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Use of endoanal ultrasound in detecting obstetric anal sphincter injury immediately after birth
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology.
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.ORCID iD: 0000-0001-8871-7783
Department of Obstetrics and Gynecology, Östersund Hospital, Östersund, Sweden.
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.ORCID iD: 0000-0001-5838-9133
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2023 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 102, no 3, p. 389-395Article in journal (Refereed) Published
Abstract [en]

Introduction: Obstetric anal sphincter injury (OASI) complicates around 5% of deliveries in primiparas. The study objective was to assess the utility of three-dimensional endoanal ultrasonography (3D-EAUS) in the diagnosis of OASI.

Material and methods: The present study was designed to mirror screening settings with an unselected cohort of nulliparous women. All enrolled patients underwent clinical examination of the perineum by the caregiver, and 3D-EAUS was conducted. Post-processing of ultrasonography volume data was performed by an experienced colorectal surgeon who was blinded to all other data. The sensitivity, specificity, negative predictive value, and positive predictive value of 3D-EAUS in the diagnosis of OASI was evaluated. The trial is registered at ISCRTN: 18006769.

Results: A total of 680 scans were performed, of which 18.5% were judged as “non-assessable”, resulting in 554 assessable recordings. Sphincter defects were observed in 12.8% of all assessable recordings on 3D-EAUS (n = 71). With clinical examination set as the reference standard, ultrasound sensitivity in the diagnosis of OASI was 30.4%, whereas its specificity was 87.9%. The negative predictive value was 96.7% and the positive predictive value was only 9.9%. Comments were left on 175 examinations, of which 74% referred to the management of the examination.

Conclusions: Using 3D-EAUS in a maternity ward is demanding because staff generally have little experience in endoanal ultrasound, which contributes to difficulties in obtaining good image quality. When 3D-EAUS is performed to mirror screening settings, it adds no convincing diagnostic power to clinical examination in the diagnosis of OASI.

Place, publisher, year, edition, pages
John Wiley & Sons, 2023. Vol. 102, no 3, p. 389-395
Keywords [en]
endoanal ultrasound, feasibility, obstetric anal sphincter injury, pelvic floor, postpartum, three-dimensional endoanal ultrasonography
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
URN: urn:nbn:se:umu:diva-204498DOI: 10.1111/aogs.14514ISI: 000916695700001PubMedID: 36683208Scopus ID: 2-s2.0-85147035441OAI: oai:DiVA.org:umu-204498DiVA, id: diva2:1735162
Funder
Region Jämtland Härjedalen, 8176Västerbotten County CouncilVisare NorrAvailable from: 2023-02-08 Created: 2023-02-08 Last updated: 2024-04-09Bibliographically approved
In thesis
1. To tear and to heal: pelvic floor dysfunction and childbirth
Open this publication in new window or tab >>To tear and to heal: pelvic floor dysfunction and childbirth
2023 (English)Doctoral thesis, comprehensive summary (Other academic)
Alternative title[sv]
Att brista och att läka : bäckenbotten efter förlossning
Abstract [en]

Background: Up to 80% of women are affected by a perineal laceration after their first vaginal birth. An estimated 40–50% of lacerations involve the perineal muscles, and up to 7% are obstetric anal sphincter injuries (OASI). There is a lack of knowledge about the extent of short-term complications such as pelvic floor dysfunction (PFD) following spontaneous or iatrogenic pelvic floor trauma. Women’s experiences of daily life after childbirth complicated by OASI is poorly understood. Three-dimensional endoanal ultrasonography (3D-EAUS) is a welldocumented method for evaluating damage to the anal sphincter in other contexts. Adding ultrasonography to standard clinical examination has revealed injuries previously missed, and research evaluating diagnostic methods for the routine screening of OASI has been called for.

Aim: This thesis aims to evaluate the diagnostics of OASI, determine if the degree of perineal injury or anal sphincter defects after childbirth are associated with pelvic dysfunction, and explore women’s experiences of OASI.Methods Studies I and IV were prospective cohort-studies to evaluate any association between perineal tear or sphincter defect to PFD. Study II was an interview study addressing women’s experiences of OASI by qualitative content analysis. Study III was a cross-sectional study designed to examine the utility of endoanal ultrasound to detect OASI. Participants were clinically examined after birth and 3D-EAUS was performed immediately after giving birth and 3 months postpartum. PFD was evaluated using a web-based questionnaire one year after delivery.

Results: A total of 511 women completed the one-year questionnaire (Study I) and a purposive sample of 11 women were invited to take part in Study II. In Study III, 680 women underwent a clinical examination and 3D-EAUS recording immediately after birth. In Study IV, 239 women who attended all follow-ups were included. PFD was experienced by women with a perineal laceration of any grade, but also those with an intact perineum. Dyspareunia and urinary incontinence were the most common problems. Women with OASI had a higher risk for developing vi symptoms of prolapse, urinary urge incontinence, dyspareunia, and pain as well as experiencing a negative impact on their daily life. Elements that negatively influenced women’s experiences of OASI were pain and symptoms of PFD, normalisation of symptoms by healthcare providers, and unrealistic expectations about this period in life. 3D-EAUS immediately after delivery had poor sensitivity and specificity in detecting clinically diagnosed OASI. Postpartum anal sphincter defects were associated with genital pain and dyspareunia.

Conclusions: OASI is an evident risk factor for pelvic floor dysfunction after childbirth, but symptoms of pelvic floor disorder were found to be common, even in women with mild to moderate perineal laceration. OASI has a negative impact on how a woman experiences relationships, social contact, and sexuality. Using 3D-EAUS in a maternity ward to diagnose OASI is demanding. Staff generally have little experience in 3D-EAUS. There are also difficulties in obtaining good image quality, due to local oedema, bleeding, positioning of the woman, and unintentional movements. These factors all complicate the interpretation of images.

Place, publisher, year, edition, pages
Umeå: Umeå University, 2023. p. 92
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2241
Keywords
pelvic floor disorders, endosonography, dyspareunia, perineum, pain, qualitative research, delivery
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
Medicine
Identifiers
urn:nbn:se:umu:diva-206520 (URN)978-91-7855-997-8 (ISBN)978-91-7855-998-5 (ISBN)
Public defence
2023-05-05, Hörsalen, Östersunds sjukhus, Östersund, 09:00 (Swedish)
Opponent
Supervisors
Funder
Region Jämtland Härjedalen, 8176Region Jämtland Härjedalen, 8266Visare Norr, 2048
Available from: 2023-04-14 Created: 2023-04-10 Last updated: 2023-04-13Bibliographically approved

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Huber, MalinLarsson, CharlottaStrigård, KarinNordin, PärTunón, Katarina

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