Jessica Caudwell-Hall

Does the Epi-No® birth trainer prevent vaginal birth-related pelvic floor trauma? A multicentre prospective randomised controlled trial

Vaginal childbirth may result in levator ani injury secondary to overdistension during the second stage of labour. Other injuries include perineal and anal sphincter tears. Antepartum use of a birth trainer may prevent such injuries by altering the biomechanical properties of the pelvic floor. This study evaluates the effects of Epi‐No® use on intrapartum pelvic floor trauma.

Intrapartum predictors of maternal levator ani injury

Damage to the pelvic floor during vaginal childbirth is common, and may take the form of levator avulsion or irreversible overdistension of the levator hiatus (microtrauma). Such trauma is a major risk factor for pelvic organ prolapse later in life. In this study we aimed to identify intrapartum risk factors for levator trauma.

Can pelvic floor trauma be predicted antenatally

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.

The Association Between Levator-Urethra Gap Measurements and Symptoms and Signs of Female Pelvic Organ Prolapse.

Objectives Levator avulsion is associated with pelvic organ prolapse in women. It is diagnosed clinically by a widened gap on palpation between the insertion of the puborectalis muscle on the inferior pubic ramus and the urethra. This gap can also be assessed on imaging. This study aimed to determine the association between sonographically determined levator-urethral gap (LUG) measurements and symptoms and signs of prolapse. Methods This is a retrospective study on 450 women seen in a tertiary urogynecological center for symptoms of pelvic floor dysfunction between January 2013 and February 2014. All had a standardized interview, International Continence Society Pelvic Organ Prolapse Quantification assessment and 4-dimensional translabial ultrasound. Post-imaging analysis of archived ultrasound volumes for LUG measurement was undertaken on tomographic slices at the plane of minimal hiatal dimensions and within 5-mm cranial to this plane, bilaterally at an interslice interval of 2.5 mm, blinded against all clinical data. A LUG of 25 mm or greater was considered abnormal. Results Mean LUG and maximum LUG in individuals were 22.5 mm (SD, 4.6) and 26.4 mm (SD, 6.0), respectively, with at least 1 abnormal LUG in 51% (n = 222). An abnormal LUG in all 3 slices involving the plane of minimal hiatal dimensions and within 5 mm cranial to this plane on at least 1 side was fulfilled in 24% (n = 103). The LUG measurements were strongly associated with bother, symptoms and signs of prolapse (P < 0.001 to 0.002). This remained significant on multivariate analysis controlling for potential confounding factors. Conclusions Sonographically determined LUG is strongly associated with symptoms, symptom bother, and pelvic organ prolapse on clinical examination and imaging.

OP20.03: Translabial ultrasound for the diagnosis of urethral diverticula: Short oral presentation abstracts

Objectives: Urethral diverticula (UD) are an uncommon cause of lower urinary tract symptoms in women. There is often significant delay to diagnosis. This study was designed to review ten years of experience with UD diagnosed by 4D translabial ultrasound. Methods: This was a retrospective review of patients seen between 2008 and 2018. 4121 women were examined by 3D/4D TLUS and urethroscopy with a 0-degree cystoscope. Archived US volumes were analysed in all women with the tentative or final diagnosis of ’urethral diverticulum’. Results: Of 4121 women seen during the inclusion period, 25 were found to have a major urethral abnormality on TLUS (0.6%). Of those, 17 had a cystic structure while 8 showed other abnormalities such as multiple hyperechogenic foci (HF). Urethroscopy confirmed a diverticulum in 16; 13 of which had had a cystic structure, and three multiple HF. In the 16 patients with confirmed UD, mean age was 48 (33-70) years, mean parity 2 (0-4). 7/16 (43%) presented with recurrent UTIs; the same number showed an anterior vaginal wall mass on exam. All except one were posterior. Mean maximum diameter was 13.4 (5-24) mm. The UD was simple in 8/13 (62%) and complex (ie. multilocular and/or covering >80% of the urethral circumference) in 5/13. A tract was identified on TLUS in 11/13 (84%). Conclusions: Translabial ultrasound is a valid noninvasive firstline method for the diagnosis of UD. Incidence is well below 1% in our population. A cystic structure traversing the rhabdosphincter has a high predictive value for the urethroscopic diagnosis of UD. Multiple hyperechogenic foci may indicate the presence of a small diverticulum.

OC25.05: Subjective and objective success after uphold mesh

Methods: The study group was 100 images and the test group was 186 images. (1) The study group: 3 doctors used MATLAB to trace and create the whole profile of the UH. Then the UH was induced and the semi-automatic software was obtained. (2) 2 doctors(D1 and D2)used the semi-automatic software and the manual measurement to measure the test group respectively, then, made statistical analysis to compare the measurements of the two methods. Results: 1. The semi-automatic measurement software was able to intelligently identify the UH. 2. Semi-automatic measurement was faster than manual measurement, with P=0.00. For manual measurement, the mean duration of D1 was 42.42±11.08s and that of D2 was 43.45±9.09s. For semi-automatic measurement, the mean duration of D1 was 7.49±1.51s and that of D2 was 7.52±1.37s 3. The repeatability of the two methods both were good. (1) Comparing the repeatability between two measurements of the same measurer: the values of ICC of manual measurers ranged from 0.903∼0.992, the values of ICC of semi-automatic measurers ranges from 0.931∼0.994. (2) Comparing the consistency among the different measurers: the values of ICC of manual measurers ranged from 0.896∼0.985 together with Bland-Altman plot showed that the consistency among different measurers were good, the values of ICC of semi-automatic measurers ranges from 0.933∼0.997.4. The credibility of semi-automatic measurements was good. (1) Relativity: pearson correlation coefficient(r) were 0.857∼0.985 and 0.853∼0.979. (2) Consistency: the value of ICC are 0.846∼0.985 and 0.843∼0.979. (3) Bland-Altman plot: the two methods had a good consistency and they could instead of each other. Conclusions: The intelligent identification and semi-automatic measurement software is able to intelligently identify the parameters of UH with a reliable result.

Atraumatic normal vaginal delivery: how many women get what they want?

BACKGROUND: 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.