Retained products of conception - a retrospective analysis of 200 cases of surgical procedures for the diagnosis of residua postpartum.

OBJECTIVES: Postpartum retained products of conception are a relatively rare diagnosis occurring in approximately 1% of cases after spontaneous deliveries and abortions. The most common clinical signs are bleeding and abdominal pain. The diagnosis is based on clinical signs and ultrasound examination. MATERIAL AND METHODS: Retrospective analysis of 200 surgical procedures for the diagnosis of residua postpartum obtained in 64 months. We correlated the method and accuracy of diagnosis with definitive histological findings. RESULTS: During 64 months, we performed 23 412 deliveries. The frequency of procedures for diagnosis of retained products of conception (RPOC) was 0.85%. Most (73.5%) of the D&C were performed within six weeks of delivery. Histologically, the correct diagnosis was confirmed in 62% (chorion + amniotic envelope). There was interestingly lower concordance of histologically confirmed RPOC in post-CS patients (only 42%). In women after spontaneous delivery of the placenta, the diagnosis of RPOC was confirmed by histological correlate in 63%, and the highest concordance occurred in women after manual removal of the placenta in 75%. CONCLUSIONS: Concordance with histological findings of chorion or amnion was seen in 62% of cases; this means that the incidence rate in our study was around 0.53%. The lowest concordance is after CS deliveries, 42%. D&C for RPOC should be performed after adequate clinical evaluation and in the knowledge of 38% false positivity. There is certainly more space for a conservative approach under appropriate clinical conditions, especially in patients after CS.

The amenorrhea as a protective factor for healing of hysterotomy - a retrospective analysis one year postpartum.

OBJECTIVES: The good healing of the hysterotomy after cesarean section is important for subsequent pregnancies. However, the factors which improve this healing have not been completely described, yet. In this study, we focused on factors which may affect healing of hysterotomy within one year after delivery, such as menstruation, breastfeeding, and the use of the contraception. MATERIAL AND METHODS: Following delivery, total of 540 women were invited for three consecutive visits at six weeks, six months, and 12 months postpartum. The presence of menstruation, frequency of breastfeeding and contraception use were recorded. The scar was evaluated by vaginal ultrasound as already described. The impact of menstruation, breastfeeding, and contraception method on presence of niche was evaluated. RESULTS: The presence of menstruation increased odds to have niche by 45% (CI 1.046-2.018, p = 0.026). Secondarily, our results demonstrated a statistically significant protective effect of breastfeeding on the incidence of niche with OR 0.703 (CI 0.517-0.955, p = 0.024). Breastfeeding decreases odds to have niche by 30%. Also, the use of gestagen contraception lowered the odds by 40% and intrauterine device (IUD) or combine oral contraceptive (COC) by 46.5%. The other possibly intervening factors were statistically controlled. CONCLUSIONS: Amenorrhea, breast-feeding and progesterone-contraceptive decreases the risk of uterine niche within one year follow up.

Prevention of intrauterine adhesions.

Intrauterine adhesions are a serious complication that occurs after intrauterine procedures, most often in connection with pregnancy. Manifestations such as amenorrhea, pelvic pain, and infertility for a woman, especially in reproductive age, are serious and together with intrauterine adhesions we call them Asherman's syndrome. Primary prevention after intrauterine procedures is important. Published studies show that the use of hyaluronic acid gel, especially after abortions, leads to the prevention of moderate and severe intrauterine adhesions and also increases the pregnancy rate.

The fertility sparing therapy in ectopic pregnancy.

OBJECTIVE: A review of current knowledge on the possibilities of fertility sparing therapy in case of ectopic pregnancy. METHODS AND RESULTS: Ectopic pregnancy is defined as implantation of an embryo outside the endometrial cavity, most often in the fallopian tube. This dia-gnosis is very common among young women. Ectopic pregnancies can be treated using the following three approaches, which can be combined: expectantly, pharmacologically or surgically. Fertility-sparing salpingostomy may be performed during surgical treatment. Medical (pharmacological) treatment consists in the application of methotrexate with a success rate of 75-96%, depending on the initial level of the free beta subunit of human chorionic gonadotropin (b-hCG). This is a safe treatment with minimal side effects. There is no standardization of the blood b-hCG level limits or of the size of the ectopic pregnancy mass for choosing expectant, surgical or medical treatment. A considerable increase in the rate of Cesarean sections over the last decades has led to an increase in the occurrence of the implantation of the gestational sac in the hysterotomy scar. There are several options to address this dia-gnosis, but none is clearly preferred. This issue is also discussed in the article. CONCLUSION: The goal of ectopic pregnancy treatment is to choose a safe and effective therapy with a low incidence of side effects and maintaining the maximum fertility of women. Properly set indication criteria are most important when choosing the right option.

A severe case of pemphigoid gestationis persisting after labour - case report and review of the literature.

BACKGROUND AND AIM: Pemphigoid gestationis (PG) is a rare skin disease of pregnancy. Given its incidence in pregnant women, physicians and especially obstetricians may not encounter this diagnosis in their entire career. We find this to be a major problem and there is an obligation to report it in as much detail as possible along with recommended treatments with proven efficacy. CASE REPORT: We describe the case of a 27 year old patient who was referred to the dermatology department with severe dissemination of blisters in the 9th week of pregnancy. She was diagnosed with pemphigoid gestationis in her first pregnancy. High doses of corticosteroids were initiated but due to inadequate effect cyclosporine was added. The pregnancy was complicated with gestational diabetes. The patient gave birth in her 33rd week by caesarian section due to premature rupture of the membrane. Vesicles were seen on the newborn immediately after birth which diminished spontaneously over 2 weeks. Blisters were still seen on the patient 1 month after labor even with the combination of systemic corticosteroids with cyclosporine. CONCLUSION: PG is a rare dermatosis of pregnancy. The course of the disease can be severe, necessitating systemic therapy. As described in this patient, systemic corticosteroids may not be sufficient and adding another immunosuppressive treatment may be needed. If pemphigoid gestationis has occurred during a previous pregnancy it is advised to reconsider another pregnancy.

Complications of planned home births in the Czech Republic.

OBJECTIVES: This study evaluated complications that can occur during planned home births that require transfer to the hospital. These factors were assessed to improve the current status of deliveries performed outside health care facilities in the Czech Republic. MATERIALS AND METHODS: This prospective cohort study included data on 105 cases of complicated home births during 2017 to 2021 using an online form accessible to all hospital maternity wards in the Czech Republic. RESULTS: Planned home births were complicated by fetal/neonatal causes, maternal causes, and combined fetomaternal complications in 28 (26.7%), 20 (19%), and 2 (1.9%) cases, respectively. The need for transfer was most often realized after the birth of the fetus (86; 81.9%); however, it was realized during birth in 19 (18.1%) cases. The following complications were noted most often: postpartum hemorrhage (23; 21.9%); neonatal asphyxia (17; 16.2); placental retention (14; 13.3%); birth injury (12; 11.4%); neonatal hypothermia (5; 4.8%); and placental birth (5; 4.8%). Indications for transfer during labor were as follows: labor obstruction (10; 9.5%); fetal hypoxia (5; 4.8%); bleeding during labor (2; 1.9%); preeclampsia (1; 0.9%); and fetal malformation (1; 0.9%). Perinatal death occurred in 8 (7.6%) cases. Permanent neonatal morbidity occurred in 4 (3.8%) cases. CONCLUSIONS: Patients with home birth complications were transferred to the hospital most often after the birth of the fetus. The low proportion of transfers during childbirth is caused by the unprofessional management of planned home births, resulting in a high number of perinatal deaths and high rate of permanent neonatal morbidity.

Endometriosis in postmenopause.

In our review article, we focused on the rare topic of endometriosis in postmenopause. Endometriosis is primarily a disease of women of reproductive age. In postmenopause, atrophy of endometriosis foci usually occurs. However, recurrence or even de novo occurrence of endometriosis in postmenopause has also been described. The prevalence in postmenopause has been reported to be around 2-5%. Factors that may account for the recurrence of endometriosis are exogenously administered estrogens, self-production of estrogens in peripheral adipose tissue, or activation of aromatase in the focus of endometriosis. When hormonal therapy is required, the best results are achieved by administration of Tibolone. Risk factors for recurrence and subsequent difficulties are the extent of endometriosis, the retained uterus and adnexa. Pain was the most common symptom in 43.5% and palpable finding in 28%. Endometriotic cells are capable of proliferation, survival in an ectopic localization and metastasis to distant locations. The risk of malignant transformation is around 1% and the most common are ovarian tumors. Endometriosis-associated ovarian tumors are typically low-grade disease, histologically endometrioid or clear cell carcinomas. Dia-gnosis is based on ultrasound and magnetic resonance imaging. The basis of therapy for newly developed endometriosis or when symptoms associated with the risk of endometriosis appear is a surgical solution, primarily to exclude the cancerous process.

Cesarean scar pregnancy - a retrospective analysis of cases in the years 2012-2021.

INTRODUCTION: With the increasing number of caesarean sections, the number of cesarean scar pregnancies (CSP) is also increasing. This is a relatively new entity of an ectopic pregnancy, which is risky mainly because of its possible association with placenta accreta spectrum. CSP is thought to represent about 6% of the total number of ectopic pregnancies in all women who have a history of at least one caesarean section. The estimated incidence of CSP is about 1/1,688 of all pregnancies and about 1/2,000 of all caesarean sections. MATERIAL AND METHODS: Retrospective analysis of individual cases of cesarean scar pregnancies managed in our health care facility in the years 2012-2021. RESULTS: In total, we managed 16 cases of pregnancy in the caesarean scar in 15 women. In one woman, we recorded CSP twice. The mean age of the women was 36.6 years (27-41). The mean number of caesarean sections was 1.6 (1-3) and gestational week was 7 (4-10). The average time since the caesarean section was 3.6 years (2-11). The management was methotrexate administration once, hysteroscopic resection once and 11times primarily vacuum aspiration only, when in two cases we had to attach laparoscopic uterine artery ligation due to postoperative bleeding. We performed primary ligature of uterine arteries twice before performing vacuum aspiration. In pregnancies above 10 weeks of gestation, we observed more bleeding complications requiring surgical management. Bleeding complications were also related to the presence of fetal cardiac action. CONCLUSION: Early correct dia-gnosis is essential in the management of CSP. Pregnancies up to the 10th week of gestation are managed by simple vacuum aspirations under ultrasound guidance. If the pregnancy is over the 10th week of gestation and especially with cardiac activity, we add laparoscopic uterine artery ligation before vacuum aspiration. All patients are subsequently advised to undergo laparoscopic resuturing of the lower uterine segment.

A patient with primary adenocarcinoma of the appendix metastasizing to the ovary.

OBJECTIVE: The aim of this work is to draw attention to the difficulty of differential dia-gnosis of rare adenocarcinoma of the appendix and the histological diversity of ovarian tumors. CASE REPORT: We present a case of a 62-year-old patient sent by an attending gynecologist for the finding of an asymptomatic adnextumor diagnosed during a routine preventive examination. Based on preoperative examinations, a malignant ovarian tumor was suspected. Standard surgery was performed including hysterectomy with bilateral adnexectomy, total omentectomy, appendectomy, pelvic and paraaortic lymphadenectomy. Definitive histopathological analysis revealed a secondary ovarian tumor, with the adenocarcinoma of the appendix appearing to be the primary site. CONCLUSION: Up to 25% of all ovarian tumors are secondary metastatic tumors. Appendix neoplasia should be considered in the differential diagnosis of right-sided adnextumors. Due to their localization, they can only mimic an ovarian tumor during imaging examinations, or they can be the primary origin of an already metastatic ovary, as in our case.

Telemedicine in prenatal care.

Telemedicine, as a health service provided remotely, is increasingly becoming a common part of health care. Telemedicine is defined as "an umbrella term for health activities, services and systems operated remotely through information and communication technologies to promote global health, prevention and health care, as well as education, health management and health research". It also describes telemedicine as "the provision of services where distance is a critical factor, using information and communication technologies to exchange valid information for the diagnosis, treatment and prevention of disease and injury, for research and evaluation, and for the continuing education of healthcare providers to improve the health of individuals and communities". Both definitions imply that two of the hallmarks of telemedicine include the use of communication and information technologies to overcome distance as a critical factor, a factor that is well known to us, not least from the recent months of the COVID-19 pandemic. Distance medicine can thus act as a tool for improving access to health care and also complement health care itself in a very appropriate way.

Cesarean scar pregnancy.

OBJECTIVE: To summarize the current knowledge on pregnancy in a cesarean scar. METHODOLOGY: A literature review on the topic using the PubMed database. RESULTS: Gravidity in a cesarean scar is a relatively new type of ectopic pregnancy that will be an increasingly common problem in an era of increasing cesarean section rates. It is still a relatively rare event, occurring in about 6% of the population. Diagnosis is based primarily on ultrasound examination and is essential early on in pregnancy. The pathogenesis of the disease is due to a disorder of the basal layer of the endometrium and can lead to conditions that we refer to as placenta accreta spectrum. The management is completely individualized and depends on hCG values, ultrasound findings, fetal viability, the wishes of the pregnant woman and the experience of the gynecologist concerned. CONCLUSION: This is still a rare occurrence of ectopic pregnancy but with increasing potential. The solution is completely individualized based on a precise and early ultrasound diagnosis.

Fertility sparing approach in young women with endometrial cancer.

The incidence of endometrial cancer in young women is increasing, especially in developed countries. Although it is predominantly a disease of peri- and postmenopausal women, there is an absolute increase in younger women of childbearing age who, with today's lifestyle and pushing back maternal needs, do not have fulfilled reproductive plans. About 67% of cancers are diagnosed in the early stages. For these women, fertility-preserving procedures can be considered until reproductive plans are fulfilled. Subsequently, however, definitive management is appropriate even in the absence of carcinoma. This article discusses the most common gynecologic pelvic cancer, endometrial adenocarcinoma, and the possibility of fertility-preserving procedures.

Comparison of complications in very obese women undergoing hysterectomy - Abdominal vs laparoscopic approach with short- and long-term follow-up.

BACKGROUND: Surgical treatment of obese female patients represents a real challenge. Over the last decade, minimally invasive techniques for hysterectomy have emerged. These approaches reduce the invasiveness of standard surgical procedures while maintaining efficacy and feasibility. OBJECTIVE: To evaluate the rates of perioperative, early, mid-term and late postoperative complications in very obese [body mass index (BMI) ≥ 35 and < 40 kg/m2] and severely obese (BMI ≥ 40 kg/m2) women who underwent total (non-radical) hysterectomy. DESIGN: A prospective comparative multi-centre non-randomized study. METHODS: In total, 328 consecutive total (non-radical) hysterectomies were performed at seven teaching gynaecological centres. Of these, 153 (46.6%) were performed using an open laparotomy (LT) approach and 175 (53.4%) were performed laparoscopically (LS). All data were collected by medical specialists at the pre-operative examination prior to surgery, during surgery and three times postoperatively (during hospital stay, at 6-week follow-up and 6 months following surgery). Another analysis considered a total of 206 women who underwent laparoscopic hysterectomy. The subjects were divided according to BMI into 120 very obese women (BMI ≥ 35 and < 40 kg/m2) and 86 severely obese women (BMI ≥ 40 kg/m2). RESULTS: The total number of composite perioperative complications was significantly lower in the LS group (p = 0.006). Composite complications occurred significantly more often in patients in the LT group compared with the LS group in the early (p < 0.001) and mid-term (p < 0.001) postoperative periods. In the late postoperative period, the total number of composite postoperative complications did not differ significantly between the groups (p < 0.396). Among 206 patients who underwent laparoscopic hysterectomy, the number of complications was generally low; the rates of composite perioperative (p = 0.393), early (p = 0.642), mid-term (p = 0.738) and late (p = 1) postoperative complications were generally low; and frequency did not differ significantly with BMI. CONCLUSION: The LS approach does not increase intra-operative morbidity associated with surgery, and has significantly better outcomes in terms of the postoperative complication rate.

Peripartum rupture of renal artery aneurysm - case report.

We present a case of silent rupture of the renal artery aneurysm in a pregnant woman brought to the maternity hospital in shock. Renal artery aneurysms (RAA) are rare and account for 0.01-0.5% of all aneurysms with an incidence of approximately 0.09%. Rupture of the renal artery aneurysm is a rare and severe complication associated with extremely high morbidity and mortality in both mother and fetus. Thanks to the improvement and effectiveness of medical care in the 21st century, fetal mortality decreased by 70-80%, and 60-70 % for the mother. The essence of a successful management of this serious, life-threatening condition is a close cooperation between obstetricians, midwives, anesthesiologists, general surgeons, and vascular surgeons.

Laparoscopic single-stapler technique in rectosigmoid resection in women with deep infiltrating endometriosis.

OBJECTIVE: To demonstrate the use of a single-stapler technique during rectosigmoid resection in women with deep infiltrating endometriosis (DIE). DESIGN: A step-by-step video demonstration of rectosigmoid resection and end-to-end anastomosis using two circularly placed sutures and one circular stapler. SETTING: Institute for the Care of Mother and Child, Prague, Czech Republic. PATIENT(S): A 39-year-old woman presented with primary sterility and deep infiltrating endometriosis, and an EZIAN score of A2,B2,C3. A nodule was located 9 cm from the anus and was 38 × 9 mm in size. This included an intramural fibroma of 6 cm and a left-sided ovarian endometriotic cyst of 6 cm. Her pain on the visual analogue scale were dysmenorea 6, dyspareunia 5-6, dyschezie 7, dysuria 0, and acyclic pain 5. INTERVENTIONS: The primary objective was to replace the linear-stapler resection with two simple, strictly circularly placed sutures, to cut the intestinal wall between them, and to form the end-to-end anastomosis with a circular stapler. The one-stapler technique consisted of the following steps: intestinal wall cleansing as in the limited segmental resection; placement of one strictly circular suture just below the DIE nodule, without fixation; placement of the first circular suture just below the DIE nodule, ideally with at least three full-thickness "bites" of the intestinal wall; placement of the second circular stitch approximately 2 cm below the first one in a similar manner (three full-thickness "bites"); interruption of the intestinal wall with a harmonic scalpel; end-to-end intestinal anastomosis with a circular stapler; and airtightness test of the anastomosis. This results in only one incision line and therefore a lower risk of leakage. Intestinal resection time was on average 10 minutes longer compared to that for the linear stapler technique. So far, we have successfully performed the procedure in 25 women. Perioperative leakage was observed in two of these 25 patients in the classical procedure group and in none of the 25 patients in the group with the one-stapler technique. There were no differences in C-reactive protein (CRP) on third and fifth postoperative days or in other complications such as bleeding and pyrexia). The cost of procedure is lowered by the decrease in the number of staplers from 3 to 1. The patients' postoperative follow-up was uneventful, and they were discharged from the hospital at the same time as the women in whom the classical stapler technique was performed. MAIN OUTCOME MEASURES(S): The primary outcome was the development of a new surgical approach to resection rectosigmoid endometriotic nodules that would decrease the number of incision lines on the intestine. The secondary outcome measures were peri- and postoperative complications (i.e., bleeding, intestinal leakage, postoperative infection, CRP), length of the surgery and hospitalization, and cost of the procedure. CONCLUSION: Multiple incision lines following resection of the rectosigmoid colon and end-to-end anastomosis are risk factors for postoperative intestinal leakage. Therefore, a single incision line formed with two circular sutures, and one circular stapler may reduce the risk of postoperative complications and also financial expenses of the procedure. We believe that this method is suitable and easiest for nodules located less than 6 cm from the anal verge because of possible complications with angulation of linear stapler.

Parasitic leiomyoma - a case report and review of the literature.

OBJECTIVE: The aim of this study is to report a case of parasitic leiomyoma in a brief literature report. CASE REPORT: A 40-year-old woman was repeatedly examined for chronic abdominal pain in 2020. Lesions presented on CT images showed suspicion of carcinomatosis or endometriosis. Her past history is a laparoscopic myomectomy and hysteroscopic transcervical resection of myoma. CONCLUSION: Parasitic leiomyoma or leiomyomatosis peritonealis disseminata is an extremely rare variant of uterine leiomyoma occurring outside the uterus. According to the International Federation of Gynecology and Obstetric classification, parasitic leiomyoma has been classified as type 8. Previous laparoscopic myomectomy with intraperitoneal morcellation has been implicated in its etiology. The most common symptom - if present, is abdominal pain, pressure, bloating during eating or nausea.

Risky sexual behaviour and contraceptive use among young women in the Czech Republic.

OBJECTIVE: This study aimed to obtain sexual and reproductive behaviour data of late adolescent women in the Czech Republic and to analyse the relationships between sexual behaviour and social, demographic, and behavioural factors. METHODS: Data were obtained using the Computer-Assisted Web Interviewing method from 25 April to 2 May 2018 from a representative group of sexually active women aged 18-24 years. Results were statistically evaluated using sign schema on adjusted residuals. RESULTS: A total of 525 women participated (median age of coitarche - 16 years, condom use with/without hormonal contraception - 65%, unprotected sex - 9.3% in the sexual debut). Anamnestic artificial abortion and sexually transmitted disease (STD) rates were 5.3% and 3.8%, respectively. Early coitarche, number of sexual partners, history of abortion, and STDs were positively correlated with current hormonal contraceptive use; the number of sexual partners and use of hormonal contraception were negatively correlated. Hormonal contraceptive users were more likely vaccinated against human papilloma virus (HPV) in comparison with women without any contraception. There was no correlation between risky sexual behaviour, contraceptive use, and socio-demographic factors. CONCLUSION: Women with early coitarche and a high cumulative number of sexual partners have more unwanted pregnancies and STDs; moreover, those with regular coital activity without contraception are less frequently vaccinated against HPV.

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.

Interposition of the mesorectal flap as prevention of rectovaginal fistula in patients with endometriosis.

INTRODUCTION AND HYPOTHESIS: Endometriosis is a gynecological condition characterized by endometrial tissue outside of the uterus. It affects up to 15% of women of reproductive age. In the case of bowel infiltration, about 90% of lesions are localized on the sigmoid colon or the rectum and may interfere with bowel function. Three surgical approaches are possible: (1) shaving technique, (2) discoid resection of the nodule, and (3) segmental resection with end-to-end anastomosis. A rectovaginal fistula is feared as a postoperative complication mainly in simultaneous resection of the vaginal and the rectosigmoid nodules. Its prevention is a two-step surgery (the first operation on the vagina and the second on the colon) or a preventive colostomy, both of which are often thought to be too invasive for a benign condition. Herein, we suggest a one-step surgery to prevent its development. METHODS: In three women, a concomitant laparoscopic resection of the vaginal and rectosigmoid endometrial nodule was completed with interposition of a mesorectal flap. RESULTS: All surgeries were uncomplicated with no rectovaginal fistula in the postoperative period. CONCLUSION: In the hands of skilled surgeons, this one-step technique can be used to prevent rectovaginal fistula development.

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.