Risk factors for anal sphincter injury during vaginal delivery

To determine the risk factors that may lead to occult injury of the anal sphincter or pudendal nerve during normal or assisted vaginal delivery. We compared the results of bowel function questionnaire, quantitative EMG changes, and anal endosonography in 70 pregnant women, before and 6-8 weeks after delivery. They were classified into 3 groups, Group I, 30 nullipara delivered vaginally [normal and assisted]; Group II, 30 multipara delivered vaginally [normal and assisted] and Group III, [control grroup] delivered by elective cesarean sections. Postpartum pudendal nerve terminal motor latency was measured in all women. In Group I, prolonged gestational age, duration of labor > 12 hours and oxytocin augmentation were associated with altered fecal continence, OR = 2.3, 95% CI = [1.3 - 4.1]; 2.8, [1.6 - 4.7] and 2.04, [1.52 - 6.25] respectively. But these factors were not associated with altered fecal continence in Group II, OR = 1.8, 95% CI = [0.91 - 1.66]; 0.8, [0.4-1.1] and 1.4, [0.3-5], respectively. Odds ratio of instrumental delivery in Group I, who complained of fecal incontinence was, OR = 16.6, 95% CI = [12.3-30], while in Group II, it was, OR = 9.94, 95% CI = [7.2-12.4], p < 0.001. Odds ratio of perineal tear in symptomatic nulliparous women was, OR = 11.3, 95% CI = [4.6-31.3], p < 0.001, while in symptomatic multipara it was, OR = 9.2, 95% CI = [7.1-12.2], p < 0.001. Postpartum QEMG changes of the external anal sphincter was observed in 5 [17%] in Group I, 3 [60%] of them had instrumental deliveries, OR = 7.3, 95% CI = [4.0 - 13.2], p < 0.001 and 2 [40%] of them had prolonged second stage of labor, OR = 2.55, 95% CI = [1.03 - 2.30], p < 0.001. In Group II, prolonged second stage was not associated with postpartum QEMG changes of the external anal sphincter. Perineal tears were found in 3 [60%] women in Group I, who had EMG changes, OR = 6.2, CI = [5 - 17], p < 0.001. Again, in Group II, 6 [20%] women, had postpartum QEMG changes recorded from their external anal sphincter, 2 [33%] of them had instrumental delivery, OR = 6.6, 95% CI = [5 - 17], p < 0.001 and 3 [50%] of them had perineal tear, OR = 5.5, 95% CI = [5-15], p < 0.001. There was a significant increase in the mean PNTML in the multiparous group as compared to the nulliparous or control groups p < 0.001. Postpartum anal endosonogaphic study in the control group showed that there was no defect in either external or internal anal sphinicters. But in Group I, 8 [26%] women had anal endosonographic defects and in Group II, 5 [16%] women had anal endosonographic defects Instrumental delivery and prolonged second stage of labor are the greatest risk factors for the development of anal sphincter injury and dysfunction after vaginal delivery. Electromyography [EMG], pudendal nerve terminal motor latency and anal endosonography are conclusive for the evaluation of subclinical patients with fecal incontinence

Apoptosis in some chronic arthritic patients

In multicellular organisms, cellular homeostasis is maintained through a delicate balance between cell death.Physiological cell death occurs through a process of cell suicide called apoptosis. The aim of the present study was to determine the extent of apoptosis of neutrophils and lymphocytes in some chronic arthritic patients and to study its role in the pathogenesis of chronic arthritis process. The study included 27 SLE patients, 12 RA patients without joint effusion and 8 RA patient suffered from joint effusion, 13 osteoarthritic patients and 12 normal healthy subjects as control. All the studied cases were subjected to the following: full history, complete clinical examination, laboratory investigations including routine lab as C.BCs, ESR, CRP, RP, ANA. anti nDNA. and specific laboratory investigations: separation of lymphocyte and neutrophils from peripheral blood of all cases and from SF. of cases with joint effusion, detection of lymphocyte apoptosis after 48 h. of invitro culture and detection of neutrophil apoptosis at time of separation [zero hour], after 24 h. and 48 h. of invitro culture. The results were found that significant increase in apoptosis of PBL in SLE patients more than the other groups [P < 0.001], significant increase in synovial fluid lymphocyte and neutrophil at 0, 24 and 48 h. apoptosis in RA patients more than PBL apoptosis of all groups [p< 0.001]. Significant increase in synovial fluid also there was significant positive correlation between; PBL apoptosis and ESR and CRP in SLE patients but significant negative correlation between PBL apoptosis and absolute lymphocytic count in patients of SLE is found. Also, there was no significant difference in PBL, apoptosis between control and RA and OA patient [P > 0.05]. Lastly, there is no significant difference in PB neutrophil apoptosis between all groups at time of separation and after 24 h., 48 h. of invitro culture [P > 0.05]