Göran Lingman

Long-term ailments due to anal sphincter rupture caused by delivery--a hidden problem.

Questionnaires concerning ailments were sent postpartum (mean two years) to 62 women with anal sphincter ruptures (ASR), who were compared with a matched control population. The frequency of anal sphincter rupture at the hospital during delivery in the period, 1978-82, was 0.7% (n = 63). Primiparity, instrumental deliveries, abnormal presentation, large babies and oxytocin stimulation were all risk factors. Of 59 women answering the questionnaire 37 (63%) stated that they had had ailments three months postpartum, mainly with pain and involuntary passage of flatus but also with dyspareunia and occasional incontinence of faeces. Long-term symptoms were noted by 28 (48%) of the women, mainly with involuntary passage of flatus but also perineal pain, dyspareunia and occasional incontinence of faeces. Long-term symptoms occurred in 7 (88%) of women with ASR also involving the anal mucosa, but only in 21 (39%) of those with ASR only. Three of the patients subsequently underwent reconstructive surgery, and three complained of psychological problems.

Three methods for hysterectomy: a randomised, prospective study of short term outcome

Objective To detect differences in clinical short term outcome between total abdominal hysterectomy, vaginal hysterectomy and laparoscopic assisted vaginal hysterectomy.

Blood flow in the fetal descending aorta; intrinsic factors affecting fetal blood flow, i.e. fetal breathing movements and cardiac arrhythmia

An ultrasonic method combining real-time ultrasonography and pulsed Doppler technique was used for the examination of blood flow in the fetal descending aorta. The mean aortic blood flow velocity in the last trimester of normal pregnancies was 29.0 cm/s; the peak maximum velocity 97.3 cm/s and the mean blood flow 238.4 ml/min/kg. The blood flow velocity did not change significantly with gestational age, the aorta diameter showed a linear growth. During labour, the aortic blood flow in undistressed fetuses was not different from the flow recorded during late pregnancy. Fetal breathing movements modulate the flow velocity signals in the descending aorta, the inferior vena cava and the umbilical vein of the fetus; therefore, when quantifying fetal blood flow, only periods without fetal breathing movements should be considered. A group of fetuses with various types of cardiac arrhythmias was examined. Postextrasystolic potentiation was found to be present already during intrauterine life. The present method enables quantitative evaluation of the hemodynamic effects of cardiac arrhythmias.

Anal sphincter function after delivery: a prospective study in women with sphincter rupture and controls

Twenty-one consecutive women with anal sphincter muscle rupture during delivery (0.79%) and 15 controls were examined. The anal sphincter was immediately repaired in the study group and the function determined with anal profilometry at 3 days and 3 months after delivery, and in ten of the patients after 12 months. Anal sphincter strength was reduced soon after delivery in the controls but regained normal strength within 3 months. In the anal sphincter rupture group, an improvement was found over the first 3 months after delivery, but afterwards no further change occurred. The anal sphincter strength was significantly reduced compared to the control group, both soon after delivery and after 3 months. Their voluntary anal pressure increased from 1.7 kPa immediately after delivery to 3.2 kPa at 3 months in the study group and the corresponding values in the control group were 4.0 and 6.5 kPa, respectively. For the closing pressure, that is the resting pressure minus the rectal pressure, the values in the study group were 4.2 and 6.7 kPa, and in the control group 7.2 and 9.4 kPa, respectively. In the women with anal sphincter rupture, however, a significantly increased frequency of gas incontinence was found.

Fetal central blood circulation in the third trimester of normal pregnancy, a longitudinal study. I: Aortic and umbilical blood flow

Fetal central blood circulation was evaluated in 21 uncomplicated pregnancies every other week from the 27th gestational week till term. Blood flow in the fetal descending thoracic and abdominal aorta and in the intra-abdominal umbilical vein was measured with a combined ultrasound real-time and 2 MHz pulsed Doppler technique. The mean fetal blood velocities were fairly constant at the three measuring sites during the last trimester: 34.6 cm X s-1 (S.D. 5.5), 32.7 cm X s-1 (S.D. 5.5) and 12.6 cm X s-1 (S.D. 3.1), respectively. The aortic diameter increased with gestational age, whereas the umbilical vein diameter increased until the 34th gestational week followed by a stagnation. The mean weight-related blood flow in the fetal thoracic descending aorta decreased slightly towards term (from 240.8 ml X min-1 X kg-1 (S.D. 53.6) in the 28th week to 212.6 ml X min-1 X kg-1 (S.D. 37.3). In the umbilical vein, the corresponding blood flow decrease was linear and more pronounced: from 138.7 ml X min-1 X kg-1 (S.D. 76.0) to 65.2 ml X min-1 X kg-1 (S.D. 14.2). The results indicate that the placental proportion of fetal blood flow decreases with gestational age.

The female pelvic floor: A dome‐not a basin

Background. Classically and based on necropsy observations, the muscles of the pelvic floor (the levator ani and coccygeus muscles) have been described as having the shape of a basin. In a previous study by Hugosson et al. (1991), magnetic resonance imaging revealed the dome shape of the pelvic floor in live subjects when muscular tonus is present.

Ultrasound measurement of fetal blood flow in predicting fetal outcome

Summary. The efficacy of fetal blood flow assessment in predicting fetal outcome was evaluated in 159 pregnancies suspected of intrauterine growth retardation (IUGR). Blood flow in the fetal aorta and umbilical vein was measured with imaging and pulsed Doppler ultrasound. Volume blood flow values and variables describing the waveform of the maximum aortic blood velocity were checked for relations to subsequent fetal outcome. A new semi‐quantitative velocity waveform variable, blood flow class (BFC), was designed and tested. The occurrence of IUGR, imminent fetal distress, a low Apgar score at f and 5 min, and a low pH in the umbilical artery and vein were adopted to characterize fetal outcome. Receiver operating characteristic curves were used to demonstrate the sensitivity and false positive rate, and the Cohens Kappa index was used to compare the predictive capacity of the various blood flow variables. BFC, describing the blood velocity waveform with emphasis on its end‐diastolic part, was found to be the most powerful marker of imminent fetal asphyxia (Kappa = 0.66) and of intrauterine growth retardation (Kappa—0.48).

Fetal central blood circulation in the third trimester of normal pregnancy - a longitudinal study. II. Aortic blood velocity waveform

Waveform of the maximum blood velocity recorded from the fetal descending thoracic and abdominal aorta was analyzed in a longitudinal study on 21 normal pregnancies from the 27th gestational week till term. Measurements of blood velocity were performed with combined real-time linear array and 2 MHz pulsed Doppler ultrasound technique every second week. The rising (RS) and the descending (DS) slopes did not change with gestational age in the thoracic descending aorta. The peak maximum velocity, the pulsatility index (PI) and the acceleration time percentage were constant during the last trimester of pregnancy, in both the thoracic and the abdominal aorta. In the former, the mean RS was 29.9 (S.D. 4.9), mean DS 5.3 (S.D. 0.9), mean peak velocity 115.6 cm X s-1 (S.D. 19.0), mean PI 1.96 (S.P. 0.31) and the mean acceleration time percentage 19.2% (S.D. 2.2). In the abdominal aorta, the mean RS was 25.7 (S.D. 5.6), mean DS 4.5 (S.D. 0.9), mean peak velocity 99.7 cm X s-1 (S.D. 18.8), mean PI 1.68 (S.D. 0.28) and the mean acceleration time percentage 19.1% (S.D. 2.2). The PI and the DS, considered to reflect mainly peripheral vascular resistance, were mutually related (r = 0.72). The acceleration time percentage, RS and PI did not show any relation to fetal heart rate or gestational age which justifies the use of gestational age-independent reference values for those parameters during the last 3 months of gestation, at least within the normal fetal heart rate range.

Circulatory Changes in Fetuses with Imminent Asphyxia

Blood flow was measured in 11 term fetuses who were later delivered by means of emergency caesarean section because of cardiotocographic changes indicating imminent asphyxia. Blood flow was recorded in the fetal descending aorta and in the intraabdominal part of the umbilical vein by combined real-time and 2-MHz pulsed Doppler ultrasound method. In all 11 fetuses, the waveform of the maximum aortic blood velocity was changed in a typical way with elimination of the diastolic flow (zero flow). In 4 of the fetuses, a short-lasting reversal of the diastolic flow occurred. In 5 fetuses, the pulsatility index of the aortic flow was increased, and the aortic volume flow was pathologically low in 3 fetuses. In the umbilical vein, the volume flow was within normal limits in all cases. The umbilical flow, which normally is continuous and nonpulsatile, showed heart-synchronous pulsations in 3 of the fetuses. The typical changes in the aortic diastolic flow occurred 1-3 days before the onset of the cardiotocographic changes. This suggests that the changes in the fetal aortic blood velocity might be a clinically useful early sign of imminent asphyxia.

Validation of fractional moving blood volume measurement with power Doppler ultrasound in an experimental sheep model

To compare fractional moving blood volume (FMBV) estimation using power Doppler ultrasound (PDU) with blood flow estimation using radioactive microspheres (RMS) for evaluation of fetal organ blood perfusion.