Multilevel musculo-fascial defect magnetic resonance study of female pelvic floor: retrospective case control study in women with pelvic floor dysfunction after the first vaginal delivery.

INTRODUCTION: Magnetic resonance imaging (MRI) provides a detailed display of the pelvic floor structures responsible for normal pelvic floor anatomy. The aim of the study is to assess the appearance of musculo-fascial defects in women with pelvic floor dysfunction following first vaginal delivery. MATERIAL AND METHODS: Analysis of axial T3 (Tesla 3) MRI scans from a case control study of symptomatic (n = 149) and asymptomatic (n = 60) women after first vaginal delivery. Presence and severity of pelvic organ support and attachment system defects in three axial pelvic planes were assessed. RESULTS: In the symptomatic group, major muscular defects were found in 67.1% (for pubovisceral muscle complex) and 87.9% (for iliococcygeal muscle). Only 6.7% of major pubovisceral and 35.0% of major iliococcygeal defects were identified in the controls (p = 0.000). Prolapse patients had an odds ratio (OR) of 22.1 (95% CI 8.94-54.67) to have major pubovisceral muscle complex defect and OR of 4.9 (95% CI 1.51-15.71) to have major iliococcygeal muscle defect. Fascial defects were found in 60.4% and 83.2% the symptomatic group, respectively. Those with prolapse had an OR of 29.1 (95% CI 9.77-86.31) to have facial defect at the level of pubovisceral muscle complex and an OR of 16.9 (95% CI 7.62-37.69) to have fascial defect at the level of iliococcygeal muscle. Uterosacral ligaments detachment was associated with prolapse with an OR of 10.1 (95% CI 4.01-25.29). For the model based on combination on all MRI markers, the area under the receiver operating characteristic curve is 0.921. CONCLUSIONS: This study provides comprehensive data about first vaginal delivery-induced changes in the levator ani muscle and endopelvic fascial attachment system. These changes are seen also in asymptomatic controls, but they are significantly less expressed.

Ultrasound cesarean scar assessment one year postpartum in relation to one- or two-layer uterine suture closure.

INTRODUCTION: This study compared healing of the scars after cesarean section during the first postpartum year using a single- or double-layer suturing technique. Scarring was assessed by a transvaginal ultrasound. We explored the appearance and localization of uterine scars with regard to the obstetric history. Our aim was to compare the position of the scar or defect, if present, its dimensions, and any residual myometrium with respect to the suturing technique during the cesarean section. MATERIAL AND METHODS: Women with uncomplicated singleton pregnancies indicated for elective or acute cesarean section were randomly allocated to the uterine closure technique group. During the first postpartum year, their lower uterine segment was examined with a transvaginal ultrasound in three consecutive visits at 6 weeks, 6 months and 12 months. RESULTS: 324 women attended the 12-month visit; of these, 149 underwent single-layer closure of the uterine incision and 175 double-layer technique. A higher proportion of the defects is seen in the single-layer closure technique of suturing. Defects in the single-layer group were wider (0.002) and the residual myometrial thickness in the single-layer group were thinner (0.019). Women who underwent cesarean section at the stage of full cervical dilation had scars that were closer to the external cervical os (0.000). The position of the uterus varies greatly between controls (0.000). The combination of uterine position and scar defect presence changed significantly between controls (0.001), and was significantly dependent on the suturing method (0.003). Defects with or without contact with the uterine cavity changed statistically between controls (0.017). Both types of defects were more common in the single-layer closure technique group. CONCLUSIONS: The findings of this study demonstrate that double-layer technique with the first continuous nonlocking suture followed by a second continuous nonlocking suture is associated with better suture healing and greater residual myometrial thickness. No difference was observed between single- and double-layer closure for the presence of maternal infectious morbidity, wound infection or blood transfusion.

The effect of the first vaginal birth on pelvic floor anatomy and dysfunction.

INTRODUCTION AND HYPOTHESIS: First vaginal delivery severely interferes with pelvic floor anatomy and function. This study determines maternal and pregnancy-related risk factors for pelvic floor dysfunction (PFD), including urinary incontinence (UI), urgency, anal incontinence (AI), pelvic organ prolapse (POP) and levator ani muscle (LAM) avulsion. METHODS: This is a single-centre prospective observational cohort study on healthy women in their first singleton pregnancy. All underwent clinical and 3D transperineal ultrasound examination at 6 weeks and 12 months postpartum. Objective outcomes were POP-Q and presence or absence of LAM trauma. Functional outcomes were measured by the ICIQ-SF and PISQ 12. Multivariate regression was performed to determine birth and maternal habitus-related risk factors for UI, urgency, AI, dyspareunia, LAM avulsion and ballooning. RESULTS: Nine hundred eighty-seven women were included. Risk factors for UI were maternal age per year of age (OR: 1.09; 95% CI: 1.04-1.13; p = 0.0001) and BMI before pregnancy (OR: 1.08; 95% CI: 1.04-1.13; p = 0.001); for POP stage II+ maternal age (OR: 1.08; 95% CI: 1.08-1.14; p = 0.005). Avulsion was more likely after forceps (OR: 3.22; 95% CI:1.54-8.22; p = 0.015) but less likely after epidural analgesia (OR: 0.58; 95% CI: 0.37-0.90; p = 0.015) and grade I perineal rupture (OR: 0.50; 95% CI: 0.29-0.85; p = 0.012). Ballooning was more likely at increased maternal age (OR: 1.08; 95% CI: 1.02-1.13; p = 0.005), epidural (OR: 1.64; 95% CI: 1.06-2.55; p = 0.027) and grade I perineal rupture (OR: 1.79; 95% CI: 1.10-2.90; p = 0.018). CONCLUSION: Though maternal characteristics at birth such as age or BMI increase the risk of PFD, labour and birth factors play a similarly important role. The most critical risk factor for MLA avulsion was forceps delivery, while an epidural had a protective effect.

Finite element model focused on stress distribution in the levator ani muscle during vaginal delivery.

INTRODUCTION AND HYPOTHESIS: During vaginal delivery, the levator ani muscle (LAM) undergoes severe deformation. This stress can lead to stretch-related LAM injuries. The objective of this study was to develop a sophisticated MRI-based model to simulate changes in the LAM during vaginal delivery. METHODS: A 3D finite element model of the female pelvic floor and fetal head was developed. The model geometry was based on MRI data from a nulliparous woman and 1-day-old neonate. Material parameters were estimated using uniaxial test data from the literature and by least-square minimization method. The boundary conditions reflected all anatomical constraints and supports. A simulation of vaginal delivery with regard to the cardinal movements of labor was then performed. RESULTS: The mean stress values in the iliococcygeus portion of the LAM during fetal head extension were 4.91-7.93 MPa. The highest stress values were induced in the pubovisceral and puborectal LAM portions (mean 27.46 MPa) at the outset of fetal head extension. The last LAM subdivision engaged in the changes in stress was the posteromedial section of the puborectal muscle. The mean stress values were 16.89 MPa at the end of fetal head extension. The LAM was elongated by nearly 2.5 times from its initial resting position. CONCLUSIONS: The cardinal movements of labor significantly affect the subsequent heterogeneous stress distribution in the LAM. The absolute stress values were highest in portions of the muscle that arise from the pubic bone. These areas are at the highest risk for muscle injuries with long-term complications.

TVT and TVT-O for surgical treatment of primary stress urinary incontinence: prospective randomized trial.

INTRODUCTION AND HYPOTHESIS: A study was conducted to compare the efficacy and complications of TVT and TVT-O. METHODS: This study is a prospective randomized trial involving 300 women with primary SUI; 149 received TVT, and 151 patients were treated with TVT-O. At the 1 year follow-up, 141 TVT patients and 147 TVT-O patients (dropout, 5.3% and 2.6%) were evaluated using urodynamic studies, validated questionnaires, and a 1-h pad test. RESULTS: The mean operating time was shorter in the TVT-O group (p < 0.001). Urinary retention was not significantly different (p > 0.05). Inner thigh discomfort was reported by 5.4% of TVT-O patients. In the TVT and the TVT-O groups, respectively, 90.1% and 88.4% women were objectively cured. The satisfaction with the surgical outcome reflects the significant decrease in the questionnaire mean symptom scores in both groups. Postoperative de novo urgency was significantly more common in the TVT-O patients (p = 0.015). CONCLUSION: The groups showed comparable objective and subjective cure rates.

TVT-S for surgical treatment of stress urinary incontinence: prospective trial, 1-year follow-up.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to evaluate the effectiveness of and morbidity associated with the tension-free vaginal tape-secur (TVT-S) procedure in women with stress urinary incontinence (SUI). METHODS: We performed a prospective trial, examining 86 women with primary SUI. Eighty-two patients had a 1-year follow-up (dropout rate = 4.6%). The preoperative evaluation included urinalysis, urodynamic studies, and validated questionnaires. The 1-year outcome evaluation also included a 1-h pad testing. RESULTS: At the 1-year follow-up, 43 (52.4%) women were objectively cured, and 14 (17.1%) women were objectively improved. Subjectively, 49 (59.7%) patients did not experience urine loss, and 18 (22.2%) women improved in this respect. Postoperative de novo urge incontinence symptoms developed in 24.4% (n = 20) of patients. Vaginal defect healing occurred in 6.1% (n = 5) of patients, and one (1.2%) case of urethral erosion was reported. CONCLUSION: Objective and subjective cure rates following TVT-S are inferior to other tape procedures.

Comparison of labor course and women's sexuality in planned and unplanned pregnancy.

OBJECTIVE: This study compares several parameters of sexual life and course of labor in women with planned and unplanned pregnancy. METHODS: 339 primiparas participated in our study; they filled in a questionnaire concerning their sexual life during pregnancy on the second or third day after the delivery. One question also stressed planning of pregnancy. 246 women (i.e., 72.6%) indicated planned pregnancy, 93 pregnancies (i.e., 27.4%) were not planned. RESULTS: Significant decrease of coital activity and number of orgasms and increase of sexual dysfunctions were observed in the whole study group during pregnancy. Significant differences between women with planned and unplanned pregnancy were observed only in frequency of vaginal dryness and pelvic pain. CONCLUSIONS: According to the results of this study, unplanned pregnancy has no adverse effect on parameters of the labor. The equal rate of partner's presence at delivery shows a high involvement of the partners of unmarried women.

Predicting term birth weight using ultrasound and maternal characteristics.

OBJECTIVES: The aim of the study was to compare an ultrasound-based prediction formula of Shepard, Hadlock, our new equation and equation of Nahum based on maternal characteristics. STUDY DESIGN: Two groups of 125 (group A) and 130 (group B) healthy term pregnant women were sampled. Standard ultrasonographic measurements were performed and maternal characteristics recorded. A new birth weight equation was developed by multiple stepwise regression analysis from the group A data and then compared to the different birth weight prediction equations of Hadlock, Shepard and Nahum on group B. RESULTS: New prediction equation: log(10) EFW=0.64041xBPD-0.03257xBPD(2)+0.00154xACxFL. Our new (Halaska) and Hadlock's ultrasound estimations are comparable. Both equations are superior to Shepard and Nahum's equations. The Nahum equation is comparable to the Shepard estimation. Halaska equation tends to have the highest overall accuracy, Hadlock's estimation predicts better fetuses over 4000g, but this needs to be further validated. CONCLUSIONS: The Halaska and Hadlock's estimations are comparable to one another; the Nahum equation is comparable to Shepard's and can be used as simple, inexpensive and approximative estimate.

New approach to the urogynecological ultrasound examination.

OBJECTIVE: To evaluate a new system for the ultrasound evaluation of urethral mobility. STUDY DESIGN: We studied the structure of interpubic disc and found landmarks that can be used to align different images and set up an universal system of coordinates. The method for capturing and post-processing of the introital ultrasound examination is described. The urethra in its entire course is evaluated. Ten patients were examined and some important points at the interpubic disc and the urethra were traced to assess the reproducibility of the method. RESULTS: The mean intra-observer difference for x and y coordinates were 1.88 mm (S.D. 1.53) and 2.00 mm (S.D. 1.54), respectively. The inter-observer difference was 2.30 mm (S.D. 1.64) and 2.50 mm (S.D. 1.79), respectively for x and y coordinates. CONCLUSION: The method shows good inter- and intra-observer correlation and presents data that can be further used for biomechanical analysis.