Teresa Worstell

Using the Brink score to predict postpartum anal incontinence.

OBJECTIVE To evaluate whether antepartum pelvic floor muscle strength, as measured by the Brink scale, predicts postpartum anal incontinence. STUDY DESIGN This prospective cohort study of primigravid women used validated questionnaires and standardized pelvic examinations to evaluate subjects during the third trimester and at 2 postpartum time points. RESULTS Of the initial 129 subjects, 102 and 81 completed 2 week and 6 month postpartum visits. 35% had cesarean deliveries. The antepartum prevalence of fecal incontinence (14%) did not differ significantly from the postpartum (17% at 2 weeks, 11% at 6 months). However, the prevalence of flatal incontinence fell from antepartum (65%) to postpartum (47% at 2 weeks, P = .001; 49% at 6 months, P = .012). Mean Brink score decreased postpartum; no correlations were found between Brink score and questionnaire scores. CONCLUSION Anal incontinence symptoms are common in the third trimester of a first pregnancy and may regress or resolve after delivery. Brink score did not predict postpartum anal incontinence.

Length of the Second Stage of Labor: What Is the Effect of an Epidural?

INTRODUCTION: We evaluated the length of the second stage of labor in women with and without epidural analgesia to estimate the effect of an epidural. METHODS: This was a retrospective cohort study of 4,605 women without a history of cesarean delivery at a single community hospital. Length of the second stage of labor with and without an epidural was analyzed for nulliparous and multiparous women by median and 95th percentile. Data were stratified by parity. Subanalysis was performed for women with vaginal delivery. Statistical analysis was performed by Wilcoxon rank-sum test. RESULTS: Nulliparous women with epidural had second stage median length 1 hour longer than women without epidural (105 compared with 42 minutes). However, the 95th percentile for second stage length in nulliparous women with epidural compared with without was almost 2 hours longer (338 compared with 221 minutes). In multiparous women, median second stage length with epidural was 16 minutes longer than without (26 compared with 10 minutes), but the 95th percentile was 112 minutes longer (168 compared with 56 minutes). When analyzing for women who had achieved vaginal delivery, the difference in 95th percentile with and without epidural was 95 minutes for nulliparas and 101 minutes for multiparas (Table 1). All comparisons had P value <.001. Table 1 Second Stage Length* CONCLUSIONS: Even among women who achieve vaginal delivery, the increase in length of second stage in women who received an epidural was greater than 90 minutes in both nulliparous and multiparous women. These data should inform guidelines surrounding the management of the second stage of labor.

Measuring the levator hiatus with axial MRI sequences: Adjusting the angle of acquisition

We aimed to compare MRI measurements of the female levator hiatus and the most caudal “levator ani” muscles between image slices in a plane axial to the body (AxB) and an axial plane parallel to the direction of the puborectalis muscle (AxPRM).

Reference lines in dynamic magnetic resonance imaging of the pelvic floor

Objective: To compare the variability in two commonly used reference lines in pelvic magnetic resonance imaging (MRI), the pubococcygeal line (PCL) and the sacrococcygeal to inferior pubis (SCIPP) line, with respect to their distance from pelvic floor points of interest. Methods: We obtained pelvic MR images of 20 asymptomatic nulliparous women who are part of an ongoing pelvic floor nerve injury postpartum study. The subjects underwent a high-resolution two-dimensional, T2-weighted sagittal pelvic MRI in the supine position using a GE Signa scanner with a body phased-array coil. We also obtained dynamic T2-weighted sagittal MR images in supine position during Kegel and Valsalva maneuvers. Using the midsagittal image, we measured the length of two reference lines: the PCL and the more cephalad SCIPP line. From each line, we then measured the perpendicular distance to the bladder neck and to the posterior margin of the anorectal angle (M-line). We compared the mean values of all measurements between the two reference lines with paired Student t tests. Result: The SCIPP line (mean [SD], 11.60 [0.91] cm) is longer than the PCL (mean [SD], 10.54 [0.85] cm) at rest (P < 0.001). There is no significant change in length from resting to Kegel maneuver or from resting to Valsalva maneuver in either reference line. Only the resting to Valsalva maneuver for the M-line was significantly different between the 2 reference lines (P = 0.02). The resting to Kegel for the perpendicular distance to the bladder neck and the M-line was not significantly different between the two lines. Conclusions: Both reference lines remain stable during pelvic floor maneuvers.

Delivery planning after a third- or fourth-degree perineal laceration.

INTRODUCTION: We evaluated the outcomes associated with planning an elective cesarean compared with vaginal delivery for women with a history of obstetric anal sphincter injuries. METHODS: A decision analytic model was built using TreeAge software to compare offering an elective cesarean delivery or trial of labor in women with a history of obstetric anal sphincter injuries. A theoretical cohort of 75,152 women with past obstetric anal sphincter injuries was assigned to either elective cesarean delivery or trial of labor. Using baseline probabilities from the literature (Table 1), outcomes evaluated included maternal death, fecal incontinence, and urinary incontinence (UI). Duration of incontinence was assumed to be 1 year; sensitivity analysis was performed to evaluate these parameters. Table 1 Elective Cesarean Delivery Compared With Trial of Labor After Obstetric Anal Sphincter Injuries RESULTS: In this hypothetical cohort, trial of labor had better outcomes (Table 1), including 17 fewer maternal deaths, more than 50,000 fewer cesarean deliveries, and a savings of

Concentric Needle Quantitative Electromyography of Pubovisceralis Muscle Group: Normative Data From Asymptomatic Nulliparous Women

4,000 per pregnancy. Rates of repeat obstetric anal sphincter injuries, UI, and fecal incontinence were varied over reasonable expected ranges, and trial of labor remained favored. When duration of UI and fecal incontinence were varied, trial of labor was favored until duration of 1.75 and 5.3 years, respectively. When UI and fecal incontinence duration was varied only in the arm experiencing repeat obstetric anal sphincter injuries, trial of labor was favored until a threshold of 4.8 years in women with second obstetric anal sphincter injuries. CONCLUSION: Women with a history of obstetric anal sphincter injuries experience more postpartum UI and fecal incontinence. However, the burden of postpartum incontinence is high in general and cesarean delivery is not entirely protective. Because cesarean delivery is a major abdominal surgery with its own complications, including increased maternal death and implications for future deliveries, this model can inform counseling regarding delivery after obstetric anal sphincter injuries.

Effects of dietary saw palmetto on the prostate of transgenic adenocarcinoma of the mouse prostate model (TRAMP)

Objectives: The muscles of the pelvic floor closest to the vaginal opening are subject to the greatest degree of stretch during vaginal childbirth. We aim to define normative quantitative electromyography parameters for the pubovisceralis (PV) muscle in nulliparous women, and compare them with the external anal sphincter (EAS). Methods: In 31 asymptomatic nulliparous women, concentric needle electromyography of the PV and the EAS was performed. Multi-motor unit action potential and interference pattern algorithms were used to obtain quantitative electromyography parameters. We used paired t tests to compare PV and EAS parameters. Results: The motor units for the PV were of greater duration (P < 0.002) and had more turns (P = 0.03) than the paired motor units in the EAS. The EAS demonstrated more turns/s (P = 0.02), greater activity (P = 0.01), and more short segments (P = 0.009) than the PV. Conclusions: The PV has longer and more complex motor units than the EAS. This knowledge continues to improve our ability to detect neuropathic changes in this vulnerable muscle area after childbirth or in women with pelvic floor dysfunction. In addition, the PV muscle group appears less responsive to requests for increased neuromuscular activity than the EAS. This needs to be further evaluated, as it may be associated with understanding which portion of the muscle functionally shortens to maintain the closure of the levator hiatus.