Browsing by Author "Langer, Susanne"
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Item Atraumatic normal vaginal delivery: how many women get what they want?(Elsevier Inc., 2018) Caudwell-Hall, Jessica; Kamisan Atan, Ixora; Guzmán Rojas, Rodrigo; Langer, Susanne; Shek, Ka Lai; Dietz, HansBACKGROUND: Trauma to the perineum, levator ani complex, and anal sphincter is common during vaginal childbirth, but often clinically underdiagnosed, and many women are unaware of the potential for long-term damage. OBJECTIVE: In this study we use transperineal ultrasound to identify how many women will achieve a normal vaginal delivery without substantial damage to the levator ani or anal sphincter muscles, and to create a model to predict patient characteristics associated with successful atraumatic normal vaginal delivery. STUDY DESIGN: This is a retrospective, secondary analysis of data sets gathered in the context of an interventional perinatal imaging study. A total of 660 primiparas, carrying an uncomplicated singleton pregnancy, underwent an antepartum and postpartum interview, vaginal exam (Pelvic Organ Prolapse Quantification), and 4-dimensional translabial ultrasound. Ultrasound data were analyzed for levator trauma and/or overdistention and residual sphincter defects. Postprocessing analysis of ultrasound volumes was performed blinded against clinical data and analyzed against obstetric data retrieved from the local maternity database. Levator avulsion was diagnosed if the muscle insertion at the inferior pubic ramus at the plane of minimal hiatal dimensions and within 5 mm above this plane on tomographic ultrasound imaging was abnormal, ie the muscle was disconnected from the inferior pubic ramus. Hiatal overdistensibility (microtrauma) was diagnosed if there was a peripartum increase in hiatal area on Valsalva by >20% with the resultant area ≥25 cm2. A sphincter defect was diagnosed if a gap of >30 degrees was seen in ≥4 of 6 tomographic ultrasound imaging slices bracketing the external anal sphincter. Two models were tested: a first model that defines severe pelvic floor trauma as either obstetric anal sphincter injury or levator avulsion, and a second, more conservative model, that also included microtrauma. RESULTS: A total of 504/660 women (76%) returned for postpartum follow-up as described previously. In all, 21 patients were excluded due to inadequate data or intercurrent pregnancy, leaving 483 women for analysis. Model 1 defined nontraumatic vaginal delivery as excluding operative delivery, obstetric anal sphincter injuries, and sonographic evidence of levator avulsion or residual sphincter defect. Model 2 also excluded microtrauma. Of 483 women, 112 (23%) had a cesarean delivery, 103 (21%) had an operative vaginal delivery, and 17 (4%) had a third-/fourth-degree tear, leaving 251 women who could be said to have had a normal vaginal delivery. On ultrasound, in model 1, 27 women (6%) had an avulsion and 31 (6%) had a residual defect, leaving 193/483 (40%) who met the criteria for atraumatic normal vaginal delivery. In model 2, an additional 33 women (7%) had microtrauma, leaving only 160/483 (33%) women who met the criteria for atraumatic normal vaginal delivery. On multivariate analysis, younger age and earlier gestation at time of delivery remained highly significant as predictors of atraumatic normal vaginal delivery in both models, with increased hiatal area on Valsalva also significant in model 2 (all P ≤ .035). CONCLUSION: The prevalence of significant pelvic floor trauma after vaginal child birth is much higher than generally assumed. Rates of obstetric anal sphincter injury are often underestimated and levator avulsion is not included as a consequence of vaginal birth in most obstetric text books. In this study less than half (33-40%) of primiparous women achieved an atraumatic normal vaginal delivery.Item Can pelvic floor trauma be predicted antenatally?(Nordic Federation of Societies of Obstetrics and Gynecology/ Wiley, 2018) Caudwell‐Hall, Jessica; Kamisan Atan, Ixora; Brown, Chris; Guzmán Rojas, Rodrigo; Langer, Susanne; Shek, Ka Lai; Dietz, HansIntroduction: Levator trauma is a risk factor for the development of pelvic organ prolapse. We aimed to identify antenatal predictors for significant damage to the levator ani muscle during a first vaginal delivery. Material and Methods: A retrospective observational study utilizing data from two studies with identical inclusion criteria and assessment protocols between 2005 and 2014. A total of 1148 primiparae with an uncomplicated singleton pregnancy were recruited and assessed with translabial ultrasound at 36 weeks antepartum and 871 (76%) returned for reassessment 3-6 months postpartum. The ultrasound data of vaginally parous women were analyzed for levator avulsion and microtrauma. The former was diagnosed if the muscle insertion at the inferior pubic ramus in the plane of minimal hiatal dimensions and within 5 mm above were abnormal on tomographic ultrasound imaging. Microtrauma was diagnosed in women with an intact levator and if there was a postpartum increase in hiatal area on Valsalva by >20% with the resultant area ≥25 cm2 Results: The complete datasets of 844 women were analyzed. Among them, 609 delivered vaginally: by normal vaginal delivery in 452 (54%), a vacuum birth in 102 (12%) and a forceps delivery in 55 (6%). Levator avulsion was diagnosed in 98 and microtrauma in 97. On multivariate analysis, increasing maternal age, lower body mass index and lower bladder neck descent were associated with avulsion. Increased bladder neck descent and a family history of cesarean section (CS) were associcated with microtrauma. Conclusions: Maternal age, body mass index, bladder neck descent and family history of CS are antenatal predictors for levator traum.Item The evolution of transperineal ultrasound findings of the external anal sphincter during the first years after childbirth(Springer, 2016) Shek, Ka Lai; Della Zazzera, Vincent; Atan, Ixora Kamisan; Guzmán Rojas, Rodrigo; Langer, Susanne; Dietz, Hans PeterINTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injuries (OASI) are a major form of maternal birth trauma. Ultrasound imaging is commonly used to evaluate the condition. We undertook a study to compare the sonographic appearance of the external anal sphincter (EAS) 3 to 6 months and 2 to 3 years after a first birth. METHODS: A retrospective analysis of data of primiparous women obtained in a prospective perinatal imaging study. Women were invited for postnatal assessment 3 - 6 months and 2 - 3 years after a first delivery. All had completed a standardized questionnaire, and had undergone clinical examination and translabial 4D ultrasound imaging. A "significant" EAS defect was diagnosed if four out of six slices on tomographic ultrasound imaging showed a defect of ≥30° circumference. RESULTS: Datasets of 76 women with complete data and no intervening birth were assessed. Their mean age was 30.0 years (range 19.5 - 45.3 years) at the time of antenatal assessment. They were delivered at a mean gestation of 40 weeks (range 37 - 42 weeks), by caesarean section in 19, normal vaginal delivery in 42, vacuum delivery in 14 and forceps delivery in 1. A significant EAS defect on transperineal ultrasound imaging was found in 13 of 57 women (23 %) at an average of 4.7 months and in 12 of 57 (21 %) at a mean 26.4 months after a first vaginal delivery. CONCLUSIONS: In this cohort of primiparous women after a term singleton delivery, we found only minor improvement in sonographic appearance of the EAS between 4.7 months and 26.4 months on transperineal ultrasound imaging, arguing against any significant degree of structural recovery during this time period.