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Pregnancy and parturition negatively impact vaginal angle and alters expression of vaginal MMP-9.

Am J Obstet Gynecol; 2017 Nov 16.
Artículo en Inglés | MEDLINE | ID: mdl-29155140


Parity is the greatest risk factor for the development of pelvic organ prolapse. The normally supported vagina is pulled up and back over the levator ani. Loss of vaginal angulation has been associated with prolapse and may represent injury to the vaginal supportive tissues.


We propose that 1) pregnancy and delivery impact support to the vagina leading to loss of vaginal angle; 2) vaginal angulation is restored postpartum; and 3) uncomplicated vaginal delivery (VD) is associated with accelerated remodeling of the vaginal fibrillar matrix.


We prospectively enrolled a cohort of nulliparas in 1st trimester and abstracted demographic and delivery data. Vaginal metalloproteinase 9 (MMP-9) activity was determined in 1 and 3 trimesters and 1 year postpartum using a substrate activity assay. Uncomplicated VD was defined as no Cesarean, forceps, vacuum, shoulder dystocia, obstetric anal sphincter laceration, or prolonged 2nd stage labor and women were grouped dichotomously for comparison based on this definition. A subset underwent transperineal ultrasound.


We enrolled 173 women, with mean age of 25±6 years and BMI of 20±7kg/m . 67% were white/Caucasian, 27% black/African American, and 6% Hispanic/Latina. Mean delivery age was 39±3 weeks with 59% experiencing uncomplicated VD. MMP-9 median activity (ng/mg protein) was 242.0 (IQR 18.7, 896.8,n=157) in 1st trimester, 130.8 (IQR 14.6, 883.8,n=148) in 3rd trimester, and 463.5 (IQR 92.2, 900.0,n=94) postpartum. MMP-9 activity increased between 3rd trimester and 1 year postpartum (p=0.006) with no significant difference between MMP-9 in 1st and 3rd trimesters (p=0.674). Vaginal angle became less acute from 1st to 3rd trimester and this change persisted postpartum. The vaginal angulation over the levator plate became more acute between 3 trimester and postpartum in those women who experienced uncomplicated VD compared to those who did not (-6.4±22.1 vs 17.5±14.8,p=0.017). Higher MMP-9 activity postpartum was associated with uncomplicated VD, with 67% in 3rd tertile achieving uncomplicated VD vs 39% in 1st tertile (p=0.029).


Loss of vaginal angulation occurs between trimesters and women do not recover their baseline resting angle postpartum. MMP-9 activity increases postpartum. Women experiencing uncomplicated VD demonstrate higher postpartum MMP-9 activity and are more likely to have recovered their vaginal angle.