and vascular endothelium, cells staining positive for CD34 within the mucosa/submucosae, and cells staining positive for PAX7 were similar among all groups. Local injection of CXCL12 reduces postinjury fibrosis and results in statistically similar muscle content and organization between treated animals and controls. Further studies are needed for this promising new treatment for postparturient anal sphincter injury.NEW & NOTEWORTHY Local injection of CXCL12 cytokine reduces postinjury fibrosis in a rabbit model of anal sphincter injury and fecal incontinence. The larger size of the rabbits aided in targeted injury and treatment. Further studies are needed to explore noninvasive treatment options for postparturient anal sphincter injury.

Management of obstetric anal sphincter injury: Colorectal surgeons' perspectives in Australia and New Zealand

BACKGROUND

Obstetric anal sphincter injuries (OASIs) are a significant complication of vaginal delivery, and a leading cause of anal incontinence in women.

AIMS

The aims were to explore the management of OASIs in Australia and New Zealand (ANZ) by colorectal surgeons and how this compares with current recommendations and international experience, and to identify the deterrents to the provision of best-practice care among colorectal surgeons.

MATERIALS AND METHODS

Three hundred colorectal surgeons of the Colorectal Surgical Society of ANZ were mailed questionnaires. Areas of interest included: surgeon demographics; exposure to OASIs; understanding of current recommendations; and opinions regarding the importance of symptoms and assessment tools in OASIs.

RESULTS

There were 94 completed questionnaires (response rate 31.3%). Fifty-seven surgeons (60.6%) reported low exposure to OASIs during their fellowship training. Greater than 90% believed patients with grade three tears and above should have anal sphincter assessment. Sixty-six (70.2%) reported that they routinely review women who have had OASIs. However, 56.4% were unaware if their obstetrics department followed a standard protocol for OASIs. Surgeons practising in metropolitan centres reported higher rates of their obstetrics department following a protocol (P = 0.013), and greater access to investigative tools (P < 0.001), when compared to rural-based surgeons.

CONCLUSIONS

Most ANZ colorectal surgeons have had minimal training in OASI management. Colorectal surgeons are more commonly involved with OASI patients in the non-acute setting. Management protocols involving a multidisciplinary team of both colorectal surgeons and obstetricians should be clearly defined, and the gap between metropolitan and rural centres needs to be reviewed.

Management of subsequent pregnancies following fourth-degree obstetric anal sphincter injuries (OASIS)

OBJECTIVES

The management of subsequent pregnancy in women who sustained OASIS remains an enigma. Nearly all studies include all grades of OASIS including fourth-degree tears. In addition, most protocols require endoanal ultrasound and anal manometric assessment to provide advice regarding mode of delivery. In reality, most women who sustain an OASI do not undergo these investigations. The aims of our study were firstly to evaluate outcomes of fourth-degree OASIS in terms of sphincter defects, anal manometry and anal incontinence symptoms. Secondly, we wished to review recommendations made regarding subsequent mode of delivery after fourth-degree OASIS according to different published protocols.

STUDY DESIGN

An observational study of all women who had undergone a primary repair of a fourth-degree tear and seen in the perineal clinic of a tertiary urogynaecology unit between January 2006 and December 2017. Three-dimensional endoanal ultrasound and anal manometry were performed on all women, and symptoms assessed using the validated modified St Mark's Score for anal incontinence. Diagnostic test accuracy analysis was performed for use of symptoms in predicting abnormal investigations.

RESULTS

74 fourth-degree tears were identified (mean follow-up 5.9 months; SD 11.5). Endoanal scan showed an internal anal sphincter defect in 77 % and an external anal sphincter defect in 49 %. Only 18 % had no defect. The mean incremental pressure rise was 12.6 mmHg (SD 15.5). 61 % were asymptomatic with a mean St Mark's Score of 3.8 (SD 5.4). The presence of symptoms alone had poor accuracy in predicting abnormal investigations. Based on Royal College of Obstetricians and Gynaecologists guidance, only 7% would not be offered a caesarean section as they are asymptomatic women with normal scan and manometry findings and would be counselled for a vaginal delivery.

CONCLUSIONS

Given that only a few units offer these specialist investigations to their OASI population, it would be reasonable to offer caesarean section to all women who have sustained a fourth-degree tear. However, in centres where endoanal ultrasound and anal manometry are available, individualised counselling can be offered.

Risk factors for the recurrence of obstetrical anal sphincter injury and the role of a mediolateral episiotomy: an analysis of a national registry

OBJECTIVE

The assessment of risk factors, including mediolateral episiotomy (MLE), for the recurrence of obstetric anal sphincter injury (rOASI).

DESIGN

Population-based cohort study.

SETTING

Data from the nationwide database of the Dutch Perinatal Registry (Perined).

POPULATION

A cohort of 391 026 women at term, of whom 9943 had an OASI in their first delivery and had a second vaginal delivery of a liveborn infant in cephalic position.

METHODS

Possible risk factors were tested for statistical significance using univariate and multivariate logistic regression analysis.

MAIN OUTCOME MEASURES

Rate of rOASI.

RESULTS

The rate of rOASI was 5.8%. Multivariate analysis identified a birthweight of ≥4000 g (adjusted OR, aOR, 2.1, 95% CI 1.6-2.6) and a duration of second stage of ≥30 minutes (aOR 1.8, 95% CI 1.4-2.3) as statistically significant risk factors for rOASI. Mediolateral episiotomy was associated with a statistically significant lower rate of rOASI in spontaneous vaginal delivery (SVD) (aOR 0.4, 95% CI 0.3-0.5) and in operative vaginal delivery (OVD) (aOR 0.2, 95% CI 0.1-0.5).

CONCLUSIONS

Women with a history of OASI have a higher rate of OASI in their next delivery. Duration of the second stage of ≥30 minutes and a birthweight of ≥4000 g are significantly associated with an increased rate of rOASI. Mediolateral episiotomy is associated with a significantly lower rate of rOASI in both SVD and OVD.

TWEETABLE ABSTRACT

Mediolateral episiotomy is associated with a significant lower recurrence rate of OASI in women with an OASI in their first delivery.