A pilot study on surgical reduction of the levator hiatus-the puborectalis sling.

INTRODUCTION AND HYPOTHESIS: Female pelvic organ prolapse recurrence has been shown to be associated with levator hiatal distensibility. Reducing hiatal size surgically may reduce recurrence risk. This study aims to demonstrate a novel surgical procedure, the puborectalis sling (PR sling), designed to reduce the levator hiatal area, and to assess the medium-term safety and efficacy of this procedure. METHODS: One hundred fifteen women undergoing prolapse repair with a pre-operative hiatal area on Valsalva of ≥ 35 cm2 were recruited into this phase 1 prospective multicentre pilot study. All underwent a PR sling procedure after completion of standard repairs. Primary outcome was levator hiatal area measured on ultrasound. RESULTS: One hundred ten patients were evaluated at least 3 months post-operatively. At 2.5 years average follow-up, there was an average of 12 cm2 (range 6-16 cm2) reduction in hiatal area from a mean pre-operative hiatal area of 43.9 (35-63) cm2. Thirty per cent (28/93) were symptomatic of prolapse, 66% (61/93) had clinical prolapse recurrence whilst 49% (46/93) had sonographic recurrence. Three patients required a return to theatre; one case of infection resulted in mesh removal, one had severe obstructed defecation requiring sling loosening and another had buttock pain with faecal impaction that resolved after manual disimpaction. There were no long-term sequelae. CONCLUSIONS: The levator hiatal area can be reduced surgically, with almost 30% reduction in area seen in this pilot study. The reduction was significant and sustained up to 2 years with no major long-term complications.

All Hypertensive Disorders of Pregnancy Increase the Risk of Future Cardiovascular Disease.

Hypertensive disorders of pregnancy are associated with vascular dysfunction in the pregnancy and an increased risk of long-term cardiovascular disease (CVD) in the mother. What remains to be understood is whether the length, severity of the disease, the treatment of hypertension in pregnancy, or the subtype of hypertensive disorders of pregnancy are significant predictors of future CVD. We undertook a retrospective cohort study to review all women who gave birth at a tertiary hospital in Sydney between the years 1980 and 1989 (n=31 656). A cohort of women was further defined by having hypertension during the antenatal, intrapartum, or postnatal periods (n=4387). Randomly selected records of women (n=1158) with a hypertensive disorder of pregnancy were individually reviewed to collect data on their pregnancy and pregnancy outcomes. The entire cohort then underwent linkage analysis to future CVDs. Women who presented with gestational hypertension were at greater risk of future hypertension and ischemic heart disease compared with the women who were diagnosed with preeclampsia. There was no significant difference between the women who were treated with antihypertensive medication and the women who did not receive antihypertensive medication or the duration of hypertensive disorders of pregnancy and future admission for CVD, although severity of hypertension tracked with increased risk of future hypertension in all groups. This study demonstrated that all women who present with any of the subtypes of hypertensive disorders in pregnancy are at significant risk of future CVD compared with women who remain normotensive during their pregnancy.

What do antenatal care providers understand and do about oral health care during pregnancy: a cross-sectional survey in New South Wales, Australia.

BACKGROUND: There is mounting evidence to support the lack of awareness among pregnant women about health consequences and long term risks associated with poor oral hygiene during pregnancy. A recognised and important point of influence is their interaction with health professionals, particularly when receiving Antenatal Care. However, there is limited evidence about the perceptions of ANC providers in Australia toward the provision of perinatal oral healthcare. This study was undertaken to explore the knowledge, attitudes and practices of Antenatal Care (ANC) providers in New South Wales (NSW), Australia providing perinatal oral healthcare and to identify barriers to and predictors of their practices in this area. METHODS: A cross sectional survey was undertaken of ANC providers (general practitioners, obstetricians/gynaecologists and midwives) practising in NSW, Australia. Participants were recruited through their professional organisations via email, postal mail, and networking at conferences. The survey addressed the domains of knowledge, attitude, barriers and practices towards oral healthcare, along with demographics. Data was entered into SPSS software and analysed using descriptive and inferential statistics. RESULTS: A total of 393 surveys (17.6% response rate) were completed comprising 124 general practitioners, 74 obstetricians/gynaecologists and 195 midwives. The results showed limited knowledge among ANC providers regarding the impact of poor maternal oral health on pregnancy/infant outcomes. Most (99%) participants agreed that maternal oral health was important yet few were discussing the importance of oral health or advising women to visit a dentist (16.4-21.5%). Further, less than a third felt they had the skills to provide oral health advice during pregnancy. ANC providers who were more knowledgeable about maternal oral health, had training and information in this area and greater experience, were more likely to engage in practices addressing the oral health of pregnant women. CONCLUSION: The findings suggest that ANC providers in NSW are not focussing on oral health with pregnant women. ANC providers seem willing to discuss oral health if they have appropriate education/training and information in this area. Further research at a national level is required to confirm whether these findings are similar in all Australian states.

Hypertension in pregnancy and long-term cardiovascular mortality: a retrospective cohort study.

BACKGROUND: There is growing evidence that hypertensive disorders of pregnancy are associated with increased long-term cardiovascular mortality in the mother. Hypertension in pregnancy, until recently, however, has been ignored largely as a risk factor for future cardiovascular disease and mortality because the link between the 2 is not fully understood. OBJECTIVE: To determine the association between women with hypertension in pregnancy and long-term cardiovascular disease mortality. STUDY DESIGN: All women who delivered at a metropolitan hospital between the periods of January 1, 1980, and December 31, 1989, were identified by use of the International Statistical Classification of Diseases and Related Health Problems, 9th Revision, Australian Modification. RESULTS: The total number of deliveries in the given time period was 31,656, with 4387 (14%) of the women identified as having had hypertension in their pregnancy. Using information from the New South Wales Births, Deaths and Marriages Registry and the Australian Bureau of Statistics Death Registry, we identified a total of 651 deaths from this cohort (n = 31,656). There were 521 deaths among the women who remained normotensive in their pregnancy and 129 deaths for women who had hypertension during their pregnancy. Overall, the women with hypertensive disorders of pregnancy were at greater risk of death than the women who remained normotensive in their pregnancy (odds ratio 1.56; 95% confidence interval 1.28-1.89; P < .001). CONCLUSION: Women with a history of hypertension in their pregnancy are at an increased risk of future cardiovascular mortality, and this work identifies a group of women who may benefit from early screening and intervention strategies to help decrease their risk of future cardiovascular disease.

The incidence of preeclampsia and eclampsia and associated maternal mortality in Australia from population-linked datasets: 2000-2008.

OBJECTIVE: To determine the incidence of preeclampsia and eclampsia and associated mortality in Australia between 2000 and 2008. STUDY DESIGN: Analysis of statutorily collected datasets of singleton births in New South Wales using International Classification of Disease coding. Analyzed using cross tabulation, logistic regression, and means testing, where appropriate. RESULTS: The overall incidence of preeclampsia was 3.3% with a decrease from 4.6% to 2.3%. The overall rate of eclampsia was 8.6/10,000 births or 2.6% of preeclampsia cases, with an increase from 2.3% to 4.2%. The relative risk of eclampsia in preeclamptic women in 2008 was 1.9 (95% confidence interval, 1.28-2.92) when compared with the year 2000. The relative risk of a woman with preeclampsia/eclampsia dying in the first 12 months following birth compared with normotensive women is 5.1 (95% confidence interval, 3.07-8.60). CONCLUSION: Falling rates of preeclampsia have not equated to a decline in the incidence of eclampsia. An accurate rate of both preeclampsia and eclampsia is vital considering the considerable contribution that these diseases make to maternal mortality. The identification and treatment of eclampsia should remain a priority in the clinical setting.

Paravaginal defects: a comparison of clinical examination and 2D/3D ultrasound imaging.

BACKGROUND: Paravaginal defects are often assumed to be the underlying anatomical abnormality in anterior compartment descent. Neither clinical examination nor ultrasound assessment are generally accepted diagnostic modalities. AIMS: To compare clinical examination and translabial 3D ultrasound in the detection of such defects. METHODS: Fifty-nine women without previous prolapse or incontinence surgery were seen prospectively. Clinical and ultrasound assessments were carried out in blinded fashion. 3D translabial ultrasound was undertaken after voiding and supine. Volumes were acquired at rest, on Valsalva and on levator contraction. Loss of paravaginal support ('tenting') in the axial plane was taken to signify paravaginal defects. RESULTS: Paravaginal defects were reported clinically in 14 cases on the left (24%), 19 times on the right (32%). Two 3D ultrasound examinations did not yield satisfactory volumes, leaving 57 for analysis. Neither midsagittal nor coronal views yielded data that correlated with clinical assessments. In the axial plane there was absence of tenting at rest in 32/57 (57%) patients, but this did not correlate with clinical findings. Loss of tenting on Valsalva was observed less often (21/57, 37%) and was weakly associated with clinically observed lateral defects (P = 0.036). CONCLUSIONS: Pelvic floor ultrasound in midsagittal, axial or coronal planes does not correlate well with clinical assessment for paravaginal defects. This could be due to poor clinical assessment technique or limitations of the ultrasound method. On the other hand, paravaginal defects may be uncommon or clinically irrelevant. On present knowledge, the paravaginal defect has to be regarded as an unproven concept.

Which bowel symptoms are most strongly associated with a true rectocele?

BACKGROUND: Posterior vaginal wall prolapse is common in parous women and may be due to rectocele, enterocele or perineal hypermobility. Translabial ultrasound can be used to detect defects of the rectovaginal septum, that is, a 'true rectocele', potentially avoiding the need for defecation proctography. However, it is currently unknown whether specific sonographic appearances are associated with bowel symptoms. AIMS: To correlate symptoms of bowel dysfunction and sonographic findings. METHODS: In a prospective observational study, 505 women were seen during attendance at tertiary urogynaecological clinics and underwent a standardised interview, which included a set of questions regarding bowel function. They were assessed clinically and by translabial ultrasound, supine and after voiding. The presence of a rectocele was determined on maximal Valsalva. RESULTS: Clinically, 314 women (64%) were found to have a rectocele. There were associations between clinical staging and ampullary descent on ultrasound (P < 0.001), the presence of a true rectocele (P < 0.001) and the depth of a defect (P < 0.001). Defects of the rectovaginal septum ('true rectocele') were identified in 54%. They were associated with symptoms of incomplete bowel emptying (P < 0.001) and digitation (P = 0.002), and less so with dyschezia (P = 0.01), faecal incontinence (P = 0.02) and chronic constipation (P = 0.04). CONCLUSIONS: True rectoceles are found in more than half of women presenting with pelvic floor disorders. This finding correlates strongly with clinical prolapse grading--large clinical rectoceles are more likely to be caused by a fascial defect. Incomplete bowel emptying and digitation are significantly associated with such defects detected on ultrasound.