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.

The consequences of undiagnosed obstetric anal sphincter injuries (OASIS) following vaginal delivery.

INTRODUCTION AND HYPOTHESIS: We aimed to compare anal and urinary incontinence symptoms and anal manometry between women with undiagnosed obstetric anal sphincter injuries (OASIS) and women who had OASIS diagnosed and repaired. METHODS: This was a matched retrospective cohort study. Each missed OASI was matched with a diagnosed OASI for severity [minor (3a/b) or major (3c)], parity and length of follow-up. Women completed the modified St Mark's Incontinence Score and International Consultation on Incontinence Questionnaire. Women with OASIS or those without OASIS but with anal incontinence symptoms were seen in perineal clinic for perineal examinations, anorectal manometry and three-dimensional endoanal ultrasound 8-12 weeks postnatally or in a subsequent pregnancy. RESULTS: Forty missed OASIS were matched with 40 recognised OASIS (16 3a/b; 24 3c). The median modified St Mark's scores were higher for missed tears [11 (4, 15) vs. 1 (0, 4), p < 0.001] as well as the urinary incontinence scores [4 (0, 6) vs. 0 (0, 2), p = 0.01] than for the control group. Missed OASIS patients had a shorter perineal body [1.6 ± 1.3 vs. 2.4 ± 0.8, p = 0.009]. All missed OASIS had larger defects on endoanal ultrasound. One in four missed OASIS required further surgery [aOR 4.1 (95% CI 1.0-16.3), p = 0.04] and almost all needed colorectal input [aOR 24.1 (95% CI 7.3-80.0), p < 0.0001]. There were no differences in anal manometry. CONCLUSIONS: Women with symptomatic missed OASIS are compromised in terms of anal and urinary incontinence symptoms, sphincter defect size and perineal body size requiring additional colorectal input. This highlights the importance of preventing OASIS and perseverance with training to diagnose OASIS.

Post partumpneumomediastinum (Hamman syndrome): A case report.

Excessive pushing and valsalva during labour is associated with subcutaneous emphysema and pneumomediastinum during labour and post partum. Although rare but is a potentially serious complication that must be identified and managed appropriately to avoid its rare consequence called malignant pneumomediastinum, requiring surgical intervention. A 30 year old, primigravida, presented to a tertiary care hospital with complaints of shortness of breath of 4 days duration after a normal vaginal delivery. CT chest showed bilateral consolidation and pneumomediastinum. She was managed conservatively with supportive measures and was clinically stable before being discharged on request to a nearby health facility. On follow up complete resolution of pneumomediastinum was reported. Recognition of post partum pneumomediastinum, its presentation and associated complications need to be acknowledged in a teriary care hospital, with proper management. Although the condition is rare, but in subsequent pregnancies physicians need to be cautious, and instrumental delivery or caesarean section may be considered to avoid excessive valsalva. No definite evidence of recurrence has been proven.

Prevalence of Maternal Birth Trauma in Nepali Women.

OBJECTIVES: Pelvic organ prolapse is very common among women in Nepal, especially uterine prolapse. This would suggest a high rate of levator trauma, which is a strong predictor of such prolapse in the Western world. Hence, we decided to study the prevalence of maternal birth trauma in Nepali women. METHODS: In November 2016, we offered an interview, clinical examination, and 4-dimensional translabial sonography to women attending a gynecology clinic. Of 129 women seen, 5 were excluded due to previous pelvic surgery. Translabial sonography volume data sets were obtained and analyzed by tomographic imaging for levator ani and anal sphincter trauma at a later date, blinded against all clinical data. RESULTS: Mean age was 39 (21-74) years, median vaginal parity was 2 (0-9), mean age at first delivery 21 (14-40). Seventeen (14%) had not given birth vaginally; of these, 14 (11%) delivered by cesarean only, and 3 (2%) were nulliparous. Tomographic assessment for levator avulsion and anal sphincter trauma was possible in 124 women and performed as previously described. We found 2 (2%) unilateral avulsions and significant external anal sphincter defects in another 2 women. CONCLUSIONS: Levator and anal sphincter trauma are significantly less prevalent in Nepali women in comparison to Western populations. This is intriguing, especially in view of the high prevalence of prolapse in Nepali women.

Using an Elastic Band Device After a Severe Obstetric Pubic Symphyseal Separation: Clinical and Imaging Evaluation.

BACKGROUND: Severe separation of the pubic symphysis is a rare delivery complication. Facing this pathology, we decided to study a new elastic band device. METHOD: To evaluate the elastic band device, clinical (pain-rated) and imaging (magnetic resonance imaging and radiography) evaluations with and without the device were performed. The elastic band device is a European Conformity-certified medical device, which is made of neoprene straps, that reduces the mobility of the pelvis and the use of the internal rotator muscles. EXPERIENCE: Once the elastic band device was in place, on postpartum day 1, radiography showed a decrease of the pubic width from 41 to 12 mm. Furthermore, pain decreased from 10 of 10 to 2 of 10 in 2 days, allowing the patient to ambulate and avoid surgery. After 1 month, the pubic width (6 mm) and anatomy were recovered but minor pain was still present with hip rotatory movements. The elastic band device was worn 24 hours a day from postpartum days 1-90 and 12 hours a day from postpartum days 90 to 150; afterward, the patient returned to normal life without the elastic band device. CONCLUSION: Use of an elastic band device was associated with a reduction of the pubic width and pain associated after obstetric pubic symphysis separation.

Can Anal Sphincter Defects Be Identified by Palpation?

OBJECTIVES: The aim of this study was to correlate clinical findings of anal sphincter defects and function with a sonographic diagnosis of significant sphincter defects. METHODS: This is an observational cross-sectional study on women seen 6 to 10 weeks after primary repair of obstetric anal sphincter injuries (OASIs). All patients underwent a standardized interview including the St Mark incontinence score, a digital rectal examination, and 3-/4-dimensional transperineal ultrasound imaging. RESULTS: Two hundred forty-five patients were seen after primary repair of OASIs. Mean age was 29 (17-43) years. They were assessed at a median of 58 (15-278) days postpartum. One hundred fifty-seven (64%) delivered normal vaginally, 72 (29%) delivered by vacuum, and 16 (7%) delivered by forceps. A comparison of external anal sphincter (EAS) and internal anal sphincter ultrasound volume data and palpation was possible in 220 and 212 cases, respectively. Sphincter defects at rest and on contraction were both detected clinically in 17 patients. Significant abnormalities of the EAS were diagnosed on tomographic ultrasound imaging in 99 cases (45%), and significant abnormalities of the internal anal sphincter were diagnosed in 113 cases (53%). Agreement between digital and sonographic findings of sphincter defect was poor (k = 0.03-0.08). Women with significant EAS defects on ultrasound were found to have a lower resistance to digital insertion (P = 0.018) and maximum anal squeeze (P = 0.009) on a 6-point scale. The difference was however small. CONCLUSIONS: Digital rectal examination does not seem to be sufficiently sensitive to diagnose residual sphincter defects after primary repair of OASIs. Imaging is required for the evaluation of sphincter anatomy after repair.

[A multilevel obstruction of the digestive tract in a young female patient soon after delivery: a case report].

The article reports the case of a 31-year-old patient, in whom bowel ileus developed 2 days after natural delivery, and who in the second trimester underwent laparotomy due to mechanical obstruction involving the duodenum and small bowel and caused by swallowed foreign bodies. The course of pregnancy from the operation to delivery was uneventful. Preoperative diagnostics (barium meal) showed features of mechanical obstruction involving the duodenum and small bowel. The patient underwent surgery, and abdominal exploration revealed a largely distended duodenum filled by thick contents, dilated and involved in massive adhesions in the small bowel and a largely distended proximal colon. No site of critical stenosis of the bowel was found, and no other cause of disturbed intestinal passage was identified. Intraoperatively, no peristalsis was observed in the small bowel, although it was heard at abdominal auscultation before surgery. As adhesion release did not resolve the problem, a decision was made to discharge the small bowel and proximal colon by an incision of the caecum, followed by the formation of a cecostomy. Postoperative course was complicated by short episodes of upper digestive tract bleeding and diarrhoea, which disappeared soon after conservative therapy. The patient eventually recovered, and further gastroenterological investigations were inconclusive.

[Postpartum levator ani muscle injuries. Diagnosis and treatment]. / Poporodowe uszkodzenia dzwigacza odbytu. Diagnostyka i terapia.

Levator ani muscle (LAM) injuries are much more frequent than trauma to sphincter ani muscles, but so far they have been omitted in obstetric handbooks. Levator ani avulsion is observed only after vaginal delivery. Forceps delivery second stage of labor ≥ 110 min., fetal head circumference ≥ 35 cm, episiotomy and coincidence of anal sphincter trauma are risk factors for levator ani avulsion. The most vital issue in that type of trauma is pelvic organ prolapse and 2-4-fold higher risk of recurrence after prolapse surgery. The current level of evidence does not allow to conclusively determine the of role of levator avulsion in urinary incontinence. Levator injuries are occult, what constitutes the main diagnostic problem. Until recently magnetic resonance imaging has been the only diagnostic method until the development of 3-dimensional ultrasound. Nowadays, 3-D ultrasound is an essential technique in static and functional diagnosis of the levator ani. There are no effective methods of levator trauma prevention. Except the risk factors reduction, there are some pilot data about positive role of antepartal perineal muscle training. Physiotherapy plays the main role in reducing the effects of levator trauma. Mesh techniques are the most effective operative methods in coincident pelvic organ prolapse with levator avulsion, but there is still a 2-fold higher risk of recurrence.

Pelvic floor trauma: does the second baby matter?

OBJECTIVE: To ascertain the effect of a second delivery on pelvic floor anatomy. METHODS: This was a retrospective analysis of data obtained in two perinatal imaging studies. Women were invited for antenatal and two postnatal appointments. All had answered a standardized questionnaire and undergone a clinical examination and translabial four-dimensional ultrasound. Ultrasound volumes were acquired at rest, on Valsalva maneuver and on pelvic floor muscle contraction, and analyzed by postprocessing on a PC. Avulsion was diagnosed on tomographic ultrasound imaging. This study reports data obtained in those women who delivered a second child between the first and second postnatal assessments. RESULTS: Of 715 participants, 94 reported a second birth at their second postnatal appointment on average 2.7 years after their first birth; 65 had a vaginal delivery and 29 a Cesarean section. There were nine attempts at vaginal birth after Cesarean section (VBAC), of which six were successful. When we analyzed the ultrasound findings before and after a second delivery, there was no significant change observed in bladder-neck descent, cystocele descent and hiatal area on Valsalva. Delivery mode of the second birth seemed to have little effect on changes observed between follow-ups, although there was a trend towards increased bladder-neck descent in women after vaginal delivery. On reviewing patients diagnosed with avulsion at their 2-3-year visit and comparing them with findings at the first follow-up visit, we found identical (normal) findings in 87 cases. In five there was an unchanged avulsion. In one case, findings had improved from complete to partial avulsion. There was one new avulsion, in a patient who had delivered her first baby by emergency Cesarean section and her second by vacuum delivery. CONCLUSIONS: A second pregnancy and delivery do not seem to have a major effect on bladder support and/or levator function. However, we documented a case of major levator trauma after VBAC. The issue of pelvic floor trauma after VBAC may have to be investigated further.

Ultrasound of the gravid uterus.

The ultrasound findings involving the gravid uterus will be described with a focus on differentiating normal from pathologic conditions. Topics pertaining to the gravid uterus include uterine fibroids, müllerian anomalies, cervical shortening, the normal and pathologic appearance of cesarean delivery scars, and uterine rupture. Clinical management and therapeutic implications based on sonographic findings will be emphasized.

Incontinence after primary repair of obstetric anal sphincter tears is related to relative length of reconstructed external sphincter: a case-control study.

OBJECTIVE: To determine if anatomic primary repair with end-to-end reconstruction of the external anal sphincter (EAS) in its full length combined with separate repair of coexisting internal anal sphincter (IAS) tear, when present, results in less incontinence and better anal sphincter integrity compared with conventional primary end-to-end repair in which the IAS is not actively reconstructed. METHODS: Women who sustained third- or fourth-degree obstetric tears were included prospectively in the study following anatomic primary repair. Women treated with conventional primary repair prior to the study period comprised the control group. Three-dimensional endoanal ultrasonography (3D-EAUS) images were classified according to the EAUS defect score, and incontinence according to St Mark's score. RESULTS: Sixty-three women were included in the study group and 61 in the control group, with mean follow-up times of 11 and 21 months, respectively. Among women who had not delivered vaginally prior to the tear, St Mark's score ≥ 3 was reported by 9.6% (5/52) in the study group and 37.5% (15/40) in the control group at follow-up (P = 0.002). The corresponding numbers among women who had previously delivered vaginally were 36.4% (4/11) and 42.9% (9/21), respectively (non-significant). St Mark's score correlated with the EAUS defect score (P = 0.017). An EAS defect exceeding 50% of the sphincter length was significantly less common in the study group, and in a multivariable logistic regression model, mode of repair (anatomic vs conventional) was the only factor explaining the difference in EAS sphincter length between the two groups (P = 0.007). CONCLUSION: Improved continence status after anatomic primary repair was associated with a better longitudinal reconstruction of the EAS, while the integrity of the IAS did not differ between the groups. Women with a history of vaginal delivery prior to the sphincter tear had an inferior outcome regardless of mode of repair.

[Usefulness of ultrasound in the delivery room]. / Impiego degli ultrasuoni in sala parto.

The use of diagnostic ultrasound and the diffusion of the technique improved the obstetric treatment and the usefulness of ultrasound increases in the delivery room for maternal and fetal care and as method of diagnosis of some obstetric complications. The knowledge of intrapartum ultrasound imaging can be considered useful for the obstetric team, since there is evidence that ultrasound can improve the obstetric management. The mean indications are described: fetal biometry and estimated fetal weight, amniotic fluid volume, fetal situation and presentation, placental localization and anatomy, assessment of size and location of uterine leiomyomas, fetal cardiac activity, evaluation of umbilical cord and fetal cardinal movements intrapartum. Besides, the use of ultrasound is reported in obstetric and postpartum complications. Actually ultrasonography, as a non-invasive, safety and low-cost technique, offers a diagnostic method in particular conditions during labour, delivery and postpartum.

Chemical peritonitis caused by an iatrogenic rupture of mature cystic teratoma of the ovary during labor: a report of a case didactic to all the maternity health care workers.

A 37-year-old postpartum woman was presented with abdominal pain supposed to be caused by uterine involution or puerperal endometritis after vaginal delivery. During the pregnancy, she was suspected to have a subserosal myoma by ultrasound examination. The pain was finally revealed to be originated from the chemical peritonitis caused by the rupture of the mature cystic teratoma of the ovary by Kristeller's maneuver performed during vaginal delivery. When a pregnant or puerperal woman complains about abdominal pain, we need to consider the possibility of chemical peritonitis resulting from the rupture of mature cystic teratoma of the ovary.

Does levator ani injury affect cystocele type?

OBJECTIVE: To determine the prevalence of levator ani injury in patients with different types of cystocele, as defined by translabial ultrasound, in order to shed light on potential pathophysiological mechanisms. METHODS: The datasets of 222 women who had undergone a physical examination, urodynamic testing and four-dimensional (4D) pelvic floor ultrasound were evaluated offline for prolapse, levator ani hiatal dimensions and levator ani trauma using tomographic ultrasound imaging (TUI), blinded against all clinical and urodynamic data. Cystoceles reaching below the symphysis pubis on ultrasound examination were classified based on bladder neck position, retrovesical angle (RVA) and urethral rotation as Green II (cystourethrocele) or Green III (cystocele with intact RVA). RESULTS: Of 102 women who had a cystocele reaching below the symphysis pubis, 63 were classified as a Green type II cystocele and 39 as a Green type III cystocele. Women with Green type III cystoceles were older (59.4 vs. 48.7 years, P < 0.001), and had more severe prolapse (71 vs. 43%, P = 0.004) and objective voiding dysfunction (39 vs. 18%, P = 0.018). Women with Green III cystoceles also had larger hiatal dimensions and were more often diagnosed with an avulsion of the levator ani muscle (69 vs. 35%, P = 0.001). CONCLUSION: A cystocele with an intact RVA is more likely to be associated with avulsion injury of the levator ani muscle and thus more likely to be caused by birth-related trauma. This contradicts the commonly held belief that such cystoceles are caused by central rather than by lateral fascial defects.

Temporal endosonographic evaluation of anal sphincter integrity after primary repair for obstetric ruptures: a case for specific training of obstetricians.

OBJECTIVE: To evaluate primary repaired obstetric lesions of the anal sphincter complex on anal endo-ultrasound within a few days and 8 weeks after primary repair and to investigate in this way the influence of suboptimal woundhealing on the final anatomical result. Furthermore to investigate the relation between faecal incontinence and sphincter defects. DESIGN: A prospective cohort study. Setting The obstetric clinic and coloproctology outpatient clinic of the Zaans Medical Centre in Zaandam, the Netherlands. Subjects A cohort of 32 consecutive women with primary surgically repaired 3B, 3C or 4th degree anal sphincter defect after vaginal delivery. MAIN OUTCOME MEASURES: Appearance of the anal sphincter complex on anal endo-ultrasound within a few days week and 8 weeks after primary surgical repair, i.e. first and second ultrasound, respectively. Evaluation of anal continence, using the Vaizey incontinence score, at second ultrasound. RESULTS: No major wound breakdown was seen and four women had superficial, skin related wound problems. Twenty-eight women (87.5%) had a repaired external anal sphincter on the first and the second ultrasound. Of four external anal sphincter defects on first ultrasound one defect was not present on second ultrasound. The internal sphincter showed a defect on first ultrasound in 11 women and this was still present in 10 on second ultrasound. A total of 11 women had a persisting anal sphincter defect (external, internal or in combination). Mean Vaizey scores were significantly higher in women with a persisting sphincter defect (EAS, IAS or in combination) than in women with no sphincter defects, 2.3 and 0.4 respectively (95% CI 0.1-3.6, P = 0.04). CONCLUSION: Anal endo-ultrasound may be used for early evaluation of surgical repair of anal sphincter lesions after vaginal delivery. Persisting defects in the anal sphincters, in this series not because of major wound breakdown, can be explained by inadequate surgical repair.

Tomographic ultrasound imaging of the pelvic floor: which levels matter most?

OBJECTIVES: Tomographic ultrasound imaging has greatly simplified pelvic floor assessment. Abnormalities of the insertion of the levator ani can be documented in a single frame. In this study we aimed to determine which levels of the levator hiatus are associated with alterations in ultrasound parameters of pelvic organ support. METHODS: This was a subanalysis of a study conducted in 296 women seen before and after their first delivery. We analyzed postpartum changes in bladder neck descent and hiatal area as indicators of altered pelvic organ support. Tomographic ultrasound examination was performed on volumes obtained at maximal pelvic floor muscle contraction, at 2.5-mm slice intervals, from 5 mm below to 12.5 mm above the plane of minimal hiatal dimensions. RESULTS: Two hundred and eight recruits (70%) returned for a postnatal appointment. Of these, 130 had delivered vaginally and 26 (20%) were diagnosed with an avulsion injury. An abnormality in slices 3-8 was associated with increased bladder neck descent postpartum (P = 0.038 to P = 0.001) and increased hiatal area on Valsalva maneuver (P = 0.029 to P < 0.001). This was not the case for the two most distal slices. CONCLUSIONS: We found no association between levator ani defects observed on tomographic ultrasound imaging below the plane of minimal hiatal dimensions and indices of increased hiatal distension or bladder neck descent on Valsalva maneuver. This implies that defects observed below this plane are either irrelevant for pelvic organ support or artifactual.

Diaphragmatic rupture during labour, two years after an intra-oesophageal rupture of a bronchogenic cyst treated by an omental wrapping.

We report the case of a 27-year-old pregnant woman, presenting a rare but potentially fatal complication of an omental wrapping, transposed in the thorax by a phrenotomy due to an intra-oesophageal rupture of a bronchogenic cyst. Two years later, on time of delivery of her first pregnancy, she has presented a diaphragmatic rupture with a complete transposition of the volvuled stomach. The diagnosis was done using the Gastrographin transit and the CT-scan, showing the specific 'Collar sign'. An urgent surgical correction was performed including the re-instatement of all abdominal organs in the peritoneum, the omental wrapping section and the diaphragmatic closure. The two-year follow-up was uneventful. We discuss the case, the investigations needed and the possibility to cut the omental wrapping without any complication two years after this oesophageal re-inforcement. In conclusion, we believe that omental transpositions must always be done using the retrosternal route or by transhiatal approach to avoid this serious complication after delivery.

Levator trauma is associated with pelvic organ prolapse.

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.