Recurrence of Obstetric Third-Degree and Fourth-Degree Anal Sphincter Injuries

The impact of obstetrical anal sphincter injuries on the interpregnancy interval and pregnancy complications of subsequent delivery: A retrospective study

OBJECTIVE

Our primary objective was to evaluate the interpregnancy interval (IPI) of women who have experienced obstetric anal sphincter injuries during delivery. Additionally, we compared adverse perinatal outcomes in subsequent deliveries following obstetric anal sphincter injuries (OASIS) in women with longer and shorter IPIs.

METHODS

This retrospective cohort study included women who had a subsequent pregnancy following OASIS and women without a history of such injuries, who delivered in a tertiary medical center between 2015 and 2019. Data were retrieved from patient computerized medical records. Kaplan-Meier curves and Cox regression analysis were used to evaluate the IPI defined as the time from delivery to the last menstruation prior to the subsequent delivery. Data analysis for our secondary objective was performed using mean and standard deviation for quantitative variables.

RESULTS

During the study period, 233 women experienced OASIS (0.27%), of whom 142 met the study criteria. There was no significant difference in the mean IPI between women in the two groups. However, women were significantly more likely to have a repeat perineal tear (49 [34.5%], P < 0.001), an episiotomy (16 [11.3%], P < 0.001), and an elective or an emergency cesarean section (60 [42.3%], P < 0.001) in their subsequent delivery. There was no difference in pregnancy outcomes among women who had a long compared with a short IPI.

CONCLUSIONS

Women do not delay or avoid childbirth after experiencing OASIS. However, women are more likely to experience perineal tears, episiotomies, or a cesarean delivery in the subsequent pregnancy.

Episiotomy and severe perineal laceration among Asian American, Native Hawaiian, and Pacific Islander nulliparous individuals in California

Background

Asian American, Native Hawaiian, and Pacific Islander individuals have increased risks for episiotomy and severe perineal laceration during vaginal delivery. The Asian American, Native Hawaiian, and Pacific Islander population in the US is diverse yet few studies disaggregate results within specific ethnicity populations.

Objective

This study investigated the variability in risks for episiotomy and severe perineal laceration among 16 disaggregated Asian American, Native Hawaiian, and Pacific Islander groups, compared to Non-Hispanic White nulliparous individuals, and assessed what factors may explain the variability in risk.

Study design

Birth and fetal death certificate files linked to hospital discharge records were used to identify nulliparous, term, singleton, vertex vaginal deliveries among California births, 2007 to 2020. Poisson regression models were used to examine risks of episiotomy and severe perineal laceration among 16 Asian American, Native Hawaiian, and Pacific Islander ethnicity subgroups compared with Non-Hispanic White individuals. Sequential adjustment was utilized to assess if maternal social, health-related, and delivery-related factors may explain the variability in risk for episiotomy and severe perineal laceration.

Results

Among the 224,964 Asian American, Native Hawaiian, and Pacific Islander individuals in this study cohort, the overall prevalence of episiotomy was 18.5% (N = 41,559) and prevalence of severe perineal laceration was 8.9% (N = 20,013); the prevalence of both outcomes declined during the study period. Within subgroups, prevalence of episiotomy ranged from 9.8% among Other-Pacific Islander individuals to 24.5% among Korean individuals. Prevalence of severe perineal laceration ranged from 3.4% in Guamanian individuals to 15.2% in Indian individuals. In fully adjusted models, risk ratios were greater than 1.0 (with confidence intervals excluding 1.0) for 6 subgroups for episiotomy and 9 subgroups for severe perineal laceration, compared to Non-Hispanic White individuals. After adjustment, Korean individuals were at highest risk of episiotomy (adjusted risk ratio 1.80 [95% CI 1.75, 1.85]), and Indian individuals were at highest risk of severe perineal laceration (adjusted risk ratio 2.14 [95% CI 2.07, 2.21]). Adjustment for social factors (nativity; education; payer) tended to attenuate risk ratios; subsequent adjustment for maternal health and delivery-related factors including maternal age, height, pre-pregnancy body mass index, hypertension, diabetes, gestational weight gain, fetal stress/incomplete fetal head rotation (occiput transverse or posterior), large infant size or shoulder dystocia, and forceps/vacuum did not impact risk ratios substantially.

Conclusion

Prevalence and risks of episiotomy and severe perineal laceration varied widely among Asian American, Native Hawaiian, and Pacific Islander births in California from 2007 to 2020. The variability in risks was more influenced by differences in social rather than maternal health and delivery-related factors. This study adds to the growing understanding of disparities in health outcomes among Asian American, Native Hawaiian, and Pacific Islander subgroups.

Racial/Ethnic Impact on Obstetric Anal Sphincter Injuries: A Multicentric Retrospective Study

INTRODUCTION AND HYPOTHESIS

Obstetric anal sphincter injuries (OASIs), third- and fourth-degree lacerations, represent a severe obstetric complication. Previous studies reported a higher incidence of OASIs in Asian women in non-Asian countries. This study was aimed at establishing a different OASIs prevalence among the racial/ethnic groups in Southern European centers.

METHODS

A multicenter retrospective study that included pregnant women who had vaginal singleton delivery between January 2019 and September 2022 in two Italian University hospitals, Naples and Novara, was conducted. We excluded cesarean sections, nonvertex presentation, preterm delivery, multiple pregnancies, congenital malformations, or stillbirths. Statistical analysis with an independent association of ethnicity to the risk of OASIs using clinical characteristics-adjusted multivariate logistic regression was performed.

RESULTS

A total of 3,049 pregnant women were included. 2.33% (71 patients) had an OASI. The median age was 31 years (IQR 7.00) and median gestational age was 39 weeks (IQR 1.40). Mean birth weight was 3,300 g (IQR 580.00). 1' and 5' Apgar scores were 9 and 9. The univariate logistic regression was not statistically significant. Multivariate logistic regression model adjusted for baseline clinical characteristics showed an OR 2.540 (p value 0.01) for OASIs in Asian women. Primiparous and secondiparous were protective factors for OASIs with OR 0.224 (p value < 0.001) and OR 0.209 (p value 0.01).

CONCLUSIONS

Our results confirm racial/ethnic disparities regarding OASIs, with an elevated risk for Asian women in Southern Europe. Prevention strategies and obstetric care in developed countries should be modulated to offset the risk of OASIs in this population. Additional research is needed to explain the specific mechanisms of these disparities.

How to Avoid Becoming a Risk Factor of Fecal Incontinence Due to OASIS-A Narrative Review

Third- and fourth-degree anal sphincter injuries are among the most severe traumas women can experience during childbirth, often leading to lifelong continence issues. Despite extensive research, current repair techniques are often inadequate, failing to provide long-term efficiency. The repair of OASIS tends to worsen with time as fecal or anal incontinence increases. This article presents the risk factors for primary repair failure differently from those previously described in the literature, specifically focusing on avoidable risk factors related to obstetricians and surgeons who perform OASIS repair. After reviewing the literature, the following risk areas were identified and described: recurrent OASIS, pitfalls of the current WHO classification, surgical techniques, place in which the repair should be performed, surgical training, factors related to low volumes of patients with grade III-IV injuries, timing of the repair, and failure of primary repair.

A Postpartum Perineal Clinic in Nova Scotia: Characteristics Associated With Attendance and Its Association With Recurrent Obstetrical Anal Sphincter Tears

OBJECTIVES

The Healthy Recovery after Childbirth Clinic (HRCC) in Nova Scotia provides postpartum care to patients who experience obstetric anal sphincter injuries (OASIS). The purpose of this study was to describe characteristics associated with HRCC attendance, characteristics associated with a trial of labour in a subsequent delivery, and OASIS recurrence by HRCC attendance status.

METHODS

A retrospective cohort study using the Atlee Perinatal Database and clinical record review included primiparous individuals who sustained an OASIS at IWK Health in Halifax between 2013 and 2020. The χ2 and Fisher exact tests were performed to compare groups.

RESULTS

Of the 1041 individuals included, 67% attended HRCC. Attendance increased from 58% in 2013-2015 to 77% in 2019-2020. Younger age (<25 years) and smoking were associated with lower HRCC attendance (P = 0.07 and <0.01, respectively). Other characteristics, including area-level income and driving distance to HRCC, were not associated with attendance (P > 0.05). Of the 439 individuals who had a subsequent delivery, 92% had a trial of labour. Individuals with fourth-degree injury were less likely to attempt a trial of labour than those with third-degree injury (73% vs. 94%, P < 0.01). Of those who delivered vaginally, OASIS recurrence was similar in those who did and did not attend the HRCC (7.5% vs. 6.5%, P = 0.84).

CONCLUSIONS

HRCC attendance was high, but the disparity by age and smoking status suggests some barriers to access that should be explored. Although we found no difference in OASIS recurrence by HRCC attendance, more research with larger samples with adjustment for confounders is needed.

Caesarean section and anal incontinence in women after obstetric anal sphincter injury: A systematic review and meta-analysis

BACKGROUND

Approximately 50% women who give birth after obstetric anal sphincter injury (OASI) develop anal incontinence (AI) over their lifetime.

OBJECTIVE

To evaluate current evidence for a protective benefit of planned caesarean section (CS) to prevent AI after OASI.

SEARCH STRATEGY

MEDLINE/PubMed, Embase 1974-2024, CINAHL and Cochrane to 7 February 2024 (PROSPERO CRD42022372442).

SELECTION CRITERIA

All studies reporting outcomes after OASI and a subsequent birth, by any mode.

DATA COLLECTION AND ANALYSIS

Eighty-six of 2646 screened studies met inclusion criteria, with nine studies suitable to meta-analyse the primary outcome of 'adjusted AI' after OASI and subsequent birth. Subgroups: short-term AI, long-term AI, AI in asymptomatic women.

SECONDARY OUTCOMES

total AI, quality of life, satisfaction/regret, solid/liquid/flatal incontinence, faecal urgency, AI in women with and without subsequent birth, change in AI pre- to post- subsequent birth.

MAIN RESULTS

There was no evidence of a difference in adjusted AI after subsequent vaginal birth compared with CS after OASI across all time periods (OR = 0.92, 95% CI 0.72-1.20; 9 studies, 2104 participants, I2 = 0% p = 0.58), for subgroup analyses or secondary outcomes. There was no evidence of a difference in AI in women with or without subsequent birth (OR = 1.00 95% CI 0.65-1.54; 10 studies, 970 participants, I2 = 35% p = 0.99), or pre- to post- subsequent birth (OR = 0.79 95% CI 0.51-1.25; 13 studies, 5496 participants, I2 = 73% p = 0.31).

CONCLUSIONS

Due to low evidence quality, we are unable to determine whether planned caesarean is protective against AI after OASI. Higher quality evidence is required to guide personalised decision-making for asymptomatic women and to determine the effect of subsequent birth mode on long-term AI outcomes.

Gestational Glucose Intolerance and Birth Weight-Related Complications

OBJECTIVE

To evaluate the risks of large-for-gestational-age birth weight (LGA) and birth weight-related complications in pregnant individuals with gestational glucose intolerance, an abnormal screening glucose loading test result without meeting gestational diabetes mellitus (GDM) criteria.

METHODS

In a retrospective cohort study of 46,989 individuals with singleton pregnancies who delivered after 28 weeks of gestation, those with glucose loading test results less than 140 mg/dL were classified as having normal glucose tolerance. Those with glucose loading test results of 140 mg/dL or higher and fewer than two abnormal values on a 3-hour 100-g oral glucose tolerance test (OGTT) were classified as having gestational glucose intolerance. Those with two or more abnormal OGTT values were classified as having GDM. We hypothesized that gestational glucose intolerance would be associated with higher odds of LGA (birth weight greater than the 90th percentile for gestational age and sex). We used generalized estimating equations to examine the odds of LGA in pregnant individuals with gestational glucose intolerance compared with those with normal glucose tolerance, after adjustment for age, body mass index, parity, health insurance, race and ethnicity, and marital status. In addition, we investigated differences in birth weight-related adverse pregnancy outcomes.

RESULTS

Large for gestational age was present in 7.8% of 39,685 pregnant individuals with normal glucose tolerance, 9.5% of 4,155 pregnant individuals with gestational glucose intolerance and normal OGTT, 14.5% of 1,438 pregnant individuals with gestational glucose intolerance and one abnormal OGTT value, and 16.0% of 1,711 pregnant individuals with GDM. The adjusted odds of LGA were higher in pregnant individuals with gestational glucose intolerance than in those with normal glucose tolerance overall (adjusted odds ratio [aOR] 1.35, 95% CI 1.23-1.49, P <.001). When compared separately with pregnant individuals with normal glucose tolerance, those with either gestational glucose intolerance subtype had higher adjusted LGA odds (gestational glucose intolerance with normal OGTT aOR 1.21, 95% CI 1.08-1.35, P <.001; gestational glucose intolerance with one abnormal OGTT value aOR 1.77, 95% CI 1.52-2.08, P <.001). The odds of birth weight-related adverse outcomes (including cesarean delivery, severe perineal lacerations, and shoulder dystocia or clavicular fracture) were higher in pregnant individuals with gestational glucose intolerance with one abnormal OGTT value than in those with normal glucose tolerance.

CONCLUSION

Gestational glucose intolerance in pregnancy is associated with birth weight-related adverse pregnancy outcomes. Glucose lowering should be investigated as a strategy for lowering the risk of these outcomes in this group.

Prediction models for perineal lacerations during childbirth: A systematic review and critical appraisal

BACKGROUND

Perineal lacerations could lead to substantial morbidities for women. A reliable prediction model for perineal lacerations has the potential to guide the prevention. Although several prediction models have been developed to estimate the risk of perineal lacerations, especially third- and fourth-degree perineal lacerations, the evidence about the model quality and clinical applicability is scarce.

OBJECTIVES

To systematically review and critically appraise the existing prediction models for perineal lacerations.

METHODS

Seven databases (PubMed, Embase, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, SinoMed, China National Knowledge Infrastructure, and Wanfang Data) were systematically searched from inception to July 2022. Studies that developed prediction models for perineal lacerations or performed external validation of existing models were considered eligible to include in the systematic review. Two reviewers independently conducted data extraction according to the Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies. The risk of bias and the applicability of the included models were assessed with the Prediction Model Risk of Bias Assessment Tool. A narrative synthesis was performed to summarize the characteristics, risk of bias, and performance of existing models.

RESULTS

Of 4345 retrieved studies, 14 studies with 22 prediction models for perineal lacerations were included. The included models mainly aimed to estimate the risk of third- and fourth-degree perineal lacerations. The top five predictors used were operative vaginal birth (72.7 %), parity/previous vaginal birth (63.6 %), race/ethnicity (59.1 %), maternal age (50.0 %), and episiotomy (40.1 %). Internal and external validation was performed in 12 (54.5 %) and seven (31.8 %) models, respectively. 13 studies (92.9 %) assessed model discrimination, with the c-index ranging from 0.636 to 0.830. Seven studies (50.0 %) evaluated the model calibration using the Hosmer-Lemeshow test, Brier score, or calibration curve. The results indicated that most of the models had fairly good calibration. All the included models were at higher risk of bias mainly due to unclear or inappropriate methods for handling missing data and continuous predictors, external validation, and model performance evaluation. Six models (27.3 %) showed low concerns about applicability.

CONCLUSIONS

The existing models for perineal lacerations were poorly validated and evaluated, among which only two have the potential for clinical use: one for women undergoing vaginal birth after cesarean delivery, and the other one for all women undergoing vaginal birth. Future studies should focus on robust external validation of existing models and the development of novel models for second-degree perineal laceration.

PROSPERO REGISTRATION NUMBER

CRD42022349786.

TWEETABLE ABSTRACT

The existing models for perineal lacerations during childbirth need external validation and updating. Tools are needed for second-degree perineal laceration.

Universal Urogynecologic Consultation and Screening for Fecal Incontinence in Pregnant Women With a History of Obstetric Anal Sphincter Injury: A Cost-Effectiveness Analysis

IMPORTANCE

Obstetric anal sphincter injuries (OASIS) predispose for the development of fecal incontinence (FI), but management of subsequent pregnancy after OASIS is controversial.

OBJECTIVE

We aimed to determine if universal urogynecologic consultation (UUC) for pregnant women with prior OASIS is cost-effective.

STUDY DESIGN

We performed a cost-effectiveness analysis of pregnant women with a history of OASIS modeling UUC compared with no referral (usual care). We modeled the route of delivery, peripartum complications, and subsequent treatment options for FI. Probabilities and utilities were obtained from published literature. Costs using a third-party payer perspective were gathered from the Medicare physician fee schedule reimbursement data or published literature converted to 2019 U.S. dollars. Cost-effectiveness was determined using incremental cost-effectiveness ratios).

RESULTS

Our model demonstrated that UUC for pregnant patients with prior OASIS was cost-effective. Compared with usual care, the incremental cost-effectiveness ratio for this strategy was $19,858.32 per quality-adjusted life-year, below the willingness to pay a threshold of $50,000/quality-adjusted life-year. Universal urogynecologic consultation reduced the ultimate rate of FI from 25.33% to 22.67% and reduced patients living with untreated FI from 17.36% to 1.49%. Universal urogynecologic consultation increased the use of physical therapy by 14.14%, whereas rates of sacral neuromodulation and sphincteroplasty increased by only 2.48% and 0.58%, respectively. Universal urogynecologic consultation reduced the rate of vaginal delivery from 97.26% to 72.42%, which in turn led to a 1.15% increase in peripartum maternal complications.

CONCLUSIONS

Universal urogynecologic consultation in women with a history of OASIS is a cost-effective strategy that decreases the overall incidence of FI, increases treatment utilization for FI, and only marginally increases the risk of maternal morbidity.

Risk Factors for Anal Continence Impairment Following a Second Delivery after a First Traumatic Delivery: A Prospective Cohort Study

Postpartum anal incontinence is common. After a first delivery (D1) with perineal trauma, follow-up is advised to reduce the risk of anal incontinence. Endoanal sonography (EAS) may be considered to evaluate the sphincter and in case of sphincter lesions to discuss cesarean section for the second delivery (D2). Our objective was to study the risk factors for anal continence impairment following D2. Women with a history of traumatic D1 were followed before and 6 months after D2. Continence was measured using the Vaizey score. An increase ≥2 points after D2 defined a significant deterioration. A total of 312 women were followed and 67 (21%) had worse anal continence after D2. The main risk factors for this deterioration were the presence of urinary incontinence and the combined use of instruments and episiotomy during D2 (OR 5.12, 95% CI 1.22-21.5). After D1, 192 women (61.5%) had a sphincter rupture revealed by EAS, whereas it was diagnosed clinically in only 48 (15.7%). However, neither clinically undiagnosed ruptures nor severe ruptures were associated with an increased risk of continence deterioration after D2, and cesarean section did not protect against it. One woman out of five in this population had anal continence impairment after D2. The main risk factor was instrumental delivery. Caesarean section was not protective. Although EAS enabled the diagnosis of clinically-missed sphincter ruptures, these were not associated with continence impairment. Anal incontinence should be systematically screened in patients presenting urinary incontinence after D2 as they are frequently associated.

Risk factors for obstetric anal sphincter injury recurrence: A systematic review and meta-analysis

BACKGROUND

Women with previous obstetric anal sphincter injuries (OASIs) are at a higher risk of recurrence in the subsequent pregnancy, which may lead to the development or worsening of anal incontinence. Due to a lack of evidence, few recommendations can be made about the factors that may affect the risk of OASI recurrence.

OBJECTIVE

We sought to conduct a systematic review and meta-analysis to investigate potential risk factors for recurrent OASIs.

SEARCH STRATEGY

Studies up to May 2019 were identified from PubMed, Scopus, Cochrane Library, and ISI Web of Science.

SELECTION CRITERIA

Studies assessing the impact of risk factors on OASI recurrence in subsequent pregnancies were included. Reviews, letters to the editor, conference abstracts, book chapters, guidelines, Cochrane reviews, and expert opinions were excluded.

DATA COLLECTION AND ANALYSIS

Data were extracted by two independent reviewers. Odds ratio and standardized mean difference were chosen as effect measures. Pooled estimates were calculated using the random-effects model.

MAIN RESULTS

The meta-analysis showed that maternal age, gestational age, occiput posterior presentation, oxytocin augmentation, operative delivery, and shoulder dystocia were associated with the risk of recurrent OASIs in the subsequent delivery.

CONCLUSION

Prenatal and intrapartum risk factors are associated with recurrence of OASI. PROSPERO registration no. CRD42020178125.

Can sonographic fetal head circumference measurement help predict Obstetric Anal Sphincter Injury?

OBJECTIVE

Obstetric Anal Sphincter Injuries (OASIS) occur in 2 to 19% of vaginal deliveries in the United States. Neonatal parameters such as birthweight above 4000g or neonatal head circumference above 37 cm are known risk factors for OASIS. We hypothesized that sonographic fetal Head Circumference (sfHC) size assessed by ultrasound antenatally could help predict OASIS.

METHODS

This study is a retrospective cohort study between 2005 and 2016. Antenatal ultrasound Head Circumference (sfHC) assessment, maternal demographics, and labor and delivery data were abstracted and compared in women with and without OASIS.

RESULTS

Of 2057 pregnant women that had sfHC assessment, 121 (5.8%) had OASIS. In the unadjusted analysis, sfHC above the 90^th percentile was associated with OASIS OR 1.12 (1.02-1.23) p=0.015. When adjusted for gestational age at delivery, maternal age, race, prolonged 2^nd stage, BMI, infant gender, and intrapartum oxytocin use, sfHC above the 90^th percentile remained significantly associated with OASIS (OR=1.13, 95% CI 1.00-1.27, p=0.050).

CONCLUSION

In our cohort, sfHC above the 90^th percentile was associated with a greater risk of OASIS. As OASIS significantly impacts short and long-term health outcomes such as perineal pain, dyspareunia, urinary and fecal incontinence, sfHC could be an additional antenatal marker to help clinicians counsel pregnant women about the risk of OASIS.

Temporal trends in the incidence of and associations between the risk factors for obstetrical anal sphincter injuries

BACKGROUND

Obstetrical anal sphincter injuries are an important complication of vaginal deliveries that may result in short- and long-term pelvic floor morbidity and a diminished quality of life in young, healthy women. The prevalence of obstetrical anal sphincter injuries ranges from 0.1% to 8.7%. Over recent years, there seems to be a trend of increasing occurrence of obstetrical anal sphincter injuries worldwide. It is unclear why the rates are rising. Previous studies have examined the effect of different risk factors on the prevalence of obstetrical anal sphincter injuries. The change in the incidence of some risk factors for obstetrical anal sphincter injuries can partially explain the overall increase in obstetrical anal sphincter injuries. There is no previous study that explored the impact of the changes of individual risk factors over time on the risk for obstetrical anal sphincter injuries.

OBJECTIVE

The main aim of this study was to examine the temporal trends in the prevalence and odds ratio of the major risk factors known to be associated with obstetrical anal sphincter injuries in the period from 1988 to 2016.

STUDY DESIGN

This was a retrospective cohort study that included all women who underwent vaginal deliveries between 1988 and 2016 at a tertiary university medical center. The time intervals were divided into 4 periods (1988-1997, 1998-2007, 2008-2016, and the total time from 1988 to 2016) and the incidence of each risk factor was calculated for each time period. Correlation models and regression analysis were performed to examine the association between obstetrical anal sphincter injuries and the different risk factors over time. Furthermore, the trends in the odds ratios of the important risk factors over the time periods were evaluated using a multivariate regression analysis in which the primiparous women were separated from the multiparous women.

RESULTS

During the study period, there were 295,668 vaginal deliveries. Of these, 591 women were diagnosed with obstetrical anal sphincter injuries (0.2%). The significant risk factors for obstetrical anal sphincter injuries (P<.05) in the multivariable analysis were the following: primiparity, vaginal birth after cesarean delivery, vacuum extraction, and a birthweight of >4 kg. There was a significant (P<.05) increase in the incidence over the study period for the following risk factors: primiparity, vaginal birth after cesarean delivery, and vacuum extraction. No change was found in the incidence of the risk factor of a birthweight of >4 kg. In addition, we found a strengthening of the association between vaginal birth after cesarean delivery and macrosomia with obstetrical anal sphincter injuries, as opposed to a decline in the relative contribution of vacuum extraction to the overall risk for obstetrical anal sphincter injuries. Moreover, we found that obstetrical anal sphincter injuries among primiparous women increased 7-fold over the study period but was unchanged among multiparous women.

CONCLUSION

We have shown significant (P<.05) temporal trends in the incidence and odds ratio of some of the known risk factors for obstetrical anal sphincter injuries. A better understanding of the changes in the incidence and specific contribution of important risk factors for obstetrical anal sphincter injuries may explain, in part, the worldwide increase in the prevalence of this important and detrimental complication of vaginal birth.

Anal Sphincter Injury Associated with Vaginal Twin Delivery

OBJECTIVE

Obstetric anal sphincter injury remains the most common cause of fecal incontinence in women, and research in twin pregnancies is sparse. This study aimed to examine risk factors for sphincter injury in twin deliveries over a 10-year period.

STUDY DESIGN

This was a retrospective study of twin vaginal deliveries in a tertiary-level hospital over 10 years. We examined the demographics of women who had a vaginal delivery of at least one twin. Logistic regression analysis was used to examine risk factors.

RESULTS

There were 1,783 (2.1%) twin pregnancies, of which 556 (31%) had a vaginal delivery of at least one twin. Sphincter injury occurred in 1.1% (6/556) women with twins compared with 2.9% (1720/59,944) singleton vaginal deliveries. Women with sphincter injury had more instrumental deliveries (83.3 vs. 27.6%; p = 0.008). On univariate analysis, only instrumental delivery was a significant risk factor (odds ratio: 2.93; p = 0.019).

CONCLUSION

Sphincter injury occurs at a lower rate in vaginal twin pregnancies than in singletons. No twin-specific risk factors were identified. Discussion of the risk of sphincter injury should form part of patient counseling with regard to the mode of delivery.

Accuracy of obstetric laceration diagnoses in the electronic medical record

INTRODUCTION AND HYPOTHESIS

Patient safety data including rates of obstetric anal sphincter injury (OASI) are often derived from hospital discharge codes. With the transition to electronic medical records (EMRs), we hypothesized that electronic provider-entered delivery data would more accurately document obstetric perineal injury than traditional billing/diagnostic codes.

METHODS

We evaluated the accuracy of perineal laceration diagnoses after singleton vaginal deliveries during one calendar year at an American tertiary academic medical center. We reviewed the entire hospital chart to determine the most likely laceration diagnosis and compared that expert review diagnosis (ExpRD) with documentation in the EMR delivery summary (EDS) and ICD-9 diagnostic codes (IDCs).

RESULTS

We retrospectively selected 354 total delivery records. OASI complicated 56 of those. 303 records (86%) were coded identically by the EDS and IDCs. Diagnoses from the IDCs and the EDS were mostly correct compared with ExpRD (sensitivity = 96%, specificity = 100%). There was no systematic over- or under-diagnosis of OASI for either the EDS (p = 0.070) or the IDCs (p = 0.447). When considering all laceration types the EDS was correct for 21 (5.9%) lacerations that were incorrect according to the IDCs. Overall, the EDS was more accurate (p < 0.05) owing to errors in IDC minor laceration diagnoses.

CONCLUSIONS

Electronic medical record delivery summary data and EMR-derived diagnostic codes similarly characterize OASI. The EDS does not improve OASI reporting, but may be more accurate when considering all perineal lacerations. This assumes that providers have correctly identified and categorized the lacerations that they record in the EMR.

Antepartum vaginal Candida colonization and the risk for obstetrical tears

Objective: Vaginal Candida colonization is very common during pregnancy. An association between Candida colonization and obstetrical tears has not yet been investigated. We investigated whether vaginal Candida colonization during pregnancy is associated with an increased risk for obstetrical tears.Study design: A prospective cohort study was undertaken between the years 2014-2016, comparing pregnancy and delivery characteristics of women with and without Candida colonization during pregnancy. Clinical characteristics of Candida positive women and those with normal vaginal flora were collected. To test the statistical significance of the categorical variables, the chi-square test or Fisher's exact test were used, where appropriate. For continuous variables, the Student's t-test was used.Results: During the study period, 102 women with vaginal Candida during pregnancy (of whom 70% had Candida albicans species) and 102 controls with normal vaginal flora were included in the analysis. No significant differences were observed between Candida positive women and those with normal vaginal flora. Pregnancy and delivery outcomes were comparable and no increased risk of obstetrical tears was found in the Candida group.Conclusions: Vaginal colonization with Candida species during pregnancy was not found to be associated with an increased risk of obstetrical tears.

[National survey about the practice of episiotomy within French National College of Obstetricians and Gynecologists (CNGOF)]

OBJECTIVE

The main endpoint was to perform a survey about the practices of episiotomy into a CNGOF (National College of French Obstetricians and Gynecologists) members population.

METHODS

In November 2018, it was proceeded to a national survey from CNGOF members thanks to an online questionnaire. We collected prospectively: the answerer's characteristics, the rate of episiotomy and its systematics indications for spontaneous and operative delivery, the habits of the practitioners for the section and the reparation, the modalities of women's information and the data entered into the medical record.

RESULTS

Three hundred and eighty nine CNGOF members answered to the survey. They were 69% to declare performing less than 10% of episiotomy in case of spontaneous vertex delivery. The most frequent systematic indication of episiotomy was the personal history of obstetric anal sphincter injury (more than 30% of answerers). Systematic episiotomy was less frequent in case of vacuum assisted operative delivery compared to forceps (OR=0.18 [0.08-0.37]) or spatulas (OR=0.28 [0.12-0.59]). Most of practitioners (94%) declared performing mediolateral episiotomies, 64% declared cutting with an equal or more than 45° angle and 50% declared using a resorbable continuous suture technique for the reparation. Half of the answerers (46%) indicated that they inform et collected women's consent before performing an episiotomy.

CONCLUSIONS

Several practices, women's information, section angle and the reparation technique are subject to change by the latest 2018 CNGOF guidelines about perineal protection.

[Cesarean section and perineal protection: CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]

OBJECTIVE

The endpoint was to assess the interest of planned cesarean section in primary and secondary obstetrical perineal prevention.

METHODS

This is a review of the literature about the impact of the mode of delivery in urinary incontinence (UI), anal incontinence (AI), pelvic organ prolapse (POP), sexual disorders de novo or prior to delivery and history of obstetric anal sphincter injuries (OASI).

RESULTS

The studies about UI, AI and sexual disorders report a potential protective impact of cesarean section but with a possible selection bias and an inadequate comparability of the groups. Randomized trials do not report any protective effect of planned cesarean section for these 3 disorders. The literature about POP reports a higher risk for the women who delivered vaginally but still with a possible selection bias et there is no randomized trial for this outcome. About the secondary prevention of OASI, there is no evidence in the literature for a benefit of a systematic planned cesarean section for all women. For symptomatic women, the mode of delivery has to be discussed individually. In secondary prevention of UI, AI, POP and sexual disorders, there is no evidence in the literature for a benefit of planned cesarean section even if there is a history of surgical procedure for the disorder.

CONCLUSION

Planned cesarean section is not recommended in order to prevent primary or secondary obstetrical perineal disorders except for symptomatic OASI for whom an individual discussion about the mode of delivery is recommended.

Counseling after perineal laceration: does it improve functional outcome?

INTRODUCTION AND HYPOTHESIS

Since 2006, the Lausanne University Hospital (CHUV) has offered a 12-week post-partum perineum consultation for patients with third-/fourth-degree tears, providing advice for future deliveries. This study consisted of a retrospective follow-up of these patients, focused on subsequent deliveries and current urinary and anorectal incontinence symptoms.

METHODS

Patients meeting eligibility criteria were invited to complete a questionnaire on their deliveries, along with validated questionnaires grading urinary (UDI-6 and IIQ-7) and anorectal (Wexner-Vaizey score) incontinence.

RESULTS

Sixty-two percent of third-/fourth-degree tears occurred following operative vaginal deliveries. Of 160 participants, 45.6% did not redeliver, 5.6% of whom felt traumatized by their first delivery and reluctant to have another children; 33.2% had a second vaginal delivery, 19.4% had a cesarean section (CS), and 1.2% had both vaginal and CS deliveries; 28% of the CS were not medically indicated. The recurrence rate of third-/fourth-degree tears for subsequent vaginal deliveries was 3.6%. Most patients were mildly or not affected by incontinence symptoms. Symptomatic patients reported urinary incontinence during physical activity and gas leakages; 50-60% saw no change of symptoms since the consultation, 30-40% reported partial or complete recovery. Patients redelivering by CS reported significantly less urinary incontinence (p = 0.046) and less anorectal incontinence (p = 0.069).

CONCLUSION

Anal sphincter laceration is associated with urinary and anorectal incontinence, but symptoms improve or disappear in most cases and are globally not invalidating. Perineal physiotherapy seems to contribute to this positive evolution. Fertility rate among these patients is unaffected, but the CS rate is higher than average. Further consideration of sexual and emotional sequelae could improve our current service.

Third and Fourth Degree Perineal Tear in Four-Year Period at Sestre Milosrdnice University Hospital Center, Zagreb, Croatia

OBJECTIVES:

Obstetric anal sphincter injury (OASIS) includes the third and fourth degree of perineal injury. The risk for OASIS is about 1% of all vaginal deliveries. If not recognised and treated properly, obstetric anal sphincter injury can have serious consequences for reproductive age woman.

MATERIAL AND METHODS:

We have retrospectively gathered and analysed data on obstetric anal sphincter injury in a four-year period at our department. The control group in this study included vaginal deliveries in 2012.

RESULTS:

We recorded 0.34% third and fourth degree of perineal injury in all vaginal deliveries, and 87.9% of those patients were primiparae. Episiotomy was performed in 57.6% of all women with obstetric anal sphincter injury. In 30.3% of cases, newborns were large for gestational age. Gestational diabetes was found in 9.1% of OASIS cases, occipitoposterior position was found in 9.1% of cases. Induced labour took place in 39.4%, and oxytocin infusion was applied in 60.6% of OASIS cases. Vacuum extraction was performed in 12.1% of deliveries with OASIS. The average BMI in 3a and 3b injuries was 29.9. In 3c degree it was 28.0, and in the fourth degree, it was 32.1. In 27.0% of OASIS cases due to the extent of the injury surgeon engagement was necessary. When compared with vaginal deliveries in 2012 we found a significant increase in OASIS in primiparas, large for gestational age, occipitoposterior position, induced labour, vacuum extraction and hypertension (P < 0.01). There is also increased incidence of OASIS in episiotomy and oxytocin use group (P < 0.05).

CONCLUSION:

Low incidence of OASIS in our department is a result of active management of delivery, manual perineal protection and timely episiotomy.

Effect of subsequent vaginal delivery on bowel symptoms and anorectal function in women who sustained a previous obstetric anal sphincter injury

Introduction and hypothesis

Our primary objective was to prospectively evaluate anorectal symptoms, anal manometry and endoanal ultrasound (EAUS) in women who followed the recommended mode of subsequent delivery following index obstetric anal sphincter injuries (OASIs) using our unit’s standardised protocol. Our secondary objectives were to evaluate the role of internal anal sphincter defects and also to compare outcomes in a subgroup of symptomatic women with normal anorectal physiology.

Methods

This is a prospective follow-up study of pregnant women with previous OASIs who were counselled regarding subsequent mode of delivery between January 2003 and December 2014. Assessment involved the St Mark’s Incontinence Score (SMIS), anal manometry and EAUS at both antepartum and 3-month postpartum visits. Data were analysed using Wilcoxon and Mann–Whitney U tests.

Results

Three hundred and fifty women attended the perineal clinic over the study period, of whom 122 met the inclusion criteria (99 vaginal delivery [VD], 23 caesarean section). No significant worsening of anorectal symptoms was observed following subsequent delivery in the VD group (p = 0.896), although a reduced squeeze pressure was observed at 3 months postpartum (p < 0.001). There were no new defects on EAUS in either group.

Conclusions

This study showed no significant worsening of bowel symptoms and sphincter integrity apart from lower squeeze pressures at 3 months postpartum in the VD group when our standardised protocol was used to recommend subsequent mode of delivery. In the absence of a randomised study, use of this protocol can aid clinicians in their decision-making.

Outcomes of primary anal sphincter repair after obstetric injury and evaluation of a novel three-choice assessment

Background

The aim of the present study was to evaluate the subjective outcome of primary repair of obstetric anal sphincter injury (OASIS) at 6 months, the factors associated with the symptoms of anal incontinence (AI), and the role of a simple survey consisting in one question with three answer choices, combined with the Wexner incontinence score for the assessment of this patient population.

Methods

A retrospective cohort study was conducted on patients with third- or fourth-degree OASIS operated on between January 2007 and December 2013 inclusive at Tampere University Hospital, Finland. At 6 months, the patients were asked to report their Wexner’s score as well as the three-choice assessment regarding AI symptoms. Based on this assessment, the patients were divided into three groups: those, asymptomatic, those with mild symptoms who did not want further treatment and those with severe symptoms who were willing to undergo further evaluation and treatment.

Results

There were 325 patients (median age 30 years). A total of 310 patients answered the questionnaire. Of which, one hundred and ninety-eight (63.9%) patients were asymptomatic, 85 (27.4%) had mild AI, and 27 (8.7%) experienced severe symptoms. There was no statistical difference in the results between the two techniques used (overlapping vs. end-to-end), or the stage of specialization of the operating physician. Persistent symptoms were associated with instrumental vaginal delivery (OR 2.12, 95% CI 1.32–3.41), severity of the injury (OR 1.64, 95% CI 1.20–2.25), and increased maternal age (OR 1.07, 95% CI 1.02–1.13). The correlation between the three-choice symptom evaluation and the Wexner score was good (Spearman’s rho 0.82).

Conclusions

After 6 months, severe symptoms after OASIS repair were present in 9% of women and were more frequent in older women, women with high-degree tears and after instrumental vaginal delivery. A three-choice assessment of AI symptoms correlated well with the Wexner score and might be useful to triage patients who need further evaluation.

Postpartum two- and three-dimensional ultrasound evaluation of anal sphincter complex in women with obstetric anal sphincter injury

OBJECTIVE

To compare the sensitivity and specificity of two- (2D) and three- (3D) dimensional transperineal ultrasound (TPUS) and 3D endovaginal ultrasound (EVUS) with the gold standard 3D endoanal ultrasound (EAUS) in detecting residual defects after primary repair of obstetric anal sphincter injuries (OASIS).

METHODS

External (EAS) and internal (IAS) anal sphincters were evaluated by the four ultrasound modalities in women with repaired OASIS. 2D-TPUS was evaluated in real-time, whereas 3D-TPUS, 3D-EVUS and 3D-EAUS volumes were evaluated offline by six blinded readers. The presence/absence of any tear in EAS or IAS was recorded and defects were scored according to the Starck system. Sensitivity, specificity and predictive values were calculated, using 3D-EAUS as reference standard. Inter- and intraobserver analyses were performed for all 3D imaging modalities. Association between patients' symptoms (Wexner score) and ultrasound findings (Starck score) was calculated.

RESULTS

Images from 55 patients were analyzed. Compared with findings on 3D-EAUS, the agreement for EAS evaluation was poor for 3D-EVUS (κ = 0.01), fair for 2D-TPUS (κ = 0.30) and good for 3D-TPUS (κ = 0.73). The agreement for IAS evaluation was moderate for both 3D-EVUS (κ = 0.41) and 2D-TPUS (κ = 0.52) and good for 3D-TPUS (κ = 0.66). Good intraobserver (3D-EAUS, κ = 0.73; 3D-TPUS, κ = 0.78) and interobserver (3D-EAUS, κ = 0.68; 3D-TPUS, κ = 0.60) agreement was reported. Significant association between Starck and Wexner scores was found only for 3D-EAUS (Spearman's rho = 0.277, P = 0.04).

CONCLUSIONS

2D-TPUS and 3D-EVUS are not accurate modalities for the assessment of anal sphincters after repair of OASIS. 3D-TPUS shows good agreement with the gold standard 3D-EAUS and a high sensitivity in detecting residual defects. It, thus, has potential as a screening tool after primary repair of OASIS. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Evidence-Based Update on Treatments of Fecal Incontinence in Women

Fecal incontinence is a highly prevalent and distressing condition that has a negative impact on quality of life. The etiology is often multifactorial, and the evaluation and treatment of this condition can be hindered by a lack of understanding of the mechanisms and currently available treatment options. This article reviews the evidence-based update for the management of fecal incontinence.

Predicting obstetric anal sphincter injuries in a modern obstetric population

BACKGROUND

Perineal lacerations are common at the time of vaginal delivery and may predispose patients to long-term pelvic floor disorders, such as urinary incontinence and pelvic organ prolapse. Obstetric anal sphincter injuries, which are the most severe form of perineal lacerations, result in disruption of the anal sphincter and, in some cases, the rectal mucosa during vaginal delivery. Long-term morbidity, including pain, pelvic floor disorders, fecal incontinence, and predisposition to recurrent injury at subsequent delivery may result. Despite several studies that have reported risk factors for obstetric anal sphincter injuries, no accurate risk prediction models have been developed.

OBJECTIVE

The purpose of this study was to identify risk factors and develop prediction models for perineal lacerations and obstetric anal sphincter injuries.

STUDY DESIGN

This was a nested case control study within a retrospective cohort of consecutive term vaginal deliveries at 1 tertiary care facility from 2004-2008. Cases were patients with any perineal laceration that had been sustained during vaginal delivery; control subjects had no lacerations of any severity. Secondary analyses investigated obstetric anal sphincter injury (3rd- to 4(th)-degree laceration) vs no obstetric anal sphincter injury (0 to 2(nd)-degree laceration). Baseline characteristics were compared between groups with the use of the chi-square and Student t test. Adjusted odds ratios and 95% confidence intervals were calculated with the use of multivariable logistic regression. Prediction models were created and model performance was estimated with receiver-operator characteristic curve analysis. Receiver-operator characteristic curves were validated internally with the use of the bootstrap method to correct for bias within the model.

RESULTS

Of the 5569 term vaginal deliveries that were recorded during the study period, complete laceration data were available in 5524 deliveries. There were 3382 perineal lacerations and 249 (4.5%) obstetric anal sphincter injuries. After adjusted analysis, significant predictors for laceration included nulliparity, non-black race, longer second stage, nonsmoking status, higher infant birthweight, and operative delivery. Private health insurance, labor induction, pushing duration, and regional anesthesia were not statistically significant in adjusted analyses. Significant risk factors for obstetric anal sphincter injury were similar to predictors for any laceration; nulliparity and operative vaginal delivery had the highest predictive value. Area under the curve for the predictive ability of the models was 0.70 for overall perineal laceration, and 0.83 for obstetric anal sphincter injury. When limited to primiparous patients, 1996 term vaginal deliveries were recorded. One hundred ninety-two women sustained an obstetric anal sphincter injury; 1796 women did not. After adjusted analysis, significant predictors for laceration included non-black race, age, obesity, and nonsmoking status. In secondary analyses, significant predictors for obstetric anal sphincter injury included non-black race, nonsmoking status, longer duration of pushing, operative vaginal delivery, and infant birthweight. Area under the curve for the predictive ability of the models was 0.60 for any laceration and 0.77 for obstetric anal sphincter injury.

CONCLUSIONS

Significant risk factors for sustaining any laceration and obstetric anal sphincter injury during vaginal deliveries were identified. These results will help identify clinically at-risk patients and assist providers in counseling patients about modifications to decrease these risks.

Risk factors for recurrent obstetric anal sphincter injury (rOASI): a systematic review and meta-analysis

Objectives

The objective of this study was to estimate the risk of recurrent obstetric anal sphincter injury (rOASI) in women who have suffered anal sphincter injury in their previous pregnancy and analyse risk factors for recurrence through a systematic review and meta-analysis.

Data sources

A review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were made in Ovid MEDLINE (1996 to May 2015), PubMed, EMBASE and Google Scholar, including bibliographies and conference proceedings.

Methods of study selection

Observational studies (cohort/case–control) evaluating rOASI and risk factors were selected by two reviewers who also analysed methodological quality of those studies. Pooled odds ratios (OR) for rOASI and individual risk factors were calculated using RevMan 5.3.

Tabulation, integration and results

From the eight studies assessed, overall risk of rOASI was 6.3 % compared with a 5.7 % risk of OASI in the first pregnancy. The risk in parous women with no previous OASI was 1.5 %. Factors that increased the risk in a future pregnancy were instrumental delivery with forceps [OR 3.12, 95 % confidence interval (CI) 2.42–4.01) or ventouse (OR 2.44, 95 % CI 1.83–3.25), previous fourth-degree tear (OR 1.7, 95 % CI 1.24–2.36) and birth weight ≥4 kg (OR 2.29, 95 % CI 2.06–2.54). Maternal age ≥35 years marginally increased the risk (OR 1.16, 95 % CI 1–1.35).

Conclusion

The overall rate of rOASI and associated risk factors for recurrence are similar to the rate and risk factors of primary OASI. Antenatal decisions could be based on assessment of foetal weight and intrapartum decisions based upon the requirement for an instrumental delivery.

Electronic supplementary material

The online version of this article (doi:10.1007/s00192-015-2893-4) contains supplementary material, which is available to authorized users.