History Of Obstetric Anal Sphincter Injury Research Articles

Pelvic floor function after third and fourth degree perineal lacerations: a case-control study on quality of life

BackgroundThe primary aim of this study was to compare the quality of life between women with obstetric anal sphincter injury (OASI) and women with intact perineum or minor vaginal tears following their first vaginal birth through a validated urogynaecological questionnaire. As a secondary aim, we wanted to identify the specific symptoms for pelvic floor dysfunction after a vaginal birth.MethodsOne hundred thirty-three cases (III- and IV-degree vaginal tears) and 133 controls (intact perineum or I- and II-degree vaginal tear) were asked to fill the PFDI-20 condition-specific and quality of life survey at three and 12 months after vaginal delivery. The survey evaluates pelvic floor dysfunction symptoms through three subsections: the Pelvic Organ Prolapse Distress Inventory (POPDI), the Colorectal-Anal Distress Inventory (CRADI), and Urinary Distress Inventory, (UDI). The scoring system ranges from 0 (no distress) to 100 (maximum distress) for each subsection, subsequently summed up to obtain the summary score (0 to 300). The patients recruited were asked to complete the survey at 3- and 12-months follow-up visit. Accordingly, data collection started. Categorical variables were subjected to Chi-square test or Fisher’s Exact test. Quantitative variables were compared through Student’s t-test or Mann-Whitney test.ResultsAll surveys have shown statistically significant differences when comparing the cases to the control group. Consequently, PFDI-20 has shown a strong correlation between III- and IV-grade lacerations and pelvic floor dysfunction persistence at 12 months after delivery. Intestinal symptoms were the most reported disturbances among women with previous OASI.ConclusionsMajor vaginal tears have demonstrated to have a strong impact on women’s quality of life up to a follow-up of 12 months. The use of PFDI-20 questionnaire is a useful and valid tool in the diagnosis and follow-up of genital prolapse, fecal and urinary incontinence in primiparous women with a history of OASI. Thus, its application in clinical practice can help offering the most adequate rehabilitative treatment.

Impact of Crohn's disease on obstetrical management

ObjectivePatients with Crohn's disease (CD) may have perineal lesions or a history of anorectal surgery that raise concerns about complications during delivery resulting in a discussion of cesarean section. Our objective was to study the impact of CD on the mode of delivery. MethodWe conducted a retrospective study between 2005 and 2019 of the pregnancy outcomes of patients with CD. The primary endpoint was the performance of a cesarean section for a reason related to CD. ResultsAmong 76 consecutive pregnancies, 19 patients underwent CD-related cesarean section (25%). The main element associated with scheduling a cesarean section was the existence of perineal involvement in 94.7% of cases, compared to 12.3% in the rest of the CD population (p<0.05). The perineal lesions most often involved were fistulas (47.4% versus 1.7%; p = 0.042). There was a history of perineal surgery in 78.9% of cases in the cesarean group vs 10,5% (p < 0.05) and a history of obstetric anal sphincter injury (OASI) in 10.5% of cases vs. 0 (p = 0.047). In women who gave birth vaginally, there were 17.9% episiotomy and one case of OASI (2.6%). ConclusionThe factors that influenced the choice of delivery route were perineal damage, history of perineal surgery and history of OASI.

3T external phased-array magnetic resonance imaging in detection of obstetric anal sphincter lesions: a pilot study.

Three-dimensional endoanal ultrasound (3D EAUS) has been the gold standard for detecting anal sphincter lesions in patients with a history of obstetric anal sphincter injury (OASI). Advances in imaging technologies have facilitated the detection of these lesions with external phased-array magnetic resonance imaging (MRI), which could offer an alternative imaging modality for the diagnosis of residual OASI (ROASI) in centers where 3D EAUS imaging is not available. To compare two diagnostic modalities: the 3D EAUS and 3T external phased-array MRI in the detection of residual anal sphincter lesions. A total of 24 women with a history of OASI were imaged with both 3D EAUS and 3T external phased-array MRI after primary repair of the injury. Intraclass correlation (ICC) and interrater reliability (IRR) values were calculated for the grade and circumference of the sphincter lesion. Sphincter lesions were graded according to the Sultan classification. There was an almost perfect agreement between 3D EAUS and 3T external phased-array MRI in determining the extent of the sphincter lesions according to the Sultan classification (κ = 0.881; P < 0.001) and the circumference of the external anal sphincter defects, measured in degrees (κ = 0.896; P < 0.001). The results of this study indicate that 3T external phased-array MRI and 3D EAUS yield comparable results in the diagnosis of ROASI. These findings suggest that 3T external phased-array MRI could serve as an alternative diagnostic modality to 3D EAUS in the diagnosis of ROASI.

Obstetric Anal Sphincter Injuries (OASIS) in Multiparous Women With the Use of Epidural Anaesthesia: A Retrospective Cohort Study

(Aust N Z J Obstet Gynaecol. 2021;61:30–34) Epidural anesthesia is the gold standard for managing labor pain. But it is also associated with longer second stage of labor and an increased risk of instrumental vaginal delivery, which can lead to obstetric anal sphincter injuries (OASIS). The risk of OASIS is 5.7% in women giving birth for the first time, compared with 1.5% in multiparous women with no history of OASIS. The aim of this study was to evaluate the impact of epidural use in multiparous women on the rates of OASIS and other outcomes.

Transperineal anal sphincter complex evaluation after obstetric anal sphincter injuries: With or without tomographic ultrasound imaging technique?

Objectives“Significant” obstetric anal sphincter injuries (OASIS) have been defined as visible defects of at least 30° in at least 4/6 slices using tomographic ultrasound imaging (TUI) with transperineal ultrasound (TPUS). The objective of this study was to assess if TUI is mandatory for the evaluation of OASIS. MethodsPatients with a history of OASIS were evaluated by performing 3D-endoanal ultrasound (EAUS) and 3D-TPUS with and without TUI. Any damage to the internal (IAS) or external (EAS) anal sphincters was recorded and scored using the Starck’s and the Norderval’s systems. Intraobserver and inter-techniques correlations were calculated. ResultsFrom September 2012 to May 2015, 63 women, mean age 32.5 ± 4.6 years, with OASIS (3a: 26 pts., 41.3 %; 3b: 26 pts., 41.3 %; 3c: 6 pts., 9.5 %, 4: 4 pts., 6.3 %, “button hole” tear: 1 pt., 1.6 %). Inter-technique and intraobserver correlations were excellent (TUI: k = 0.9; sweeping technique: k = 0.85; EAUS: k = 0.9) in determining OASIS. Using the Starck’s Score, excellent correlation was found for both TPUS modalities (TUI: k = 0.86; sweeping technique: k = 0.89). However, for the different individual parameters, the correlation was moderate for EAS depth (TUI: k = 0.44; sweeping technique: k = 0.5) and good for IAS depth (TUI: k = 0.7; sweeping technique: k = 0.78). Similar results were found using the Norderval’s classification. ConclusionsOASIS can be assessed by TPUS without TUI technique, dragging the rendered box and following the anal canal from the anal verge to the anorectal junction in the longitudinal plane and describing findings.

Parity and anal sphincter trauma.

Obstetric anal sphincter injury (OASI) is a form of maternal trauma secondary to vaginal birth. Women with a history of OASI are deemed to be at a higher risk of recurrence. However, it is unclear if multiparity is associated with higher prevalence. The aim of the study was to test the following hypothesis: the prevalence of external anal sphincter (EAS) tears diagnosed on transperineal ultrasound (TPUS) is related to vaginal parity. A retrospective observational study on 1,273 women who attended a tertiary urogynecology service between January 2014 and December 2016. Patients had undergone a standardized interview, clinical examination and 4D TPUS. Tomographic ultrasound imaging was used to evaluate the EAS, blinded to all clinical data. Of 1,273 women, 1,143 (90%) were vaginally parous, with a mean vaginal parity of 2 (range 1-8). Mean age was 54 (range 17-89) years. Anal incontinence was reported in 186 women (15%) with an average St Mark's incontinence score of 12 (range 1-23). EAS defects on ultrasound were identified in 148 (12%). On univariate analysis, there was no significant difference in the prevalence of EAS defects in vaginally primiparous and multiparous women (p = 0.460). There is no significant difference in the prevalence of EAS tears between vaginally primiparous and multiparous women. This argues against additional traumatic effects of subsequent vaginal births.

Anatomic and functional evaluation of the levator ani muscle after an obstetric anal sphincter injury.

To study the relationship between symptoms of anal incontinence (AI) and the anatomy and functionality of the levator ani muscle in women with a history of obstetric anal sphincter injury (OASI). This is a cohort study including patients with OASI from 2013 to 2016. Patients were assessed by a physical examination, endoanal ultrasound using Starck Scale, perineometry and 4D transperineal ultrasound. AI in all patients was measured with the Wexner scale. Correlation between variables has been analyzed in these patients. 72 patients were analyzed: 28 with a IIIA degree tear, 26 with a IIIB, 13 with a IIIC and 5 with a IV. 38 patients showed a residual anal sphincter (AS) defect on endoanal ultrasound with an average Starck score of 6.5 ± 3.7. 21 patients expressed AI, withan average Wexner score of 4.1 ± 2.4. In 27 (37.5%) patients, a levator ani avulsion was observed: 17 unilateral and 10 bilateral. Patients with a levator ani defect had weaker pelvic floor muscle (PFM) function. These differences were statistically significant with perineometry (p = 0.01 and p = 0.03) but not for the Oxford test (p = 0.08). Patients with a residual AS defect as well as an injury to the levator ani muscle expressed greater AI symptomatology than patients with residual sphincter injury who maintain the integrity of the levator ani: Wexner 4.9 0.9 vs 3.3 1 (p = 0.02). The PFM has correlation with AI symptom development in patients with a history of OASI. Therefore, we suggest a key role of anatomical and functional assessments of the levator ani muscle in these patients.

012 Sexual function in women with obstetric anal sphincter injuries in the postpartum period. Analysis according to the mode of delivery

To evaluate sexual function in women with and without history of obstetric anal sphincter injuries (OASIS), according to the mode of delivery. A total of 320 women were included in a prospective study: 140 with history of primary repaired OASIS and 180 women without OASIS as the control group. All patients filled out the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) at 6 months postpartum (score 0-48, the more the better). Questions number 5 (pain), 6 (urinary incontinence during intercourses) and 12 (quality of orgasm) were analyzed individually. Sexual function of women was compared according to the mode of delivery. Results of PISQ-12 of women with and without history of OASIS were similar (8.1±3.6 OASIS vs 7.5±1.8 no-OASIS;NS), as the percentage of women sexually active (PWSA) at 6 months postpartum was (73%OASIS vs 69% no-OASIS). Considering patients with normal deliveries (with and without OASIS), no differences were found considering the PISQ-12 (8±1.9 both), but the PWSA was significantly higher among women without OASIS: 44/60 (73%) and 43/44 (98%). Surprisingly, when patients with instrumental deliveries (ID) were compared, the PWSA was significantly higher among women with OASIS (59/80, 73%) vs no-OASIS (82/136, 60%). Results of PISQ-12 were non significantly higher in the OASIS group (8.1±4.5 OASIS and 7.3±41.8 no-OASIS; NS). When all participants were compared according to the mode of delivery (normal vs ID), clear differences were found in PISQ-12 total score (6.6±3.4 normal vs 5±4.5 ID;p<0.001). ID scored worse in question 5, 6 and 12 than women with normal deliveries.

Development of a Risk Score to Predict Obstetric Anal Sphincter Injuries in Laboring Patients [8OP

INTRODUCTION: We piloted the utility of a scoring system to predict patient risk of obstetric anal sphincter injury (OASIs) during labor. METHODS: Among the 9,800 women with singleton term cephalic vaginal deliveries within Kaiser Permanente Northern California between January and December 2013 with complete study data, 8.5% (n=833) of the nullipara and 3.5% (n=343) of the multipara incurred OASIs. Multivariable logistic regression and classification and regression tree analyses were used to identify risk factors. Maternal and gestational age, race/ethnicity, duration of second stage of labor, vacuum delivery, and history of OASIs were associated with OASIs. Stratified by parity, points were assigned to each risk factor as an integer on a 10-point scale based on effect size and impact in the regression analyses, and were externally validated within a similar separate patient cohort using multivariable logistic regression. RESULTS: Different OASIs risk score cut-offs were assessed. Among nulliparous women, a score ≥6 had 40% sensitivity and 91% specificity, whereas a score ≥4 had 51% sensitivity and 84% specificity. Among multiparous women, a score ≥7 had 89% sensitivity and 60% specificity compared to a score ≥10, which had 74% sensitivity and 72% specificity. CONCLUSION: These pilot scores, demonstrating a reasonable predictor of OASIs risk, illustrate the utility of a clinical risk score to inform providers of patients' risk of OASIs prior to delivery and facilitate a shared decision-making approach to labor management.

Residual defects after repair of obstetric anal sphincter injuries and pelvic floor muscle strength are related to anal incontinence symptoms.

The aim was to analyze the correlation between residual anal sphincter (AS) defects and pelvic floor muscle (PFM) strength on anal incontinence (AI) in patients with a history of obstetric AS injuries (OASIS). From September 2012 to February 2015, an observational study was conducted on a cohort of females who underwent repair of OASIS intrapartum. The degree of OASIS was scored intrapartum according to Sultan's classification. Participants were assessed at 6months postpartum. Incontinence symptoms were evaluated using Wexner's score and PFM strength using the Modified Oxford Scale (MOS). 3D-endoanal ultrasound was performed to classify AS defects according to Starck's system. Correlation between Sultan's and Starck's classifications was calculated using Cohen's kappa and Spearman's rho (Rs) test. The impact of residual AS defects and PFM strength on AI was analyzed using a multiple regression model. A total of 95 women were included in the study. Good correlation (κ= 0.72) was found between Sultan's and Starck's classifications. Significant positive correlation was observed between Wexner's score and both Sultan's (p = 0.023, Rs =0.212) and Starck's (p < 0.001, Rs =0.777) scores. The extent of the residual AS defect was the most relevant factor correlating with AI symptoms. In patients with severe AS injuries, higher MOS values were associated with lower Wexner's score. The degree of AS tear measured intrapartum was the most important factor related to AI after primary repair of OASIS. PFM strength was associated with lower incontinence symptoms in the postpartum period.

Familial risk of obstetric anal sphincter injuries: registry‐based cohort study

To investigate the aggregation of obstetric anal sphincter injuries (OASIS) in relatives. Population-based cohort study. The Medical Birth Registry of Norway from 1967 to 2008. All singleton, vertex-presenting infants weighing 500g or more. Through linkage by national identification numbers, 393856 mother-daughter pairs, 264675 mother-son pairs, 134889 mothers whose sisters later became mothers, 132742 fathers whose brothers later became fathers, 131702 mothers whose brothers later became fathers and 88557 fathers whose sisters later became mothers were provided. Comparison of women with and without a history of OASIS in their relatives. Relative risk of OASIS after a previous OASIS in the family. The risk of OASIS was increased if the woman's mother or sister had OASIS in a delivery (aRR 1.9, 95% CI 1.6-2.3; aRR 1.7, 95% CI 1.6-1.7, respectively). If OASIS occurred in one brother's partner at delivery, the risk of OASIS in the next brother's partner was modestly increased (aRR 1.2, 95% CI 1.1-1.4). If OASIS occurred in one sister at delivery, the risk of OASIS in the brother's partner was also increased a little (aRR 1.2, 95% CI 1.1-1.4). However, there was no excess occurrence in sisters whose brothers' partners had previously had OASIS (aRR 1.1, 95% CI 0.9-1.3). There appears to be increased familial aggregation of OASIS. These risks are stronger through the maternal rather than the paternal line of transmission, suggesting a strong genetic role that shapes aggregation of OASIS within families. These observations must be cautiously interpreted because of bias from unmeasured confounding factors may have impacted the findings.

Risk of Recurrence and Subsequent Delivery After Obstetric Anal Sphincter Injuries

Please cite this paper as: Baghestan E, Irgens L, Bordahl P, Rasmussen S. Risk of recurrence and subsequent delivery after obstetric anal sphincter injuries. BJOG 2012;119:62–69. Objective To investigate the recurrence risk, the likelihood of having further deliveries and mode of delivery after third to fourth degree obstetric anal sphincter injuries (OASIS). Design Population-based cohort study. Setting The Medical Birth Registry of Norway. Population A cohort of 828 864 mothers with singleton, vertex-presenting infants, weighing 500 g or more, during the period 1967–2004. Methods Comparison of women with and without a history of OASIS with respect to the occurrence of OASIS, subsequent delivery rate and planned caesarean rate. Main outcome measures OASIS in second and third deliveries, subsequent delivery rate and mode of delivery. Results Adjusted odds ratios of the recurrence of OASIS in women with a history of OASIS in the first, and in both the first and second deliveries, were 4.2 (95% CI 3.9–4.5; 5.6%) and 10.6 (95% CI 6.2–18.1; 9.5%), respectively, relative to women without a history of OASIS. Instrumental deliveries, in particular forceps deliveries, birthweights of 3500 g or more and large maternity units were associated with a recurrence of OASIS. Instrumental delivery did not further increase the excess recurrence risk associated with high birthweight. A man who fathered a child whose delivery was complicated by OASIS was more likely to father another child whose delivery was complicated by OASIS in another woman who gave birth in the same maternity unit (adjusted OR 2.1; 95% CI 1.2–3.7; 5.6%). However, if the deliveries took place in different maternity units, the recurrence risk was not significantly increased (OR 1.3; 95% CI 0.8–2.1; 4.4%). The subsequent delivery rate was not different in women with and without previous OASIS, whereas women with a previous OASIS were more often scheduled to caesarean delivery. Conclusion Recurrence risks in second and third deliveries were high. A history of OASIS had little or no impact on the rates of subsequent deliveries. Women with previous OASIS were delivered more frequently by planned caesarean delivery.

Risk of recurrence and subsequent delivery after obstetric anal sphincter injuries

To investigate the recurrence risk, the likelihood of having further deliveries and mode of delivery after third to fourth degree obstetric anal sphincter injuries (OASIS). Population-based cohort study. The Medical Birth Registry of Norway. A cohort of 828,864 mothers with singleton, vertex-presenting infants, weighing 500 g or more, during the period 1967-2004. Comparison of women with and without a history of OASIS with respect to the occurrence of OASIS, subsequent delivery rate and planned caesarean rate. OASIS in second and third deliveries, subsequent delivery rate and mode of delivery. Adjusted odds ratios of the recurrence of OASIS in women with a history of OASIS in the first, and in both the first and second deliveries, were 4.2 (95% CI 3.9-4.5; 5.6%) and 10.6 (95% CI 6.2-18.1; 9.5%), respectively, relative to women without a history of OASIS. Instrumental deliveries, in particular forceps deliveries, birthweights of 3500 g or more and large maternity units were associated with a recurrence of OASIS. Instrumental delivery did not further increase the excess recurrence risk associated with high birthweight. A man who fathered a child whose delivery was complicated by OASIS was more likely to father another child whose delivery was complicated by OASIS in another woman who gave birth in the same maternity unit (adjusted OR 2.1; 95% CI 1.2-3.7; 5.6%). However, if the deliveries took place in different maternity units, the recurrence risk was not significantly increased (OR 1.3; 95% CI 0.8-2.1; 4.4%). The subsequent delivery rate was not different in women with and without previous OASIS, whereas women with a previous OASIS were more often scheduled to caesarean delivery. Recurrence risks in second and third deliveries were high. A history of OASIS had little or no impact on the rates of subsequent deliveries. Women with previous OASIS were delivered more frequently by planned caesarean delivery.