Clinical value of transperineal ultrasound in evaluating the diagnostic grade of rectocele in Chinese women with obstructed defecation syndrome: An observational study.

We aimed to evaluate the effectiveness of transperineal ultrasound (TPUS) in diagnosing rectocele, rectal intussusception (RI), enterocele, perineal descent (PD), and cystocele in Chinese women with obstructed defecation syndrome (ODS), and to determine the grading of rectocele via TPUS. Between January 2019 and December 2021, 107 obstructed defecation syndrome patients, with a mean age of 49.76 years, received TPUS and defecation proctography (DEP). Both methods were used to diagnose anorectal angle, rectocele, RI, enterocele, and PD, while cystocele and uterine prolapse were diagnosed only through TPUS. Agreement between DEP and TPUS diagnostic results was compared using Cohen kappa statistics. Seventy-six rectoceles were reported following DEP and 72 after TPUS. DEP detected 7 enteroceles, 6 of which were diagnosed simultaneously by TPUS. 43 patients presented dyssynergic defecation (DD) upon DEP, while 51 upon TPUS. DEP and TPUS detected PD in 13 and 11 patients respectively, and RI in 82 and 73, respectively. Rectocele (kappa = 0.738), RI (kappa = 0.711), DD (kappa = 0.774), enterocele (kappa = 0.847), and PD (kappa = 0.625) were obtained by Cohen kappa statistics, which indicated a good agreement between DEP and TPUS. The cutoff values for the diagnosis of moderate and severe rectocele with TPUS were 12.05 mm (AUC: 0.941) and 18.50 mm (AUC: 0.977), respectively. The DEP-determined and TPUS-determined anorectal angles were significantly correlated in the resting and Valsalva states (P < .01). Compared with DEP, while maintaining good agreement in detecting rectocele, RI, DD, enterocele, and PD, TPUS is a repeatable and noninvasive alternative. Threshold values of 12.05 mm and 18.50 mm on TPUS may diagnose moderate and severe rectocele, respectively.

Assessment of perineal body properties in women with stress urinary incontinence using Transperineal shear wave elastography.

Limited data on the correlation between the perineal body (PB) and stress urinary incontinence (SUI) are available. The objectives of this study were to quantify the PB using shear wave elastography (SWE) technology with a high-frequency linear array probe to evaluate the relationship between the properties of PB and stress urinary incontinence (SUI). This study included 64 women with SUI and 70 female control participants. The length, height, perimeter, and area of PB in all participants were calculated using transperineal ultrasound, and the elasticity of PB was assessed by SWE at rest and during the maximal Valsalva maneuver, respectively. In addition, the comparison of PB parameters between the patients with SUI and the healthy participants was conducted. The transperineal ultrasound and SWE examination was performed in 134 participants, and the elastic modulus values were significantly increased from participants at rest to those during the maximal Valsalva maneuver in all participants (Emax: 35.59 versus 53.13 kPa, P < 0.001; and Emean: 26.97 versus 40.25 kPa, P < 0.001). Emax and Emean of PB exhibited significant differences during the maximal Valsalva maneuver between the SUI group and the control group (47.73 versus 58.06 kPa, P < 0.001; and 35.78 versus 44.33 kPa, P < 0.001) and had a negative correlation with SUI. The BMI and PB height during the maximal Valsalva maneuver in the SUI group were found to be significantly higher than that in healthy volunteers. Emax and Emean of PB negatively correlated with BMI during the maximal Valsalva maneuver (r = -0.277, P = 0.001 and r = -0.211, P = 0.014). ROC curve analysis demonstrated that PB perimeter of less than 12.68mm was strongly associated with SUI during the maximal Valsalva maneuver, and an Emax of less than 55.76 kPa had a 100% specificity in predicting SUI. SWE can quantify the elasticity of PB, identifying a significant difference between participants at rest and during Valsalva maneuver. In addition, the stiffness of the PB was significantly lower in women with SUI than in healthy women, which may provide a noninvasive clinical practice in SUI prediction.

Validation of the Barcelona-MRI predictive model when PI-RADS v2.1 is used with trans-perineal prostate biopsies.

PURPOSE: To validate the Barcelona magnetic resonance imaging predictive model (BCN-MRI PM) in men with pre-biopsy multiparametric MRI (mpMRI) reported with the Prostate Imaging Reporting and Data System (PI-RADS) v2.1, followed by transrectal and transperineal prostate biopsies. MATERIALS AND METHODS: Prospective analysis of 3,264 men with PSA >3.0 ng/mL and/or abnormal digital rectal examination who were referred to ten participant centers in the csPCa early detection program of Catalonia (Spain), between 2021 and 2023. MpMRI was reported with the PI-RADS v2.1, and 2- to 4-core MRI-transrectal ultrasound (TRUS) fusion-targeted biopsy of suspected lesions and/or 12-core systematic biopsy were conducted. 2,295 (70.3%) individuals were referred to six centers for transrectal prostate biopsies, while 969 (39.7%) were referred to four centers for transperineal prostate biopsies. CsPCa was classified whenever the International Society of Urologic Pathology grade group was 2 or higher. RESULTS: CsPCa was detected in 41% of transrectal prostate biopsies and in 45.9% of transperineal prostate biopsies (p < 0.016). Both BCN-MRI PM calibration curves were within the ideal correlation between predicted and observed csPCa. Areas under the curve and 95% confidence intervals were 0.847 (0.830-0.857) and 0.830 (0.823-0.855), respectively (p = 0.346). Specificities corresponding to 95% sensitivity were 37.6 and 36.8%, respectively (p = 0.387). The Net benefit of the BCN-MRI PM was similar with both biopsy methods. CONCLUSIONS: The BCN-MRI PM has been successfully validated when mpMRI was reported with the PI-RADS v2.1 and prostate biopsies were conducted via the transrectal and transperineal route.

A deep learning approach to identify the fetal head position using transperineal ultrasound during labor.

OBJECTIVES: To develop a deep learning (DL)-model using convolutional neural networks (CNN) to automatically identify the fetal head position at transperineal ultrasound in the second stage of labor. MATERIAL AND METHODS: Prospective, multicenter study including singleton, term, cephalic pregnancies in the second stage of labor. We assessed the fetal head position using transabdominal ultrasound and subsequently, obtained an image of the fetal head on the axial plane using transperineal ultrasound and labeled it according to the transabdominal ultrasound findings. The ultrasound images were randomly allocated into the three datasets containing a similar proportion of images of each subtype of fetal head position (occiput anterior, posterior, right and left transverse): the training dataset included 70 %, the validation dataset 15 %, and the testing dataset 15 % of the acquired images. The pre-trained ResNet18 model was employed as a foundational framework for feature extraction and classification. CNN1 was trained to differentiate between occiput anterior (OA) and non-OA positions, CNN2 classified fetal head malpositions into occiput posterior (OP) or occiput transverse (OT) position, and CNN3 classified the remaining images as right or left OT. The DL-model was constructed using three convolutional neural networks (CNN) working simultaneously for the classification of fetal head positions. The performance of the algorithm was evaluated in terms of accuracy, sensitivity, specificity, F1-score and Cohen's kappa. RESULTS: Between February 2018 and May 2023, 2154 transperineal images were included from eligible participants across 16 collaborating centers. The overall performance of the model for the classification of the fetal head position in the axial plane at transperineal ultrasound was excellent, with an of 94.5 % (95 % CI 92.0--97.0), a sensitivity of 95.6 % (95 % CI 96.8-100.0), a specificity of 91.2 % (95 % CI 87.3-95.1), a F1-score of 0.92 and a Cohen's kappa of 0.90. The best performance was achieved by the CNN1 - OA position vs fetal head malpositions - with an accuracy of 98.3 % (95 % CI 96.9-99.7), followed by CNN2 - OP vs OT positions - with an accuracy of 93.9 % (95 % CI 89.6-98.2), and finally, CNN3 - right vs left OT position - with an accuracy of 91.3 % (95 % CI 83.5-99.1). CONCLUSIONS: We have developed a DL-model capable of assessing fetal head position using transperineal ultrasound during the second stage of labor with an excellent overall accuracy. Future studies should validate our DL model using larger datasets and real-time patients before introducing it into routine clinical practice.

Three-Dimensional Transperineal Ultrasound Assessment of the Anal Sphincter Immediately After Vaginal Birth: An Exploratory Study.

OBJECTIVES: To assess the feasibility of acquiring adequate transperineal ultrasound (TPUS) volumes of the anal sphincter (AS) immediately after vaginal birth, the reproducibility of its measurements, and detecting defects therein. METHODS: Secondary analysis of TPUS volumes of the AS, acquired immediately after vaginal birth with a transversely oriented convex probe. Two independent experts ranked off-line image quality as "inadequate," "adequate," or "ideal" using the Point-of-Care Ultrasound Image Quality scale. On "adequate" and "ideal" quality volumes, the length of the external AS at 6 and 12 o'clock, and the volume of the external and internal AS were measured. Additionally, volumes were screened for AS defects on tomographic ultrasound imaging. Subsequently, we rated the intra- and interrater agreement on those findings. RESULTS: Of 183 volumes, 162 were considered "adequate" or of "ideal" quality (88.5%). Reasons for "inadequacy" were shadow artifacts (16/21), poor resolution (3/21), incomplete acquisition (1/21), or aberrant AS morphology (1/21). The intrarater reliability of two-dimensional (2D) and three-dimensional (3D) measurements was excellent, whereas interrater reliability was fair to good for 2D measurements and good for 3D measurements. In those tomographic ultrasound imaging (TUI) sequences including AS defects, the intra- and interrater reliability of the defect measurement were excellent [intraclass correlation coefficient (ICC) = 0.92 (0.80-0.94)] and moderate [ICC = 0.72 (0.63-0.79)]. In this cohort, there were only few (4/48; 8.3%) AS defects. However, grading them was poorly reproducible between experts. CONCLUSION: TPUS of the AS immediately after vaginal birth yields adequate image quality and allows for reproducible measurements. In the few patients with AS defects, there was good agreement on the presence, but it was poor for the extent of defects.

Implementation of sonopartogram: multicenter feasibility study.

OBJECTIVES: Well-established clinical practice for assessing progress in labor involves routine abdominal palpation and vaginal examination (VE). However, VE is subjective, poorly reproducible and painful for most women. In this study, our aim was to evaluate the feasibility of systematically integrating transabdominal and transperineal ultrasound assessment of fetal position, parasagittal angle of progression (psAOP), head-perineum distance (HPD) and sonographic cervical dilatation (SCD) to monitor the progress of labor in women undergoing induction of labor (IOL). We also aimed to determine if ultrasound can reduce women's pain during such examinations. METHODS: Women were recruited as they presented for IOL in three maternity units. Ultrasound assessments were performed in 100 women between 37 + 0 and 41 + 6 weeks' gestation. A baseline combined transabdominal and transperineal scan was performed, including assessment of fetal biometry, umbilical artery and fetal middle cerebral artery Doppler, amniotic fluid index, fetal spine and occiput positions, psAOP, HPD, SCD and cervical length. Intrapartum scans were performed instead of VE, unless there was a clinical indication to perform a VE, according to protocol. Participants were asked to indicate their level of pain by verbally giving a pain score between 0 and 10 (with 0 representing no pain) during assessment. Repeated measures data were analyzed using mixed-effect models to identify significant factors that affected the relationship between psAOP, HPD, SCD and mode of delivery. RESULTS: A total of 100 women were included in the study. Of these, 20% delivered by Cesarean section, 65% vaginally and 15% by instrumental delivery. There were no adverse fetal or maternal outcomes. A total of 223 intrapartum ultrasound scans were performed in 87 participants (13 women delivered before intrapartum ultrasound was performed), with a median of two scans per participant (interquartile range (IQR), 1-3). Of these, 76 women underwent a total of 151 VEs with a median of one VE per participant (IQR, 0-2), with no significant difference between vaginal- or Cesarean-delivery groups. After excluding those with epidural anesthesia during examination, the median pain score for intrapartum scans was 0 (IQR, 0-1) and for VE it was 3 (IQR, 0-6). Cesarean delivery was significantly associated with a slower rate of change in psAOP, HPD and SCD. CONCLUSIONS: Comprehensive transabdominal and transperineal ultrasound assessment can be used to assess progress in labor and can reduce the level of pain experienced during examination. Ultrasound assessment may be able to replace some transabdominal and vaginal examinations during labor. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Feasibility and reproducibility of new technique for measurement of transverse diameter of levator ani muscle hiatus using two-dimensional transperineal ultrasound in nulliparous women with term pregnancy.

OBJECTIVES: The aim of the present study was two-fold. Firstly, we aimed to develop and describe a technique for measurement of the transverse diameter (TD) of the levator ani muscle (LAM) hiatus in the coronal view using two-dimensional (2D) transperineal ultrasound (TPUS) in nulliparous women with a term pregnancy. Secondly, we aimed to evaluate the feasibility and reproducibility of 2D-TPUS assessment of LAM hiatal TD and assess intermethod agreement between 2D-TPUS and three-dimensional (3D) TPUS measurement of TD in the axial plane, which is considered the gold standard in nulliparous women with term pregnancy. METHODS: We recruited a group of nulliparous women with term pregnancy before the onset of labor. The study was conducted in two phases: Phase 1 involved developing and describing the 2D-TPUS technique for measuring LAM hiatal TD, and Phase 2 focused on assessing the technique's feasibility, reproducibility and intermethod agreement with 3D-TPUS measurement of LAM hiatal TD. In Phase 1, we enrolled 30 women. Each woman underwent acquisition of a 3D-TPUS volume, which was analyzed using multiplanar mode to identify and determine the appearance of the lateral borders of the LAM in the coronal plane, at the level of the plane of minimal hiatal dimensions. These borders were used as landmarks for TD measurement. Additionally, we measured the distance between the plane used for TD measurement and the center of the urethra in the axial view. In Phase 2, we recruited 100 women. Each woman underwent acquisition of three 2D-TPUS videoclips in the coronal plane, each encompassing a sweep of the entire LAM hiatus, and a 3D volume, all obtained during rest. On the 2D videoclips, TD was measured twice by one operator and once by another operator. In the 3D volume, TD was measured once, by one operator, in the axial plane; this measurement was considered the gold standard. Each operator was blinded to all other measurements during their assessments. We analyzed intraobserver and interobserver reproducibility and performed an intermethod (2D vs 3D) comparison. Bland-Altman analysis was conducted, and Levene's W0 test and Student's t-test were performed to explore clinical factors that might contribute to systematic differences. RESULTS: In Phase 1, we identified successfully the landmarks denoting the lateral borders of the LAM hiatal TD in the coronal view. These appeared as two symmetrical hypoechogenic indentations located at the inner border of the hyperechogenic structure of the LAM, at the point of maximum distance between the two sides of the LAM. The distance between the urethra and the plane where TD should be measured using 3D-TPUS in the axial plane had a median of 4 mm and varied from 0 to 9 mm. This enabled us to describe a method for assessing LAM hiatal TD in the coronal plane using 2D-TPUS. In Phase 2, LAM hiatal TD was measured successfully in all 2D and 3D acquisitions from the entire group of 100 women. The analyses for intraobserver and interobserver reproducibility and the intermethod comparison (2D vs 3D) revealed almost perfect agreement in TD measurements using 2D-TPUS, with intraclass correlation coefficients of 0.95 (95% CI, 0.92-0.96), 0.87 (95% CI, 0.78-0.92) and 0.85 (95% CI, 0.78-0.90), respectively. The average differences between measurements were 0.1 mm for intraobserver, 1.0 mm for interobserver and 0.2 mm for intermethod repeatability. No systematic differences were observed in any of the measurement sets, except in the interobserver analysis, although this difference was clinically not significant (38.2 vs 37.2 mm, P = 0.01). None of the examined clinical factors (maternal body mass index and maternal age) exhibited a statistically significant impact on intraobserver, interobserver or intermethod reliability. CONCLUSIONS: Utilizing our technique, described herein, to measure the LAM hiatal TD in the coronal view using 2D-TPUS is not only feasible but also highly reproducible and accurate in nulliparous women with term pregnancy. Moreover, it yields measurements that are comparable to those obtained in the reconstructed axial plane generated by 3D-TPUS. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Correlation between clinical examination and perineal ultrasound in women treated for pelvic organ prolapse.

INTRODUCTION: Lifetime risk of surgery for female pelvic organ prolapse (FPOP) is estimated at 10 to 20%. Prolapse assessment is mostly done by clinical examination. Perineal ultrasound is easily available and performed to evaluate and stage FPOP. This study's aim is to evaluate the agreement between clinical examination by POP-Q and perineal sonography in women presenting pelvic organ prolapse. MATERIALS AND METHODS: We carried out a prospective study from December 2015 to March 2018 in the gynecologic department of a teaching hospital. Consecutive woman requiring a surgery for pelvic organ prolapse were included. All women underwent clinical examination by POP-Q, perineal ultrasound with measurements of each compartment descent, levator hiatus area and posterior perineal angle. They also answered several functional questionnaires (PFDI 20, PFIQ7, EQ-5D and PISQ12) before and after surgery. Data for clinical and sonographic assessments were compared with Spearman's test and correlation with functional questionnaires was tested. RESULTS: 82 women were included. We found no significant agreement between POP-Q and sonographic measures of bladder prolapse, surface of the perineal hiatus or perineal posterior angle. There was a significant improvement of most of the functional scores after surgery. DISCUSSION: Our study does not suggest correlation between clinical POP-Q and sonographic assessment of bladder prolapse, hiatus surface or perineal posterior angle. Ultrasound datasets were limited by an important number of missing data resulting in a lack of power.

The role of transperineal ultrasonography for perinatal management: A review.

BACKGROUND: Transperineal ultrasound (TPUS) has become an increasingly popular tool in obstetrics due to its objective, non-invasive, and real-time imaging capabilities. AIM: This review aims to describe the basic approaches, current utilization, and potential future applications of TPUS. MATERIALS & METHOD: A comprehensive literature review on TPUS was conducted. In addition, discussions at academic meetings and congress focused on TPUS were also considered. RESULTS: TPUS was initially used in prostate biopsies and is currently applied to evaluating fetal head descent in labor, with the angle of progression being the most widely used parameter. It is more tolerated than conventional invasive or expensive methods, such as digital vaginal examinations or MRIs. Additionally, TPUS can assess the internal rotation of the fetal head in the birth canal. DISCUSSION: Compared to other imaging modalities like MRI and CT scans, TPUS is easier to perform and more cost-effective. It also provides real-time imaging, allowing for quick and accurate assessments. It also help clinicians make critical decisions regarding the mode of delivery and identify patients at high risk for fecal incontinence postpartum. With its many benefits, TPUS has the potential to become a standard tool in urogynecology and obstetrics. CONCLUSIONS: Transperineal ultrasound is a non-invasive imaging modality that is well-tolerated and easy to understand for patients and their family and help medical staff support the patients. Transperineal ultrasound can be applied in real-time monitoring of labor progress, helping predict the possibility of vaginal delivery during labor, and further research in this area is warranted.

Perineal ultrasound to assess the urethral spatial movement in stress urinary incontinence in women.

BACKGROUND: Perineal ultrasound as a non-invasive method for the diagnosis of female stress urinary incontinence has attracted more and more attention. However, the criteria for stress urinary incontinence in women using perineal ultrasound have not been fully established. Our study aimed to evaluate characteristics of the urethral spatial movement with perineal ultrasonography. METHODS: A total of 136 female patients with stress urinary incontinence and 44 controls were enrolled. Stress urinary incontinence was diagnosed using the International Consultation on Incontinence Questionnaire Short Form, medical history and physical examination, and severity was assessed using a 1 h pad test. We described the mobility of four equidistant points (A-D) located along the urethra length. The retrovesical and urethral rotation angles were measured using perineal ultrasonography at rest and during the maximal Valsalva maneuver. RESULTS: Patients with stress urinary incontinence showed a more significant vertical movement at Points A, B and C than controls. The mean variations in the retrovesical angle were significantly larger in patients with stress urinary incontinence at rest and during the Valsalva maneuver than in controls (21.0 ± 16.5° vs. 14.7 ± 20.1°, respectively). The cut-off value for the retrovesical angle variation was 10.7° with 72% sensitivity and 54% specificity. There was a receiver-operating characteristic curve area of 0.73 and 0.72 for Points A and B, respectively. A cut-off of 10.8 mm, and 9.4 mm provided 71% sensitivity and 68% specificity and 67% sensitivity and 75% specificity, respectively. CONCLUSIONS: The spatial movement of the bladder neck and proximal urethra, and variations in the retrovesical angle may be correlated with clinical symptoms and facilitate to the assessment of SUI.

Predictive value of head-perineum distance measured at the initiation of the active second stage of labor on the mode of delivery: A prospective cohort study.

OBJECTIVE: The objective was to assess the predictive value of head-perineum distance measured at the initiation of the active second stage of labor on the mode of delivery. MATERIAL AND METHODS: It was a prospective cohort study in an academic Hospital of Rennes, France, from July 1, 2020 to April 4, 2021 including 286 full-term parturients who gave birth to a newborn in cephalic presentation. A double-blind ultrasound measurement of the head-perineum distance was performed during the second phase of labor within five minutes after the onset of pushing efforts. The primary outcome was the mode of delivery (spontaneous vaginal delivery versus instrumental vaginal delivery or cesarean section). We performed a multivariate analysis to determine the predictive value of the head-perineum distance by adjusting on potential confounders. RESULTS: Overall, 199 patients delivered by spontaneous vaginal delivery, 80 by instrumental vaginal delivery, and seven by cesarean section. The head-perineum distance measured at the beginning of pushing efforts was predictive of the mode of delivery with a threshold at 44 mm (crude: sensitivity = 56.8 % and specificity = 79.3 %; adjusted: sensitivity = 79.4 % and specificity = 87.4 %). The risk of medical intervention was higher when the head-perineum distance is>44 mm with an adjusted OR of 2.78 [1.38; 5.76]. CONCLUSION: The head-perineum distance measured at the initiation of the active second stage of labor is predictive of the mode of delivery. Head-perineum distance below 44 mm predicts a vaginal delivery with the best diagnostic performance, and optimizes the time to start pushing efforts.

Obstetric anal sphincter injuries (OASIS): using transperineal ultrasound (TPUS) for detecting, visualizing and monitoring the healing process.

PURPOSE: The aim of this study was to examine whether OASIS, and its extent, can be confirmed or excluded using transperineal ultrasound (TPUS). A further objective of this study was to monitor the healing process over a period of 6 months and to establish a connection between the sonographic appearance of obstetric anal sphincter injury (OASIS) and anal incontinence. MATERIALS AND METHODS: In this retrospective clinical study, women with OASIS who gave birth between March 2014 and August 2019 were enrolled. All the patients underwent TPUS 3 days and 6 months after delivery. A GE E8 Voluson ultrasound system with a 3.5-5 MHz ultrasound probe was used. The ultrasound images showed a third-degree injury, with the measurement of the width of the tear and its extent (superficial, partial, complete, EAS and IAS involvement). A positive contraction effect, a sign of sufficient contraction, was documented. Six months after delivery, a sonographic assessment of the healing (healed, scar or still fully present) was performed. A Wexner score was obtained from each patient. The patients' medical histories, including age, parity, episiotomy and child's weight, were added. RESULTS: Thirty-one of the 55 recruited patients were included in the statistical evaluation. Three patients were excluded from the statistical evaluation because OASIS was excluded on TPUS 3 days after delivery. One patient underwent revision surgery for anal incontinence and an inadequately repaired anal sphincter injury, as shown sonographic assessment, 9 days after delivery. Twenty patients were excluded for other reasons. The results suggest that a tear that appears smaller (in mm) after 3 days implies better healing after 6 months. This effect was statistically significant, with a significance level of alpha = 5% (p = 0.0328). Regarding anal incontinence, women who received an episiotomy had fewer anal incontinence symptoms after 6 months. The effect of episiotomy was statistically significant, with a significance level of alpha = 5% (p = 0.0367). CONCLUSION: TPUS is an accessible, non-invasive method for detecting, quantifying, following-up and monitoring OASIS in patients with third-degree perineal tears. The width, as obtained by sonography, is important with regard to the healing of OASIS. A mediolateral episiotomy seems to prevent anal incontinence after 6 months.

Comparison of diagnostic criteria for significant anal sphincter defects between endoanal and transperineal ultrasound.

OBJECTIVE: To evaluate the agreement between three-dimensional endoanal ultrasound (EAUS) and four-dimensional transperineal ultrasound (TPUS) in measuring anal sphincter defect angle. METHODS: This was a secondary analysis of the PERINEAL study, which evaluated the effect of perineal wound infection on anal sphincter integrity. Women were reviewed once a week, until their perineal wound had healed or for up to a maximum of 16 weeks. At each visit, both EAUS and TPUS (the latter at rest and on maximum pelvic floor muscle contraction (PFMC)) were performed to evaluate the presence of external (EAS) and internal (IAS) anal sphincter defect and measure the defect size. The largest angle size of a defect at the same sphincter level was analyzed. A defect was deemed significant if it was > 30°. Kappa coefficient (κ), intraclass correlation coefficient and standard error of measurement (SEM) were calculated, using EAUS as the reference standard. RESULTS: In 73 women scanned at weekly intervals, a total of 250 EAUS and 250 TPUS scans were performed. An EAS defect was found in 55 (22.0%) EAUS images and 47 (18.8%) TPUS images. An IAS defect was found in 26 (10.4%) images on both modalities. There was excellent agreement (κ = 0.87) between TPUS and EAUS in diagnosing the presence of an EAS defect and perfect agreement (κ = 1.00) in diagnosing the presence of an IAS defect. TPUS performed at rest had poor and moderate agreement with EAUS in measuring EAS and IAS defect size, respectively, with respective SEMs of ± 16.1° and ± 27.9°. TPUS performed during maximum PFMC had poor and moderate agreement with EAUS in measuring EAS and IAS defect size, respectively, with respective SEMs of ± 16.5° and ± 26.4°. Based on the SEMs, if the diagnostic cut-off of 30° for defect size on TPUS was used, an incorrect diagnosis of significant EAS defect could occur in approximately 9-36% of women and an incorrect diagnosis of a significant IAS defect could occur in approximately 4-15% of women, using EAUS as the reference. CONCLUSIONS: This is the first study to compare directly anal sphincter defect angle measurements obtained on EAUS and TPUS. A cut-off angle of 30° should not be used for the diagnosis of a significant residual anal sphincter defect during TPUS examination. Further research is required to determine the optimal defect cut-off angle for TPUS. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Under-classified obstetric anal sphincter injuries.

INTRODUCTION AND HYPOSTHESIS: Obstetric anal sphincter injuries (OASIs) that are missed at delivery can have long-term consequences. OASIs that are under-classified at delivery are likely to be inadequately repaired, resulting in a persistent anal sphincter defect. We aimed to identify women who have persistent defects on endoanal ultrasound, inconsistent with the original diagnosis, and compare the effect on St Mark's incontinence scores (SMIS). We also aimed to look for changes in numbers of under-classification over time. METHODS: Records of women attending a perineal clinic who had endoanal ultrasound from 2012 to 2020 were reviewed. Women who had a modified Starck score implying a defect greater than the classification [indicated by the depth of external anal sphincter or internal anal sphincter (IAS) defect] at delivery were identified. RESULTS: A total of 1056 women with a diagnosis of 3a or 3b tears were included. Of these, 120 (11.36%) were found to have a defect greater than the original diagnosis and therefore were incorrectly classified at delivery. Women who had a 3b tear diagnosed at delivery, but had an IAS defect, had a significantly higher SMIS (p < 0.01). When comparing two 4-year periods, there was a significant improvement in the diagnosis of IAS tears. CONCLUSION: Some women with OASIs that have under-classified OASIs are associated with worse anorectal symptoms. This is likely because of an incomplete repair. Some improvement in diagnosis of IAS tears has been noted. We propose improved training in OASIs can help reduce the number of incorrectly classified tears and improve repair.

Automatic measurement of head-perineum distance during intrapartum ultrasound: description of the technique and preliminary results.

OBJECTIVES: To evaluate the accuracy and reliability of a new ultrasound technique for the automatic assessment of the head-perineum distance (HPD) during childbirth. METHODS: HPD was measured on a total of 40 acquisition sessions in 30 laboring women both automatically by an innovative algorithm and manually by trained sonographers, assumed as gold standard. RESULTS: A significant correlation was found between manual and automatic measurements (Intra-CC = 0.994). High values of the coefficient of determination (r2=0.98) and low residual errors: RMSE = 2.01 mm (4.9%) were found. CONCLUSION: The automatic algorithm for the assessment of the HPD represents a reliable technique.

Sonographic measurement of cervical length and head perineum distance before labor to predict time of delivery.

OBJECTIVES: This was an observational study on cervical length and head perineum distance and the prediction of time of delivery. One-hundred and twenty-five nulliparous women with uncomplicated, term, singleton pregnancy were recruited when they presented to the labor ward with show or infrequent painful uterine contractions (less than three contractions in ten minutes on a 30 min cardiotocogram). Apart from digital vaginal examination to assess cervical length and dilatation, sonographic cervical length and head perineum distance were measured by two-dimensional ultrasound. We compared women who delivered within 72 h of presentation of labor symptoms, with women who did not. After excluding ten women whose labor was induced and delivered within 72 h of presentation, one hundred and fifteen women were included for final data analysis. MAIN FINDINGS: Forty-nine women (42.6%) delivered while sixty-six women (57.4%) remained undelivered at 72 h of presentation of symptoms of labor. There was no statistically significant difference between the two groups on age, presence of show, contractions, fetal head station and presentation and mode of delivery. For the group who had delivered within 72 h of presentation of labor symptoms, the mean sonographic cervical length was 1.87 cm ± 0.62 cm, while the head perineum distance was 6.01 cm ± 1.15 cm. For the other group, the mean sonographic cervical length was 2.10 cm ± 0.83 cm; head perineum distance was 6.03 cm ± 1.18 cm. There was no statistically significant difference between the groups for both sonographic cervical length (p = .90); and head perineum distance (p = .08). We also compared the cervical length measured by digital vaginal examination versus sonography. The median sonographic measurements were 1.47 cm, 2.11 cm and 2.79 cm at "1 cm," "2 cm" and "3 cm" digital vaginal measurement, respectively. However, there was extensive overlap between digitally and sonographically measured cervical length. Prediction accuracy of cervical length and head perineum distance was poor. The area under curve (AUC) of receiver operating characteristic (ROC) curve were 0.433 for sonographic cervical length and 0.501 for HPD. CONCLUSION: Transperineal sonographical assessment of cervical length and head perineum distance before labor was not useful in predicting the time of delivery. However, it can be explored as an alternative assessment method when digital vaginal examination is not preferred.

Immediate postpartum assessment of the anal sphincter by endovaginal ultrasound: a new technical approach.

INTRODUCTION AND HYPOTHESIS: In this study we described a new technical approach to adapt endovaginal ultrasound scanning of the anal sphincter complex to the immediate postpartum period. METHODS: We analyzed the clinical and ultrasonographic examinations of 18 primiparous women presenting deep perineal tears with potential or clearly identified lesions of the anal sphincter. Potential anal sphincter lesion was defined as a second degree perineal tear extending close to the anal sphincter with exposition of its capsule or muscular fibers. We reported interesting ultrasonographic images explaining our technique in a video. RESULTS: We reported clinical and ultrasonographic features in nine cases of grade 2, four cases of grade 3a, four cases of grade 3b and one case of grade 3c perineal tears. The ultrasonographic examination confirmed the intact state of the anal sphincter complex in all patients with clinical grade 2 tears except one in which a grade 3b lesion was detected. We were not able to identify external anal sphincter lesions on ultrasound in any of the patients with clinical grade 3a tears. In patients with clinical grade 3b tears, the ultrasound confirmed the external anal sphincter lesion in all cases, but revealed additional involvement of the internal anal sphincter in 1 case (grade 3c). CONCLUSION: Immediate postpartum endovaginal ultrasound could be a promising technique to improve the management of perineal traumas after vaginal delivery.

Pelvic floor ultrasound finds after episiotomy and severe perineal tear: systematic review and meta-analysis.

AIM: Vaginal delivery is a well-known risk factor for pelvic floor muscle (PFM) injuries, mainly when associated to prolonged labor, instrumental birth and perineal trauma such as episiotomy and perineal tears. The purpose of this meta-analysis was to test the hypothesis that episiotomy and severe perineal tear may increase the risk of pelvic floor damage. METHODS: We performed a systematic literature search through electronic databases including MEDLINE via PubMed, LILACS via BVS, Embase via Elsevier and Cochrane Library up to January 2019. We included articles that reported as outcome one or more morphological aspects of the PFM evaluated by ultrasonography in primiparous women three to 24 months postpartum. This review is registered in the PROSPERO database (registration number: CRD42017075750). RESULTS: the final selection was composed of 18 articles for the systematic review, and 10 for the meta-analysis. Women with levator ani muscle (LAM) avulsion were 1.77 times more likely to have undergone episiotomy (OR = 1.77, CI 95% 1.25-2.51, five trials), 4.31 times more likely to have severe perineal tear (OR = 4.31, CI 95% 2.34-7.91, two trials). Women with defects in the anal sphincters were 2.82 times more likely to have suffered severe perineal tear (OR = 2.82, 95% CI 1.71-4.67, three trials). CONCLUSIONS: Both episiotomy and severe perineal tear are risk factors for LAM avulsion and anal sphincter injury, and this can be useful for identifying women who are at greater risk of developing PFM dysfunctions.