Spontaneous Tear Research Articles

Spontaneous retinal pigment epithelial tear in type 2 choroidal neovascularization: repair mechanisms following anti-VEGF therapy

BackgroundTo report the clinical course and the multimodal retinal imaging of a spontaneous retinal pigment epithelial (RPE) tear in a type 2 choroidal neovascularization (CNV) secondary to age-related macular degeneration treated with anti-vascular endothelial growth factor (VEGF) treatment.Case presentationA 74 year-old man presented with visual acuity deterioration in the right eye. Multimodal retinal imaging showed a predominantly classic (type 2) CNV complicated by a spontaneous RPE tear. The patient received six intravitreal injections of anti-VEGF which resulted in improvement of the vision and stabilization of the neovascular lesion on optical coherence tomography (OCT). Longitudinal changes of the RPE-photoreceptors interface, including RPE splitting, are reported on OCT.ConclusionRPE tears may spontaneously occur in type 2 CNV. Anti-VEGF treatment should be aimed at promoting RPE repair and limiting the extent of the scarring. The mechanisms of RPE repair during treatment may be documented with OCT.

Spontaneous atraumatic bilateral Achilles tendon tear: surgical reconstruction of flexor hallucis longus graft

Background and objective: Spontaneous atraumatic bilateral Achilles tendon tears are very rare. The most common risk factors for sudden bilateral Achilles tendon tears have been attributed to prolonged corticosteroid use. This study aimed to present the efficiency of surgical reconstruction of bilateral flexor hallucis longus graft on spontaneous atraumatic bilateral Achilles tendon tear. Subject and methods: This study reported a 25-year-old male who suffered from spontaneous atraumatic bilateral Achilles tendon tear. The patient was surgically managed by surgical reconstruction of bilateral flexor hallucis longus graft and immobilised with above knee cast in plantarflexion for six weeks. The patient was then subjected to physiotherapy at 6 weeks after surgery. This study was approved by the Institutional Review Board of Jagadguru Sri Shivarathreeshwara Hospital, India. Results: Flexor strength at the time of removal of the cast was 3/5. After graded physiotherapy targeted at calf strengthening, flexor strength improved to 4/5. At the end of one-year follow-up, foot function recovered well. The Leppilahti score was recorded to be 78 for the right calf and 76 for the left calf at the last follow-up. Conclusion: Idiopathic spontaneous bilateral Achilles tendon tear was successfully managed by surgical reconstruction of flexor hallucis longus graft.

PERINEAL CARE AND OUTCOMES IN A BIRTH CENTER

ABSTRACT Objective: to analyse the perineal outcomes in childbirth and post-partum perineal care in a freestanding birth centre. Method: a cross-sectional study, with data collection performed in the women’s birth records forms from Casa Angela, a freestanding birth centre, São Paulo, Brazil, in 2016-2017 (n=415). The following data was analysed: occurrence and perineal tear degree; maternal, neonatal and birth care-related variables; perineal suture prevalence; complications in wound healing and natural methods on perineal care. Data were subjected to descriptive, inferential and multiple analyses. Results: in 11.8% of women, the perineum was kept intact, 61.9% had spontaneous first-degree tear and 26.3% had second-degree tear. The variables related to the occurrence and higher spontaneous degree tears were maternal age and second period of childbirth >2 hours. The protective factors against the occurrence and higher degree tears were number of previous vaginal childbirths and maternal position different from vertical during childbirth. Perineal suture was performed in 16.0% and 70.6% of women with spontaneous first- and second-degree tears, respectively. The main perineal complications after birth were edema (53.6%) and pain (29.4%); and the perineal suture increased the chance for these complications (OR=2.5; 95%CI 1.5-4.3). Perineum icepack compress was used in 53.8% of women during post-partum period. Conclusion: maternal and health-care related factors were associated to the prevalence and degree of spontaneous perineal tear. First-degree spontaneous perineal tears were prevalent and sutured in a low number of women. There were more complications in the wound healing process when the perineal suture was performed, regardless the tear degree. The number of natural methods in post-partum perineal care was higher than the use of medicines.

Obstetric outcome of women with primary vaginismus

IntroductionDysfonction importante, le vaginisme est un problème tant individuel que du couple qui peut altérer la relation sexuelle. Il peut influencer le pronostic obstétrical. Le but de cette étude était de déterminer si les caractéristiques cliniques du vaginisme ont une incidence sur le processus de l’accouchement.MéthodesEtude rétrospective multicentrique incluant des patientes affectées par un vaginisme primaire, ayant donné naissance à terme à un premier enfant vivant, entre 2005 et 2015.RésultatsSur les 19 patientes inclues dans l’étude, nous avons constaté 9 grossesses prolongées, 14 mises en travail spontanées (dont 8 à terme atteint), 3 césariennes en dehors du travail et 2 déclenchements artificiels. Parmi les 16 femmes ayant eu un travail, nous avons dénombré 4 césariennes, 5 accouchements par voie basse avec forceps et 7 par voie basse spontanée. Parmi les 12 accouchements par voie basse, 9 épisiotomies ont été pratiquées, 7 femmes ont présenté des déchirures périnéales spontanées seules ou associées à une épisiotomie, aucune lésion périnéale de type 3 ou 4, ni de périnées intacts n’ont été recensés. Le poids moyen des nouveau-nés était de 3380g±332 (2870g-3970g, 47e percentile).ConclusionLa proportion d’accouchements dystociques et la morbidité périnéale étaient notablement élevées, ce qui parait comparable avec la plupart des données de la littérature. Il est possible que les composantes psychologiques et comportementales du vaginisme, (mécanisme de peur-évitement, anxiété) aient favorisé les grossesses prolongées, les césariennes, les dystocies mécaniques et les lésions périnéales. Des études complémentaires sont nécessaires afin de mieux cerner le vaginisme et ses implications obstétricales.

Transgenic mice overexpressing human TNF-\u03b1 experience early onset spontaneous intervertebral disc herniation in the absence of overt degeneration

There is a well-established link between cytokine expression and the progression of intervertebral disc degeneration. Among these cytokines, interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α) are the most commonly studied. To investigate whether systemic hTNF-α overexpression affects intervertebral disc health, we studied the spine phenotype of Tg197 mice, a widely used hTNF-α transgenic line. These mice were studied at 12–16 weeks of age using comprehensive histochemical and immunohistological analysis of the spinal motion segment. Micro-CT analysis was performed to quantify vertebral trabecular bone architecture. The Tg197 mice evidenced spontaneous annular tears and herniation with increased vascularity in subchondral bone and significant immune cell infiltration. The full-thickness annular tear without nucleus pulposus (NP) extrusion resulted in neutrophil, macrophage, and mast cell infiltration into the disc, whereas the disc with full-thickness tear and pronounced NP herniation showed additional presence of CD4+ and CD8+ T cells. While the observed defects involved failure of the annular, endplate, and vertebral junction, there were no obvious alterations in the collagen or aggrecan content in the NP and annulus fibrosus or the maturity of collagen fibers in Tg197 mice. Despite elevated systemic inflammation and pronounced loss of trabecular bone in the vertebrae, intact Tg197 discs were healthy and showed an increase in NP cell number. The NP cells in intact discs preserved expression of phenotypic markers: CAIII, Glut1, and Krt19. In conclusion, elevated systemic TNF-α increases the susceptibility of mice to spontaneous disc herniation and possibly radiculopathy, without adversely affecting intact intervertebral disc health.

Perineal outcome following educational intervention: a retrospective audit of primiparous women

The management of vaginal delivery appears to offer an opportunity to reduce the morbidity of pelvic floor dysfunction (PFD) which is very common in the postpartum period. Research by the authors suggests that an episiotomy is protective against PFD, in particular urinary incontinence. The aim of this subsequent audit was to see if educational intervention can alter the common medical practice of episiotomy and in turn reduce postpartum PFD. Nine hundred and fifty four primiparous women with a non-instrumental vaginal delivery were included, of which 30% had an intact perineum, 51% a spontaneous tear and 19% an episiotomy. The intervention was a teaching session by the Head of Urogynaecology encompassing the anatomy, the impact of a vaginal delivery on PFD, in addition to local and international research. Whilst no significant difference was noted overall in the episiotomy rates as a result of the educational intervention (p = .17), significant differences were noted with the different accoucheur types. Where the accoucheur was an obstetrician or obstetrics registrar, the episiotomy rates increased from 56% to 70% (p < .01); where the midwife was the accoucheur the episiotomy rate changed minimally (11–18%, respectively; p = .27). This demonstrates that feedback about the provider’s own practice patterns can change the behaviour to conform with the agreed upon standards.Impact StatementWhat is already known on this subject? Pelvic floor dysfunction (PFD) is the most common complication of childbirth, affecting approximately 85% of Australian women following a vaginal delivery. A link has been made between the perineal outcome and PFD, which has a significant impact on the quality of life. Previous research suggests that the management of a vaginal delivery offers an opportunity to reduce its morbidity, with an episiotomy being protective. However, there is a wide variation in the use of episiotomy which ranges from 9% to 100%.What the results of this study add? The literature suggests that the strongest factor associated with the episiotomy rates arises from differences in the attitude and training. Consequently, this study explored whether an educational intervention can change the common medical practice of episiotomy and in turn reduce postpartum PFD.What are the implications of these findings for clinical practice and/or further research? No significant difference was noted overall in the episiotomy rates as a result of the educational intervention, however, the response to the educational intervention was varied among the different types of accoucheurs with the obstetricians, obstetric registrars and student midwives significantly increasing their rate of episiotomy, whilst the midwives demonstrated no significant change. This suggests that there are contributing factors which may include past education and experience; this is an area for further research.

Infection and wound breakdown in spontaneous second-degree perineal tears: An exploratory mixed methods study.

Perineal trauma affects large numbers of women who have a vaginal birth. This study explores the incidence, etiology and women's experiences of wound infection/breakdown associated with spontaneous second degree tears. This was an exploratory mixed methods study set in an urban tertiary National Health Service hospital in 2014-2015. The study included a prospective observational study of second-degree tears using electronic patient records. Infection was defined using criteria adapted from Public Health England's Surgical Site Infection Surveillance Service. We also did a case-control study of maternity records to explore factors associated with perineal infection/wound breakdown, and semi-structured interviews with a purposeful sample of women who experienced wound infection/breakdown. Of 2892 vaginal births during the study period, 76.8% sustained perineal trauma, with second-degree tears most commonly recorded (n=828/28.6%). Sixteen (1.9%) had a documented infection/wound breakdown which were associated with "compromised wound status" (increased severity of wound/poor suturing; P=0.033) Women complained of a lack of information about their perineum and poor postnatal surveillance by midwives and physicians. Diagnosis and treatment were often delayed by clinicians' reliance on external signs of wound infection. Although the sample size was small, there were no differences in rates of infection between sutured and unsutured second-degree tears. Although second-degree tears were common after vaginal birth, wound infection/breakdown was relatively uncommon. Women who report feeling unwell or develop pyrexia postnatally should be assessed urgently. A prospective longitudinal study exploring the long-term sequelae of second-degree tears is needed.

Investigating the Effect of Perineal Heating Pad on the Frequency of Episiotomies and Perineal Tears in Primiparous Females

Background: Female reproductive system injury caused after vaginal delivery is very common, and episiotomy and spontaneous tears, or both are the most important contributing factors in this regard. However, several techniques have been developed to reduce this damage, yet their impact has not been fully proven. Therefore, the present study was conducted to determine the effect of perineal heating pad on the frequency of episiotomies and perineal tears in primiparous females. Methods: In this single-blind clinical trial, a total of 114 primiparous females, who referred to Imam Ali Hospital in Andimeshk and were eligible to participate in the study, were randomly divided to two groups, consisting of 57 individuals. The heating pads were used in the intervention group with the start of the second stage of labor and the childbirth process was routinely carried out in the control group without any intervention. The data collection tool was a form on demographic information and characteristics of the research subjects, as well as the maternal postpartum data collection form. Data analysis was carried out using Chi-square and independent T-test using the SPSS software version 19. P values of < 0.05 were considered significant. Results: The frequency of episiotomies was 41% and 21% in the control and intervention groups, respectively. There was a significant difference between the two groups in this regard (P = 0.025). The results also showed that the perineal intactness percentage was higher in the intervention group than the control group, although this difference was not statistically significant (P = 0.512). Conclusions: The results of the current study revealed that the use of perineal heating pad during the second stage can be effective in decreasing the episiotomy rate and improving perineal intactness in primiparous females. Since there are a few studies in this regard, it is recommended to carry out further research in this field and other interventions affecting perineal tear and the episiotomy rate.

Factors associated with spontaneous perineal lacerations in deliveries without episiotomy in a university maternity hospital in the city of Recife, Brazil: a cohort study

Objectives: The objective of this study is to determine factors associated with spontaneous perineal laceration in low-risk pregnant women who delivered vaginally without episiotomy in a university maternity hospital in Recife, Pernambuco, Brazil.Methods: A prospective cohort study was conducted with 222 low-risk, full-term pregnant women admitted in labor with a single fetus in cephalic presentation. Women with malformed fetuses were excluded from the study. The variables analyzed were: the frequency and severity of lacerations, the women’s biological, sociodemographic, clinical and obstetrical characteristics, neonatal characteristics, and data on their deliveries and procedures. For the data analysis, risk ratios and their 95% confidence intervals were calculated. A significance level of 5% was adopted and multiple regression analysis was performed.Results: Spontaneous first-degree perineal tears were registered in 47% of the women, second-degree tears in 31%, and third degree tears in only 1.8%. There were no cases of fourth-degree tears. Having experienced normal childbirth previously constituted a protective factor against vaginal tearing (OR = 0.46; 95%CI: 0.23–0.91; p = .027).Conclusion: The principal protective factor against spontaneous lacerations was having experienced normal childbirth previously. Intrapartum strategies aimed at protecting the perineum and pelvic floor muscle training during prenatal care should be encouraged in these women.

Female Sexual Function and Perineal Pain Following Median versus Mediolateral Episiotomy in Primiparous Women: A Two-Year Follow up Study

Episiotomy is the most frequently performed surgical procedure for labour management especially when expedited delivery is warranted as in non-reassuring fetal heart rate tracing, a prolonged second stage of labour, or when operative vaginal delivery is indicated [1-3]. Postpartum perineal pain and dyspareunia affect about 42% of primiparous women within the first 2 weeks after vaginal delivery. Pain resolved in the majority of women within 2 months after delivery. Spontaneous second degree tears cause less perineal pain than episiotomies [4].

Perineal tears - A review

The female perineum is the diamond-shaped inferior outlet of the pelvis. This structure is at risk of trauma during labour because of spontaneous perineal tears of varying degrees or iatrogenic episiotomies. These injuries can result in disabling immediate and long-term complications in the woman. The aim of this article is to provide general practitioners (GPs) with a good understanding of perineal tears by discussing the different classifications, immediate and long-term management, and recommendations for future deliveries. Although the majority of perineal tears are managed by obstetricians and gynaecologists, it is important for GPs to understand their management in the event that a patient presents to general practice with concerns during the antenatal or postpartum period. <div class="hor-line">&nbsp;</div>.

Maternal Morbidity in Vaginal Delivery with or without Episiotomy in Nulliparous Women

Introduction: Episiotomy incision is the most common surgical procedure around the globe and in many countries, it became a routine policy. Episiotomy in all women with vaginal delivery has no benefit. Rate of episiotomy varies widely around the globe, while in Nepal all nulliparous and primi-parous hospital deliveries are given routine episiotomy. So, this study aimed to compare the maternal morbidity during first vaginal birth in women with or without episiotomy.Methods: This is a hospital based randomized prospective comparative study conducted in the Obstetrics and Gynaecology department of a teaching hospital. The subjects were divided into episiotomy group and no episiotomy group. Under local anaesthesia mediolateral episiotomy was given in the second stage with crowning of the head in episiotomy group. Nature of morbidity seen were recorded in both the groups immediately after delivery, after 6 hours and after 1 week and compared.Results: In no episiotomy group intact perineum 26.3%, laceration 10.5%, spontaneous perineal tear (first and second degree) 63.1% was observed. Total perineal surgical repair was 81.55%. Intact perineum was high among no episiotomy group. Third degree tear, vulval haematoma, wound gaping, perineal oedema were seen in episiotomy group.Conclusion: Anterior perineal laceration rate was high in no episiotomy group than episiotomy group but overall few morbidities were in no episiotomy group than in episiotomy group. So, episiotomy should not be considered to prevent insignificant anterior perineal lacerations.

Nursing Assessment of Pain during Spontaneous Perineal Tear Repairing by Comparing Two Pharmacological Methods

Nursing Assessment of Pain during Spontaneous Perineal Tear Repairing by Comparing Two Pharmacological Methods

Pharmacological obstetric analgesia: a study of obstetric and neonatal outcomes

Objective: to investigate the association between pharmacological obstetric analgesia and obstetric and neonatal outcomes. Methods: it was a retrospective case-control study conducted with 393 pregnant women comprising 131 cases of pharmacological obstetric analgesia and 262 controls that did not perform this procedure. The sociodemographic and obstetric profile, the circumstances of parturient admission, obstetrical decisions, and obstetric and neonatal outcomes were investigated. Results: pregnant women submitted to pharmacological analgesia during labor presented an increased risk for the use of exogenous oxytocin (p<0.001), episiotomy (p=0.001), Kristeller maneuver (p=0.036), and forceps (p=0.004). Conclusion: pharmacological analgesia does not increase the risk of spontaneous perineal tear, abdominal delivery, and hospitalization in neonatal unit. Nevertheless, it influences the increased risk of synthetic oxytocin use, Kristeller maneuver, episiotomy, forceps, and the occurrence of lower first-minute Apgar scores.

An Uncommon Initial Manifestation of Eosinophilic Esophagitis: Spontaneous Esophageal Tear

Background: Eosinophilic esophagitis (EoE) is a clinicopathologic disease characterized by dense eosinophilic infiltration of the esophageal mucosa. Patients usually present with long standing dysphagia or food impaction. Mucosal tears or perforation can occur as rare complications of endoscopic dilation. Spontaneous tears are an uncommon initial manifestation of EoE. Case: A 22 year old male presented with sudden onset severe midsternal chest pain, without emesis, shortly after a meal. Prior history included intermittent dysphagia to solid foods in the preceding year. Upon arrival he was afebrile, normotensive but tachycardic with chest computed tomography scan with contrast showing pan-esophageal thickening with small bilateral pleural effusions. Barium swallow showed features of thickened distal esophagus, without strictures or perforation. Esophagogastroduodenoscopy (EGD) was performed which showed a large, cratered ulcer, 30cm from the incisors in the distal esophagus. Also pallor, linear furrowing and felinization of the mucosa was seen, with proximal and distal biopsies showing 45 and 30 eosinophils per high power field (EPHPF) respectively. The clinical presentation along with endoscopic findings were concerning for a contained esophageal perforation. Patient improved with conservative management of nil oral intake and antibiotics, and was discharged a week later with pantoprazole 40mg twice daily. On EGD evaluation 2 months later, the prior ulcer had resolved. The changes of circular rings and linear furrows remained and repeat proximal and distal esophageal biopsies showed >50 EPHPF respectively. A diagnosis of eosinophilic esophagitis (EoE) was made and the patient was initiated on fluticasone therapy.Figure: Barium swallow image showing ulceration in distal esophagus.Figure: Esophagogastroduodenoscopy image showing deep esophageal ulceration.Discussion: Our patient exemplifies a rare manifestation of EoE, that can be associated with significant morbidity. Increased fragility of the esophageal mucosa from eosinophilic infiltration and subsequent remodeling alters wall compliance and can predispose to mucosal tears. While tears can occur in 0.3% of cases after endoscopic dilation, spontaneous tears are uncommon and sparsely reported. Non-surgical management leads to improvement in 50% of patients. Increased awareness of this rare but serious complication can lead to earlier diagnosis and timely intervention. Also, an evaluation of the factors that may predict early tears or perforation in EoE, is essential to minimize the incidence of this serious complication.Figure: Repeat esophagogastroduodenoscopy showing resolution of prior ulceration.

Spontaneous Tear After Insufflation: A Unique Finding of Collagenous Colitis

Spontaneous Tear After Insufflation: A Unique Finding of Collagenous Colitis

Morphologic features of spontaneous annular tears and disc degeneration in the aging sand rat (Psammomys obesus obesus)

The sand rat, a member of the gerbil family, is a valuable small animal model in which intervertebral disc degeneration occurs spontaneously as the animal ages. Radiographic features of cervical and lumbar degeneration resemble those in human spines. We conducted a retrospective analysis of spines of 140 animals 3−41 months old focusing specifically on the presence of annular tears that are not visible by radiography and have not been described previously in the sand rat disc. During degeneration of the nucleus pulposus, notochordal cell death occurs and granular material, which stains with Alcian blue for proteoglycans, accumulates. Lamellar architecture also deteriorates and annular tears occur that are morphologically similar to the concentric, radiating and transdiscal annular tears in human discs. These tears contain granular material that provides a “marker” that can be used to distinguish the annular tears from artefactual separations during sectioning. We observed lamellar degeneration and separation in the annulus fibrosus at 4 months with associated tears that contained granular material in the nucleus. Tears that contained granular material and displacement of the degenerating nucleus were common in cervical and lumbar discs of animals older than 9 months; some specimens showed tears at 4 and 5 months. With advanced degeneration, granular globules were displaced dorsally adjacent to and into the spinal cord area and also ventrally into regions where osteophytes formed. We present morphologic data that expand the utility of this rodent model of spontaneous age-related disc degeneration and provide novel information on annular tears and disc degeneration.

Aspirin (single dose) for perineal pain in the early postpartum period.

Aspirin (single dose) for perineal pain in the early postpartum period.

Spontaneous Bronchial Tear after Severe Coughing Bouts in an Old Female

Spontaneous tears of the mucosal layers are well known in esophagus after vigorous vomiting. But severe bouts of cough leading to a tear in the bronchial tree is not commonly seen and not reported yet. We report this rare occurrence in an immune-compromised female with respiratory infection.

EFFECTIVENESS OF HANDS OFF VERSUS HANDS ON TECHNIQUES ON PERINEAL TRAUMA AND PERINEAL PAIN AMONG PARTURIENT MOTHERS

Background: Labor is the process by which the fetus and the placenta leave the uterus. Delivery can occur in two ways, vaginally or by a cesarean delivery. The majority of women who have a vaginal birth will sustain perineal trauma from a spontaneous perineal tear or episiotomy or both.Aim: This study aims to assess the effectiveness of hands off versus hands on techniques on perineal trauma and perineal pain among parturient mothers in selected hospitals, Kerala.Methods: The research design adopted in this study was true experimental post test only design. The study was conducted in 3 hospitals at Kerala such as Karothukuzhiyil hospital Pvt, Lakshmi hospital Pvt and Carmal hospital Pvt. Sample size was computed by power analysis based on the previous studies and it would be a total of 90 samples, with 30 parturient mothers in each groups. Simple random sampling technique (Lottery method) was adopted for the selection of parturient mothers into the study. Perineal trauma was assessed by the scale given by Royal College of Obstetrics and Gynaecology (RCOG), 2001, and visual analogue scale (Combined numerical and categorical pain scale) was used to assess the perineal pain of parturient mothers.Results: The results showed that, there was extremely significant difference found in perineal trauma and perineal pain of parturient mothers between study group I and study II at p=0.000 level. The mean scores of study group I was lesser than the mean scores of study group II. Conclusion: Different perineal techniques and interventions such as hands on technique, hands off technique, perineal massage, warm compresses etc can be widely used by midwives and birth attendants to prevent perineal trauma during labour. Key words: hands off technique, hands on technique, perineal trauma and perineal pain