Does vaginal delivery cause more damage to the pelvic floor than cesarean section as determined by 3D ultrasound evaluation? A systematic review.

INTRODUCTION AND HYPOTHESIS: Pregnancy and delivery are well-established risk factors for pelvic floor dysfunction (PFD), but the physiopathology, such as the delivery route, is not well understood. This study evaluated the impact of delivery route on the pelvic floor muscles via 3D ultrasound. METHODS: This review is registered in the PROSPERO database. The criteria for inclusion were prospective studies with 3D translabial ultrasound assessment in primigravida women during pregnancy and postpartum published in English, Spanish or Portuguese between 1980 and 2016. We excluded studies that did not include the topic of urogenital hiatus measurement and literature reviews. The MeSH terms were obstetric delivery, postpartum period, labor, parturition, three-dimensional images, ultrasonography, pelvic floor, and pelvic floor disorders. RESULTS: The search retrieved 155 articles. After analysis, 6 articles were included. Four studies showed that vaginal delivery (VD) was associated with a larger hiatal area. One study associated the hiatal area with levator ani muscle (LAM) defects in VD. Four articles evaluated the bladder neck, 3 of which showed a significant increase in bladder neck mobility associated with VD and 1 showed decreased bladder neck elevation, not associated with the delivery mode; the first 3 articles all evaluated LAM injuries and showed an association between VD and LAM injury. Women who underwent VD presented defects of the puborectalis muscle. CONCLUSIONS: Vaginal delivery was associated with a higher number of LAM injuries, puborectalis defects, increased bladder neck mobility, and enlargement of the hiatal area.

A case series on the use of levonorgestrel 52 mg intrauterine system after organ transplant.

OBJECTIVE: To assess the clinical performance (pregnancy and occurrence of pelvic infection) of the levonorgestrel 52-mg intrauterine system (LNG IUS) in solid organ transplant recipients. STUDY DESIGN: We performed a retrospective chart review of all patients seen in the Family Planning Clinic at the University of Campinas Department of Obstetrics and Gynecology from 2007 to 2017 to identify women with solid organ transplantation using immunosuppression who received an LNG IUS. Our routine clinical practice for such patients is to perform initial follow-up 40-60 days after placement and then every 12 months. We analyzed women's sociodemographic characteristics, duration of use of the LNG IUS, continuation and discontinuation reasons, and complications. RESULTS: Of the 23 women evaluated, 21 had kidney transplantation and 2 had liver transplantation. One woman received an LNG IUS prior to solid organ implantation (1.7 years, renal transplant). The 22 other women received the LNG IUS a median of 6.3 years (interquartile [IQ25-75] range 1.7-15 years). Seventeen (74%) women primarily used the LNG IUS for contraception; the other 6 desired the LNG IUS for contraception and heavy menstrual bleeding (HMB) treatment. We observed no cases of pregnancy or pelvic infection. Over the median follow-up time of 49.3 months (IQ25-75 15-80 months), 7 women used the same IUS for more than 60 months and 8 women received a second IUS. CONCLUSIONS: Due to the fact that no pregnancies or pelvic infections were observed in this case series, we concluded that the LNG IUS is an option for transplanted women for contraception and for HMB treatment. IMPLICATIONS: Women at reproductive age after solid organ transplantation needs contraception for long time and the LNG IUS is a safe and effective option.