Longitudinal Study of Pelvic Floor Characteristics Before, During, and After Pregnancy in Nulliparous Women.

OBJECTIVES: To investigate the changes in the pelvic floor before, during, and after pregnancy in the same collective of nulliparous women. METHODS: In a prospective observational pilot study between April 2015 and June 2019 in nulliparous women with planned pregnancy, we used the pelvic organ prolapse quantification (POP-Q) system; a 2-dimensional (2D) sonography to investigate the bladder neck, cervix, and anorectal junction positions; and a 3D/4D sonography to measure the hiatus of the levator ani muscle (LH area) during Valsalva maneuver. Five visits were planned: 1 before, 3 during, and 1 visit after pregnancy. RESULTS: Twenty-four women participated in the study. We achieved a minimum of 2 visit measurements from 10 women who became pregnant. The LH area decreased during the first trimester and then increased until the third trimester. Postpartum, the LH area reached the prepregnancy state. We observed changes in the bladder neck mobility, bladder neck position, cervix, and anorectal junction from the first trimester. Postpartum, the bladder neck mobility was higher, and the position of the bladder neck and anorectal junction was lower than before pregnancy. We observed no remarkable changes in the POP-Q state during pregnancy. CONCLUSION: This was the first study to investigate pelvic floor characteristics in the same collective before, during, and after pregnancy. We observed pelvic floor changes from the prepregnancy state to the first trimester to postpartum. The study results need to be confirmed in a larger study.

The correlation between transperineal ultrasound assessment of the levator ani muscle and postpartum urinary incontinence.

AIMS: The primary aim of the present study was to assess the association between levator ani muscle (LAM) integrity and function on the one hand, and the risk of urinary incontinence (UI) on the other. A secondary objective was to assess the association between fundal pressure in the second stage of labor (Kristeller maneuver) and the risk of postpartum UI. METHODS: In this prospective cohort study, women underwent a clinical and transperineal ultrasound examination at rest, at pelvic floor muscle contraction (PFMC), and at Valsalva maneuver 3-6 months after their first vaginal delivery. LAM avulsion and levator hiatal area (LHA) were evaluated. In addition, women were interviewed about the presence of UI, whether stress (SUI) or urgency (UUI). RESULTS: Overall, data of 244 women were analyzed. SUI was reported in 50 (20.5%), while UUI was reported in 19 (7.8%) women. Women who reported SUI had a higher prevalence of LAM avulsion and less proportional reduction in LHA from rest to a maximum contraction in comparison to women with no SUI. Women who reported UUI had a greater LHA at rest, during contraction, and during maximal Valsalva in comparison to women without UUI. No significant association was found between the Kristeller maneuver and the incidence of any UI. CONCLUSION: Levator ani avulsion and less proportional reduction of LHA with PFMC appear to be associated with a higher risk of postpartum urinary stress incontinence.

Location of obstetric anal sphincter injury scars on translabial tomographic ultrasound.

OBJECTIVE: Obstetric anal sphincter injury (OASI) is a common preventable cause of anal incontinence. Both diagnosis and primary repair of OASI are often suboptimal, partly owing to the absence of effective clinical audit. The aim of this study was to evaluate the location of scars or defects of the external anal sphincter (EAS), diagnosed by translabial ultrasound (TLUS), following primary OASI repair. METHODS: This was a retrospective analysis of 309 women who were seen at a tertiary obstetric unit after primary repair of OASI between June 2012 and May 2019. All women underwent a standardized interview, including St Mark's incontinence score, followed by clinical examination and TLUS assessment within 2-9 months after OASI repair. Postprocessing of TLUS volume datasets was performed by an investigator who was blinded to all other information. Tomographic ultrasound imaging was used to evaluate the presence of a scar or defect in the proximal and distal parts of the EAS. Women were classified into four groups according to the imaging findings: (1) no visible defect or distortion (likely false positive); (2) only proximal OASI; (3) only distal OASI; and (4) both proximal and distal OASI. RESULTS: Of the 309 women seen during the study period, 34 were excluded because they were referred for reasons other than recent (< 1 year) OASI, 16 owing to missing data and four owing to poor image quality, leaving 255 patients for analysis. Women were seen on average 0.25 ± 0.1 years after the index birth, and their mean age at delivery was 29.1 ± 4.6 years. Anal incontinence was reported by 97 (38.0%) women. A scar or defect was seen only in the proximal part of the EAS in 64 (25.1%) women and only in the distal part in 19 (7.5%) (P < 0.001). In 165 (64.7%) women, the damage affected both the proximal and distal EAS. CONCLUSIONS: EAS scars after primary OASI repair commonly affect the entire length of the EAS; however, partial tears seem to be more likely to occur proximally. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Is pelvic floor muscle contractility an important factor in anal incontinence?

OBJECTIVE: Pelvic floor muscle contractility (PFMC) may contribute to anal continence. The aim of this study was to assess the association between clinical and sonographic measures of PFMC and anal incontinence (AI) symptoms, after controlling for anal sphincter and levator ani muscle (LAM) trauma. METHODS: This was a retrospective study of 1383 women assessed at a tertiary center between 2013 and 2016. All patients underwent an interview, including the St Mark's incontinence score (SMIS) in those who reported AI symptoms, a clinical examination, including assessment of PFMC using the modified Oxford scale (MOS), and four-dimensional translabial ultrasound (TLUS). Sonographic measures of PFMC, i.e. cranioventral shift of the bladder neck (BN) and reduction of anteroposterior (AP) diameter of the levator hiatus, were measured offline using ultrasound volumes obtained at rest and on maximum pelvic floor contraction. The reviewer was blinded to all clinical data. RESULTS: Of the 1383 patients assessed during the study period, seven were excluded due to missing imaging data, leaving 1376 for analysis. Mean age of the participating women was 55 years and mean body mass index was 29 kg/m2 . AI was reported by 221 (16.1%) women, with a mean SMIS of 11.8. Mean MOS grade was 2.3. On TLUS, mean BN cranioventral shift was 5.9 mm and mean AP diameter reduction was 8.1 mm. LAM avulsion and significant external anal sphincter (EAS) defect were diagnosed in 24.8% and 8.7% patients, respectively. On univariate analysis, sonographic measures of PFMC were not associated with AI. Lower MOS grade was associated with symptoms of AI; however, statistical significance was lost on multivariate analysis. CONCLUSION: Clinical and sonographic measures of PFMC were not significantly associated with AI symptoms after controlling for EAS and LAM trauma. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Vaginal laxity: which measure of levator ani distensibility is most predictive?

OBJECTIVE: To assess the predictive value of measures of levator hiatal distension at rest and on maximum Valsalva maneuver for symptoms of vaginal laxity. METHODS: This was a retrospective study of women seen at a tertiary urogynecological unit. All women underwent a standardized interview, clinical examination and four-dimensional translabial ultrasound examination. Area, anteroposterior diameter (APD) and coronal diameter (CD) of the levator hiatus were measured at rest and on maximum Valsalva maneuver in the plane of minimal hiatal dimensions using the rendered volume technique, by an operator blinded to all clinical data. The association between levator hiatal measurements and vaginal laxity was assessed, and receiver-operating-characteristics (ROC)-curve analysis was used to determine their predictive value. RESULTS: Data from 490 patients were analyzed. Mean age was 58 (range, 18-88) years, and vaginal laxity was reported by 111 (23%) women. Measurements obtained on maximum Valsalva were significantly larger in women who reported vaginal laxity than in those who did not, with mean levator hiatal area, APD and CD of 30.45 ± 8.74 cm2 , 7.24 ± 1.16 cm and 5.60 ± 0.89 cm, respectively, in the vaginal-laxity group, compared with 24.84 ± 8.63 cm2 , 6.64 ± 1.22 cm and 5.01 ± 0.97 cm in the no-laxity group (P < 0.001 for all). Measurements obtained at rest were not significantly different between the groups. Multiple logistic regression analysis controlling for age, body mass index, vaginal parity and levator avulsion confirmed these results. The best regression model for the prediction of vaginal laxity included age, vaginal parity and levator hiatal area on maximum Valsalva. ROC-curve analysis of levator hiatal measurements on maximum Valsalva in the prediction of vaginal laxity demonstrated areas under the curve of 0.68 (95% CI, 0.63-0.73) for area, 0.63 (95% CI, 0.57-0.68) for APD and 0.68 (95% CI, 0.62-0.73) for CD. CONCLUSIONS: Levator hiatal area on maximum Valsalva seems to be the measure of levator ani distensibility that is most predictive of symptoms of vaginal laxity. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Association between pelvic floor muscle trauma and contraction in parous women from a general population.

OBJECTIVE: To study possible associations between pelvic floor muscle contraction, levator ani muscle (LAM) trauma and/or pelvic organ prolapse (POP) ≥ Stage 2 in parous women recruited from a general population. METHODS: This was a secondary analysis of data from a cross-sectional study of 608 parous women from a general population examined using the POP quantification system (POP-Q) and three-dimensional/four-dimensional transperineal ultrasound for identification of LAM macrotrauma (avulsion) and microtrauma (distension of levator hiatal area > 75th percentile on Valsalva maneuver). Muscle contraction was assessed using the modified Oxford scale (MOS), perineometry and ultrasound measurement of proportional change of anteroposterior hiatal diameter and levator hiatal area at rest and on pelvic floor muscle contraction. The Mann-Whitney U-test was used to study associations between pelvic floor muscle contraction, LAM trauma and POP. RESULTS: Women with macrotrauma (n = 113) had significantly weaker median pelvic floor muscle contraction, as measured using MOS and perineometry, than did women with an intact LAM (n = 493) (contraction strength was 1.5 (range, 0.0-5.0) vs 3.5 (range, 0.0-5.0) on MOS, and vaginal squeeze pressure was 15.0 (range, 0.0-78.0) cmH2 O vs 28.0 (range, 0.0-129.0) cmH2 O on perineometry; P < 0.001). This was also demonstrated by ultrasound measurement, with a proportional change in hiatal area of 19.9% (range, 4.1-48.0%) vs 34.0% (range, 0.0-64.0%) (P < 0.001) and proportional change in anteroposterior diameter of 16.2% (range, -5.7 to 42.6%) vs 26.0% (range, -3.4 to 49.4%) (P < 0.001). No statistically significant difference between women with (n = 65), and those without (n = 378), microtrauma was found after excluding women with macrotrauma. Women with POP had weaker muscle contraction than those without; in those with POP-Q ≥ 2 (n = 275) compared with those with POP-Q < 2 (n = 333), muscle contraction strength was 3.0 (range, 0.0-5.0) vs 3.5 (range, 0.0-5.0) on MOS, vaginal squeeze pressure was 21.0 (range, 0.0-98.0) cmH2 O vs 28.0 (range, 3.0-129.0) cmH2 O on perineometry, proportional change in hiatal area was 29.6% (range, 0.0-60.9%) vs 33.8% (range, 0.0-64.4%) and proportional change in anteroposterior diameter was 22.8% (range, -5.7 to 49.4%) vs 25.7% (range, -3.4 to 49.4%) (P < 0.001 for all). CONCLUSIONS: LAM macrotrauma was associated with weaker pelvic floor muscle contraction measured using palpation, perineometry and ultrasound. Women with POP had weaker contraction than did women without POP. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

New three-dimensional/four-dimensional volume rendering imaging software for detecting the abnormally invasive placenta.

OBJECTIVE: This study aimed to determine the role of three-dimensional (3D)/four-dimensional (4D) volume rendering ultrasound (VRU) in the diagnosis of abnormally invasive placenta (AIP). MATERIALS AND METHODS: Twelve consecutive patients strongly suspected of having AIP on the basis of conventional ultrasound (US) and clinical history performed between September 2016 and December 2016 in the main tertiary referral hospital in Surabaya, East Java were included in this prospective observational study. A Samsung WS 80A Elite US scanner with a 3D/4D "crystal vue" and "realistic vue" volume rendering mode was used to establish the diagnosis of AIP and evaluate the site, and depth of placental invasion. The VRU images were compared with the intraoperative findings. RESULTS: Using this novel US technique, all cases of suspected AIP were subsequently confirmed during surgery. Importantly, the new US technique provided a correct diagnosis of the degree of invasion in 11 out of these 12 suspected AIP cases: 5/5 for placenta percreta, 3/3 for placenta increta, and 2/3 for placenta accreta; one patient was misdiagnosed in terms of the degree of placenta accreta, and one patient had normal implantation). CONCLUSION: This new software of 3D/4D VRU represents a promising technique for the preoperative diagnosis and staging of AIP.

Is bladder neck and urethral mobility associated with urinary incontinence and mode of delivery 4 years after childbirth?

AIMS: To study changes in bladder neck, urethral mobility and urinary incontinence (UI) from pregnancy to 4 years postpartum and demonstrate any association to mode of delivery or presence of levator ani muscle (LAM) injury. Secondly, we aimed to correlate bladder neck and urethral mobility to UI symptoms. METHODS: Prospective study of 180 women, recruited in their first pregnancy and followed up 1 and/or 4 years postpartum. UI symptoms were assessed with a validated questionnaire. All underwent 4D transperineal ultrasound to assess LAM injury, bladder neck descent (BND), retrovesical angle at Valsalva (RVA), and urethral rotation between rest and Valsalva. A mixed model compared changes over time, different delivery modes, and women with and without LAM injury. Spearman's rank correlation tested the correlation of BND, RVA, and urethral rotation to UI symptoms. RESULTS: BND, RVA, and urethral rotation all increased following delivery. From 1 to 4 years postpartum, a larger increase in BND was found for women delivered vaginally with LAM injury, compared to women with intact LAM (P = 0.02) and women with cesarean section (P = 0.046). One year postpartum, BND and RVA correlated to UI symptoms, rs = 0.22, P = 0.01. Four years postpartum, RVA correlated to UI symptoms, rs = 0.19, P = 0.02. CONCLUSIONS: Although bladder neck and urethral mobility increased from pregnancy to 4 years postpartum irrespective of delivery mode, women with LAM injury had larger increase in BND, suggesting that this is important in the pathogenesis of bladder neck mobility and could lead to pelvic floor dysfunction in the long term.

Thyroid gland visualization with 3D/4D ultrasound: integrated hands-on imaging in anatomical dissection laboratory.

PURPOSE: In teaching anatomy, clinical imaging has been utilized to supplement the traditional dissection laboratory promoting education through visualization of spatial relationships of anatomical structures. Viewing the thyroid gland using 3D/4D ultrasound can be valuable to physicians as well as students learning anatomy. The objective of this study was to investigate the perceptions of first-year medical students regarding the integration of 3D/4D ultrasound visualization of spatial anatomy during anatomical education. METHODS: 108 first-year medical students were introduced to 3D/4D ultrasound imaging of the thyroid gland through a detailed 20-min tutorial taught in small group format. Students then practiced 3D/4D ultrasound imaging on volunteers and donor cadavers before assessment through acquisition and identification of thyroid gland on at least three instructor-verified images. A post-training survey was administered assessing student impression. RESULTS: All students visualized the thyroid gland using 3D/4D ultrasound. Students revealed 88.0% strongly agreed or agreed 3D/4D ultrasound is useful revealing the thyroid gland and surrounding structures and 87.0% rated the experience "Very Easy" or "Easy", demonstrating benefits and ease of use including 3D/4D ultrasound in anatomy courses. When asked, students felt 3D/4D ultrasound is useful in teaching the structure and surrounding anatomy of the thyroid gland, they overwhelmingly responded "Strongly Agree" or "Agree" (90.2%). CONCLUSION: This study revealed that 3D/4D ultrasound was successfully used and preferred over 2D ultrasound by medical students during anatomy dissection courses to accurately identify the thyroid gland. In addition, 3D/4D ultrasound may nurture and further reinforce stereostructural spatial relationships of the thyroid gland taught during anatomy dissection.

Association of urinary and anal incontinence with measures of pelvic floor muscle contractility.

OBJECTIVE: To assess the association between clinical and sonographic measures of pelvic floor muscle (PFM) function and symptoms of urinary and anal incontinence (AI). METHODS: This was a retrospective study of women seen at a tertiary urogynecological unit. All women had undergone a standardized interview, clinical examination including Modified Oxford Scale (MOS) grading, urodynamic testing and four-dimensional translabial ultrasound (TLUS). Cranioventral shift of the bladder neck (BN) and reduction in the hiatal anteroposterior (AP) diameter were measured using ultrasound volumes acquired on maximal PFM contraction, blinded against all clinical data. RESULTS: Data from 726 women with a mean age of 56 ± 13.7 (range, 18-88) years and a mean body mass index of 29 ± 6.1 (range, 17-55) kg/m(2) were analyzed. Stress (SI) and urge (UI) urinary incontinence were reported by 73% and 72%, respectively, and 13% had AI. Mean MOS grade was 2.4 ± 1.1 (range, 0-5). Mean cranioventral BN shift on TLUS was 7.1 ± 4.4 (range, 0.3-25.3) mm; mean reduction in AP hiatal diameter was 8.6 ± 4.8 (range, 0.3-31.3) mm. On univariate analysis, neither MOS nor TLUS measures were strongly associated with symptoms of urinary incontinence or AI; associations were non-significant except for BN displacement/SI (7.3 mm vs 6.5 mm; P = 0.028), BN displacement/UI (6.85 vs 7.75; P = 0.019), hiatal AP diameter/AI (9.6 mm vs 8.5 mm; P = 0.047) and MOS/SI (2.42 vs 2.19; P = 0.013). CONCLUSIONS: In this large retrospective study we did not find any strong associations between sonographic or palpatory measures of PFM function and symptoms of urinary incontinence or AI. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Changes in the mean echogenicity and area of the puborectalis muscle during pregnancy and postpartum.

INTRODUCTION AND HYPOTHESIS: Three-dimensional (3D) and four-dimensional (4D) volume transperineal ultrasound imaging is increasingly used to assess changes in the dimensions of the pelvic floor during pregnancy and after delivery. Little is known with regard to the area of the puborectalis muscle and its structural changes. Echogenicity measurement, a parameter that provides information on the structure of muscles, is increasingly used in orthopaedics and neuromuscular disease evaluation. This study is aimed at assessing the changes in the mean echogenicity of the puborectalis muscle (MEP) and the puborectalis muscle area (PMA) during first pregnancy and after childbirth. METHODS: The MEP and PMA of 254 women during first pregnancy were measured at 12 and 36 weeks' gestation and 6 months postpartum. To determine the effect of child-birth on MEP and PMA, the results at 6 months postpartum were separately analysed for vaginal deliveries, operative vaginal deliveries (ventouse) and caesarean section deliveries. Mean differences in MEP and PMA were analysed using ANOVA statistics. RESULTS: The MEP at 6 months postpartum was, independent of manoeuvre, significantly (p < 0.001) lower than MEP values during pregnancy. After caesarean delivery, the PMA was significantly smaller at maximum pelvic floor contraction than PMA after vaginal delivery (p = 0.003) or operative vaginal delivery (p = 0.002). CONCLUSION: Our study indicates that structural changes in the puborectalis muscle during and after pregnancy, as measured by MEP, occur and can be analysed. In addition, the mode of delivery affects the area of the puborectalis during contraction after delivery. For true volume analysis, as part of an assessment of contractility of the puborectalis muscle we will need 3D volume analysis.

Anal sphincter trauma and anal incontinence in urogynecological patients.

OBJECTIVES: To determine the prevalence of evidence of residual obstetric anal sphincter injury, to evaluate its association with anal incontinence (AI) and to establish minimal diagnostic criteria for significant (residual) external anal sphincter (EAS) trauma. METHODS: This was a retrospective analysis of ultrasound volume datasets of 501 patients attending a tertiary urogynecological unit. All patients underwent a standardized interview including determination of St Mark's score for those presenting with AI. Tomographic ultrasound imaging (TUI) was used to evaluate the EAS and the internal anal sphincter (IAS). RESULTS: Among a total of 501 women, significant EAS and IAS defects were found in 88 and 59, respectively, and AI was reported by 69 (14%). Optimal prediction of AI was achieved using a model that included four abnormal slices of the EAS on TUI. IAS defects were found to be less likely to be associated with AI. In a multivariable model controlling for age and IAS trauma, the presence of at least four abnormal slices gave an 18-fold (95% CI, 9-36; P < 0.0001) increase in the likelihood of AI, compared with those with fewer than four abnormal slices. Using receiver-operating characteristics curve statistics, this model yielded an area under the curve of 0.86 (95% CI, 0.80-0.92). CONCLUSIONS: Both AI and significant EAS trauma are common in patients attending urogynecological units, and are strongly associated with each other. Abnormalities of the IAS seem to be less important in predicting AI. Our data support the practice of using, as a minimal criterion, defects present in four of the six slices on TUI for the diagnosis of significant EAS trauma.

Defect-specific rectocele repair: medium-term anatomical, functional and subjective outcomes.

BACKGROUND: Rectocele is a herniation of the anterior wall of the rectal ampulla through a defect in the rectovaginal septum causing protrusion of the posterior vaginal wall. Common symptoms include symptoms of prolapse and obstructed defecation. AIMS: To describe subjective, anatomical and functional results of defect-specific rectocele repair. MATERIALS AND METHODS: This is an internal audit of 137 women who underwent defect-specific rectocele repair. Pre- and post-operative assessment included a standardised interview, clinical examination and 3D/4D transperineal ultrasound. Outcome measures were symptoms of obstructed defecation, recurrent prolapse symptoms, clinical posterior compartment recurrence and rectocele recurrence on ultrasound. RESULTS: At a mean follow-up of 1.4 years, 117 (85%) of women considered themselves cured or improved. Thirty-four (25%) complained of recurrent prolapse symptoms and 47 (34%) symptoms of obstructed defecation, a significant reduction (P < 0.0001). Clinical recurrence (Bp ≥ -1) was seen in 19 women (14%) and recurrence on ultrasound in 27 (20%). The mean depth of recurrence was 16.6 mm (10.3-25.1). We tested multiple potential predictors of recurrence, including age, BMI, vaginal parity, previous hysterectomy and/or prolapse surgery, follow-up time, pre-operative clinical and ultrasound findings. Only hiatal area on Valsalva (OR 0.95 for sonographic recurrence, P = 0.01) and enterocele (for clinical and sonographic recurrence, OR 4.03, P = 0.01 and OR 2.72, P = 0.02, respectively) reached significance. CONCLUSION: Defect-specific rectocele repair is effective both in restitution of normal anatomy and in resolving prolapse and obstructed defecation symptoms at a mean follow-up of 1.4 years.

Measuring echogenicity and area of the puborectalis muscle: method and reliability.

OBJECTIVES: To develop a semi-automated method to assess puborectalis muscle echogenicity on three-dimensional/four-dimensional (3D/4D) volume transperineal ultrasound images using 4D View and Matlab® software and evaluate its intra- and interobserver reliability. METHOD: The data of 23 women in their first trimester were included. 3D/4D volume datasets were obtained at rest. Two inexperienced observers were trained by an experienced observer to construct tomographic ultrasound images (TUI) from the original data and to delineate all structures. Puborectalis muscle area (PMA) and the mean echogenicity of the puborectalis muscle (MEP) were calculated offline. Intra- and interobserver reliability were determined by intraclass correlation coefficients (ICC) and their 95% CIs. RESULTS: The development of a semi-automated method to calculate puborectalis area and echogenicity is described in detail. PMA and MEP measurements in pregnant women demonstrated almost perfect intraobserver reliability for both inexperienced observers, with ICC values ranging from 0.88 to 0.99. The interobserver reliability showed ICCs of 0.63 for PMA and almost perfect ICC values, of 0.96-0.98, for echogenicity. The majority of intraobserver mismatch between two delineations of PMA occurred near the borders. CONCLUSIONS: Matlab software can be used to provide reliable measurements of the area and echogenicity of the puborectalis muscle. As the latter can be used to assess structural changes in the puborectalis muscle, it appears a promising new tool for studying pelvic floor structural anatomy.

Ultrasound imaging of the pelvic floor: changes in anatomy during and after first pregnancy.

OBJECTIVES: To describe changes in the absolute values of levator hiatal dimensions and in the contractility and distensibility of the levator hiatus during pelvic floor contraction and Valsalva maneuver, using three/four-dimensional (3D/4D) transperineal ultrasound in women during and after their first pregnancy. METHODS: Two-hundred and eighty nulliparous pregnant women underwent ultrasound examination at 12 and 36 weeks' gestation and 6 months postpartum. Hiatal dimensions were measured at rest, on pelvic floor contraction and on Valsalva maneuver. The contractility and distensibility were determined by the difference between hiatal dimensions at rest and those on contraction or Valsalva, respectively. After exclusions, there were 231 datasets from women at rest, 199 for pelvic floor contraction and 230 for Valsalva maneuver. Data at 36 weeks' gestation and 6 months postpartum were compared with data at 12 weeks' gestation. RESULTS: At 36 weeks' gestation, the absolute values of hiatal dimensions and the contractility and distensibility of the levator hiatus were significantly increased compared with those at 12 weeks' gestation. Women who delivered vaginally showed a persistent significant increase in hiatal dimensions on Valsalva, whereas women who delivered by prelabor or first-stage Cesarean section showed no significant changes in hiatal dimensions on Valsalva. After both vaginal and Cesarean section delivery, there was a persistent increase in the distensibility of the hiatus during Valsalva compared with in early pregnancy. CONCLUSION: During first pregnancy, the absolute values of levator hiatal dimensions and the contractility and distensibility of the levator hiatus increase. Regardless of delivery mode, increased distensibility of the levator hiatus during Valsalva persists after childbirth. This increased pelvic floor distensibility may play a role in the development of pelvic floor dysfunction in later life.

Reliability of pelvic floor measurements on three- and four-dimensional ultrasound during and after first pregnancy: implications for training.

OBJECTIVES: To evaluate the reliability of measurements of the levator hiatus and levator-urethra gap (LUG) using three/four-dimensional (3D/4D) transperineal ultrasound in women during their first pregnancy and 6 months postpartum, and to assess the learning process for these measurements. METHODS: An inexperienced observer was taught to perform measurements of the levator hiatus and LUG by an experienced observer. After training, 3D/4D ultrasound volume datasets of 40 women in the first trimester were analyzed by these two observers. Another training session then took place and both observers repeated the analyses of the same volume datasets. Finally, analyses of 40 volume datasets of the women 6 months postpartum were performed by both observers. Intra- and interobserver reliability were determined by intraclass correlation coefficients (ICC) with 95% CIs. RESULTS: For levator hiatal measurements, in the women during their first pregnancy the interobserver reliability was substantial to almost perfect after both the first and second training session (ICC, 0.62-0.83 and 0.71-0.89, respectively, for anteroposterior diameter, transverse diameter and area at rest, on contraction and on Valsalva) and the intraobserver reliability was substantial to almost perfect for both observers. For these measurements performed once the women had delivered, interobserver reliability was moderate to almost perfect. For LUG measurements performed during pregnancy, interobserver reliability was slight to moderate after the first training session (ICC, 0.14-0.54), but improved after the second training session (ICC, 0.38-0.71), and intraobserver reliability was moderate to substantial for the experienced observer and slight to moderate for the inexperienced observer. For these measurements performed when the women had delivered, interobserver reliability was fair to moderate. CONCLUSIONS: The levator hiatus and LUG can be measured reliably using 3D/4D ultrasound in primigravid and primiparous women. The technique to measure dimensions of the levator hiatus requires limited teaching, but LUG measurements are more difficult and require more extensive training.

Prevalence of anal sphincter injury in primiparous women.

OBJECTIVE: To determine the prevalence of obstetric anal sphincter injuries (OASIS) in a cohort of primiparous women and to evaluate their association with demographic, obstetric and ultrasound parameters. METHODS: This was a retrospective analysis of the ultrasound volume datasets of 320 primiparous women, acquired at 5 months postpartum. Tomographic ultrasound imaging (TUI) was used to evaluate the external anal sphincter (EAS). A significant EAS defect was diagnosed if a defect of > 30° was seen in four or more of six TUI slices bracketing the EAS. RESULTS: Significant EAS defects were found in 69 women (27.9% of those delivered vaginally). In nine of those a third-degree tear was diagnosed intrapartum and was sutured. In 60 women with significant defects there was no documentation of sphincter damage at birth, implying unidentified or occult defects (60/69, 87.0%). Among them, 29 had had a second-degree tear, two a first-degree tear and three an intact perineum. In 31 cases an episiotomy had been performed, with five extensions to a third-degree tear. On multivariate analysis only forceps delivery was significantly associated with OASIS. CONCLUSIONS: In this cohort of primiparous women we found OASIS in 27.9% of vaginally parous women, most of which had not been diagnosed in the delivery suite. There seems to be a need for better education of labor-ward staff in the recognition of OASIS. On the other hand, it is conceivable that some defects may be masked by intact tissue. The significance of such defects remains doubtful. Forceps delivery was the only identifiable risk factor.

Three- and four-dimensional HDlive rendering image of fetal acrania/exencephaly in early pregnancy.

We present two cases of fetal acrania/exencephaly reconstructed employing the three- (3D) and four-dimensional (4D) HDlive rendering mode in early gestation. Two fetuses with acrania/exencephaly were studied with the 3D/4D HDlive rendering mode at 13 and 15 weeks, respectively. In Case 1, at 13 weeks' gestation, deformed and degenerated brain tissues were clearly shown using the 3D/4D HDlive rendering mode. In Case 2, at 15 weeks and 6 days of gestation, two amniotic bands and acrania/exencephaly were depicted with the 3D/4D HDlive rendering mode. Fragile brain hemispheres with amniotic bands were rocking with fetal movements. The 3D/4D HDlive rendering mode provides physicians, couples, and their families with important and additional information, and has the potential to supplement two-dimensional and conventional 3D ultrasound in diagnosing fetal acrania/exencephaly.

Orofacial clefts: Reflections on prenatal diagnosis and family history based on a series of cases of a tertiary children hospital.

Prenatal diagnosis of orofacial clefts allows adequate counseling and planning for prenatal care and delivery. In 2001, two-dimensional ultrasound screening became universally used in Portugal by government guidelines, and after 2007 more advanced ultrasound became available. This study aimed to describe the prevalence of family history in patients with orofacial clefts and analyze prenatal diagnosis in patients born before 2001, between 2001 and 2007 and after 2007. Retrospective analysis of a cohort of patients with orofacial clefts followed by the trans-disciplinary team of a tertiary hospital. A total of 672 OFCs were identified: 40.9% isolated cleft palate, 38.1% cleft lip and palate, 19.7% cleft lip and 1.3% atypical cleft; 57.1% were male. The prevalence of family history was 26.0% of which 30.9% had a recognizable syndrome. Of those born before 2001, 13.7% had prenatal diagnosis; of those born between 2001 and 2007, 32.6% orofacial clefts were diagnosed in utero; and in children born after 2007, prenatal diagnosis increased to 47.1%. In our study, about one-fourth of children had a positive family history. Since the implementation of universal ultrasound screening in Portugal, more orofacial clefts were identified in utero (42.5% vs. 13.7%; p < 0.05) and after the availability of advanced ultrasound, prenatal diagnosis increased to 47.1% (vs. 20.4% before 2007; p < 0.05). Of all orofacial clefts diagnosed prenatally, ultrasound revealed more accuracy for the diagnosis of cleft lip and palate (65.4%) and cleft lip (24.8%). Cleft palate is the most difficult to detect in utero (9.3%). Prenatal ultrasound screening in Portugal has technically evolved with consequent better diagnostic accuracy for the identification of orofacial clefts, allowing better parenteral counseling.

Measurement of the Cobb angle by 3D ultrasound: a valuable additional method for the prenatal evaluation of congenital scoliosis.

Background: This study aimed to measure the Cobb angle of the fetal spine using three-dimensional ultrasound (3D-US) and to assess the relationship between the Cobb angle and the prognosis of congenital scoliosis. Methods: From March 2015 to June 2019, 77 pregnant women whose fetuses had suspected spinal skeletal dysplasia consented to undergo 3D-US examinations, and 54 fetuses were selected for the analysis group. The study protocol was approved by the review board of the Institutional Ethics Committee for Fetal Medicine. 3D-US was used to show the structure of the fetal spine in 3 planes, and the Cobb angle was measured on the coronal plane. The diagnostic efficacy of 3D-US was compared to that of X-ray for 33 fetuses. Results: In the diagnosis of congenital scoliosis, the sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of 3D-US were 91.7%, 90.0%, 90.7%, 88.0%, and 93.1%, respectively. The area under the receiver operating characteristic (ROC) curve with 3D-US was 0.908. The Spearman correlation coefficient between the Cobb angle measurement on an X-ray image and on the coronal plane image acquired by 3D-US was 0.84, which showed a significant correlation (P<0.05). Conclusions: 3D-US was successful in the diagnosis of congenital scoliosis. It is feasible to measure the Cobb angle on the coronal plane of the fetal spine by using 3D-US. The Cobb angle has the potential to become an auxiliary index for evaluating the prognosis of congenital scoliosis.