Intrapartum risk factors for levator trauma Shek, KL; Dietz, HP
BJOG : an international journal of obstetrics and gynaecology,
November 2010, Letnik:
117, Številka:
12
Journal Article
Recenzirano
Please cite this paper as: Shek K, Dietz H. Intrapartum risk factors for levator trauma. BJOG 2010;117:1485–1492.
Objective To determine intrapartum risk factors associated with levator trauma as ...identified by ultrasound imaging.
Design A prospective observational study.
Setting Antenatal clinic of a tertiary hospital between May 2005 and February 2008.
Population Nulliparous women (n = 488) in their first ongoing pregnancy.
Methods An interview and four‐dimensional translabial ultrasound was carried out between 36 and 38 weeks and again 3–4 months after delivery. Obstetric data were collected from the hospital database and/or participants’ records.
Main outcome measures Levator macrotrauma (‘avulsion’) and microtrauma (irreversible overdistension).
Results A total of 367 women (75%) returned for the postpartum assessment after normal vaginal delivery (n = 187, 51%), vacuum (n = 34, 9%), forceps (n = 20, 5%) and caesarean section (n = 126, 34%). Median follow up was 4.08 months (interquartile range 3.68–5.03 months). Levator avulsion was diagnosed in 32 (13%) of the women who delivered vaginally and in none of the caesarean section group regardless of indication. On multivariable regression forceps delivery was significantly associated with avulsion (P = 0.01; OR 3.83; 95% CI 1.34–10.94). Using >20% peripartum increase in hiatal area on Valsalva as the cutoff, 28.5% of vaginally parous women were shown to have suffered irreversible overdistension. This was positively associated with the length of second stage (P = 0.001; OR 1.01 per minute; 95% CI 1.0–1.02). Intrapartum epidural appeared to have a protective effect (P = 0.03; OR 0.42; 95% CI 0.19–0.93).
Conclusion Levator trauma at the time of first delivery is associated with vaginal delivery, forceps and a longer second stage. Epidural pain relief may exert a protective effect.
Objective To estimate the risk of prolapse associated with levator avulsion injury among a urogynaecological clinic population.
Design Retrospective observational study.
Setting Tertiary ...urogynaecological unit.
Sample A total of 934 women seen for interview, examination using the pelvic organ prolapse quantification (POP‐Q) staging system and imaging of the levator ani muscle by four‐dimensional translabial ultrasound.
Methods Retrospective review of charts and stored imaging data.
Main outcome measures Pelvic organ prolapse stage II and higher and presence of defects of the levator ani muscle.
Results After exclusion of 137 women with a history of anti‐incontinence or prolapse surgery, and a further exclusion of 16 women in whom either examination or imaging was impossible, we compared prolapse and imaging data in 781 women. Mean age was 53 years (range 15–89 years), and median parity was 2 (range 0–12). Women reported stress incontinence (76%), urge incontinence (69%), frequency (47%), nocturia (49%) and symptoms of prolapse (38%). Significant prolapse (stage II or higher) was diagnosed in 415 (53%) women, and 181 (23%) women were found to have levator avulsion defects. Prolapse was seen in 150/181 (83%) women with avulsion and in 265/600 (44%) women without avulsion, giving a relative risk (RR) of 1.9 (95% CI 1.7–2.1). The association was strongest for cystocele (RR 2.3, 95% CI 2.0–2.7) and uterine prolapse (RR 4.0, 95% CI 2.5–6.5).
Conclusions Women with levator avulsion defects were about twice as likely to show pelvic organ prolapse of stage II or higher than those without. This effect is mainly due to an increased risk of cystocele and uterine prolapse.
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.
Ballooning of the levator hiatus Dietz, H. P.; Shek, C.; De Leon, J. ...
Ultrasound in obstetrics & gynecology,
June 2008, Letnik:
31, Številka:
6
Journal Article
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