Levator ani muscle avulsion and subsequent vaginal delivery: 8-year longitudinal follow-up.

OBJECTIVES: To assess the evolution of levator ani muscle (LAM) avulsion from 1 year to 8 years after first delivery in women with and those without subsequent vaginal delivery. In addition, to assess whether women with full or partial avulsion 8 years after first delivery have larger LAM hiatal area and more symptoms of pelvic organ prolapse compared to women with normal LAM insertion. METHODS: In this single-center longitudinal study, 195 women who were primiparous at the start of the study were included and underwent transperineal ultrasound examination 1 year and 8 years after first delivery. Muscle insertion was assessed by tomographic ultrasound imaging in the axial plane. Full LAM avulsion was defined as abnormal muscle insertion in all three central slices. Partial LAM avulsion was defined as abnormal muscle insertion in one or two central slices. Eight years after the first delivery, LAM hiatal area was assessed at rest, during maximum pelvic floor muscle contraction and on maximum Valsalva maneuver. To assess symptoms of pelvic organ prolapse, the vaginal symptoms module of the International Consultation on Incontinence Questionnaire was used. RESULTS: At 1-year follow-up, 25 (12.8%) women showed signs of LAM avulsion, of whom 20 fulfilled the sonographic criteria of full avulsion and five of partial avulsion. Eight years after the first delivery, 35 (17.9%) women were diagnosed with avulsion, of whom 25 were diagnosed with full avulsion and 10 with partial avulsion. No woman with partial or full avulsion at 1 year had improved avulsion status at 8-year follow-up. Of the 150 women who had subsequent vaginal delivery, 21 (14.0%) women were diagnosed with partial or full LAM avulsion 1 year after first delivery, and 31 (20.7%) women were diagnosed with partial or full avulsion 8 years after first delivery. Of the 45 women without subsequent vaginal delivery, one woman with partial avulsion 1 year after first delivery was diagnosed with full avulsion at 8-year follow-up. All women with full avulsion at 1-year follow-up were diagnosed with full avulsion at 8-year follow-up regardless of whether they had subsequent vaginal delivery. At 8-year follow-up, women with full avulsion had statistically significantly larger LAM hiatal area compared to women with normal muscle insertion. Mean ± SD vaginal symptom scores ranged between 5.5 ± 5.7 and 6.0 ± 4.0 and vaginal symptom quality of life scores ranged between 0.9 ± 1.4 and 1.5 ± 2.2 and did not differ significantly between women with normal muscle insertion and women with partial or full avulsion at 8-year follow-up. CONCLUSIONS: More LAM avulsions were present 8 years compared with 1 year after first delivery in women with subsequent vaginal delivery. Except for one primipara, all women without subsequent vaginal delivery had unchanged LAM avulsion status between 1 year and 8 years after their first delivery. Larger LAM hiatal area was found in women with full avulsion compared to those with normal muscle insertion at 8-year follow-up. Vaginal symptoms scores were low and did not differ between women with normal muscle insertion and those with partial or full avulsion at 8-year follow-up. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Change in pelvic organ support during pregnancy and the first year postpartum: a longitudinal study.

OBJECTIVE: To describe changes in pelvic organ support from mid pregnancy until 1 year postpartum among nulliparous pregnant women, and to examine whether delivery route affects changes in pelvic organ support. DESIGN: Prospective cohort study. SETTING: Akershus University Hospital in Norway. POPULATION: A cohort of 300 nulliparous pregnant women included at mid-pregnancy. METHODS: Pelvic organ support assessed at 21 and 37 weeks of gestation, and again at 6 weeks, 6 months, and 12 months postpartum, by the use of the Pelvic Organ Prolapse Quantification (POP-Q) system. Linear mixed model was used to assess longitudinal change in pelvic organ support. MAIN OUTCOME MEASURES: Prevalence of anatomic POP. Change in POP-Q variables over time and between delivery groups. RESULTS: The prevalence of anatomic POP ranged from 0 to 10%. Vaginal POP-Q points made a cranial shift from mid to late pregnancy, a caudal shift following delivery, and again a cranial shift after 6 weeks postpartum. Postpartum change was present following both vaginal and caesarean deliveries, but was more pronounced following vaginal delivery. The perineal body and genital hiatus became longer from mid to late pregnancy, and shortened after 6 weeks postpartum. At 12 months postpartum all POP-Q points, except cervix, had recovered to baseline in the vaginal delivery group. CONCLUSIONS: The prevalence of anatomic POP was low in this cohort. There was change in pelvic organ support both during pregnancy and following vaginal as well as caesarean delivery. The short-term ability to recover was good after the first pregnancy and delivery. TWEETABLE ABSTRACT: Pelvic organ support changes during pregnancy. A contribution to the risk of POP?

The levator ani muscle during pregnancy and major levator ani muscle defects diagnosed postpartum: a three- and four-dimensional transperineal ultrasound study.

OBJECTIVE: To investigate associations between levator hiatus area and levator ani muscle function during pregnancy and major levator ani muscle defects postpartum. DESIGN: Observational prospective cohort study. SETTING: University hospital, Norway. SAMPLE: A cohort of 234 nulliparous women at 21 and 37 weeks of gestation, and at 6 weeks postpartum. METHODS: Ultrasound measurements of the levator hiatus at rest, during pelvic floor muscle contraction, and during the Valsalva manoeuvre were taken at 21 and 37 weeks of gestation. Levator ani muscle function was estimated as the percentage changes in levator ani muscle length from rest to contraction, and the level of muscle stretch during the Valsalva manoeuvre. Major levator ani muscle defects were diagnosed at 6 weeks postpartum using tomographic ultrasound imaging. MAIN OUTCOME MEASURES: Associations between ultrasound measurements antepartum and major levator ani muscle defects postpartum. RESULTS: Women with major levator ani muscle defects postpartum had significantly smaller levator hiatus area at rest and during the Valsalva manoeuvre at mid-pregnancy (mean difference 1.03 cm(2) , 95% CI 0.31-1.76; 2.92 cm(2) , 95% CI 1.77-4.07), and at 37 weeks of gestation (mean difference 1.47 cm(2) , 95% CI 0.62-2.32; 2.84 cm(2) , 95% CI 0.88-4.80), than women without such defects. They also had significantly less shortening of the levator ani muscle during contraction at 37 weeks of gestation. CONCLUSIONS: Smaller levator hiatus area at rest and during the Valsalva manoeuvre at mid and late pregnancy, and less shortening of the levator ani muscle during contraction at 37 weeks of gestation, are associated with major levator ani muscle defects postpartum.

Dyspareunia and pelvic floor muscle function before and during pregnancy and after childbirth.

INTRODUCTION AND HYPOTHESIS: There is limited knowledge on dyspareunia during pregnancy and postpartum and the role of the pelvic floor muscles (PFM) in women with dyspareunia. Aims of the study were to investigate the presence of dyspareunia before and during pregnancy and postpartum, and to compare vaginal resting pressure (VRP), PFM strength, and endurance between women with and those without dyspareunia. It was hypothesized that there is no difference in PFM variables between women with and those without dyspareunia. METHODS: Three hundred nulliparous women participated in this prospective cohort and answered questions about dyspareunia and the level of bother at gestational weeks 22 and 37, 6 and 12 months postpartum, and retrospectively prior to their pregnancies using ICIQ-FLUTSsex. PFM variables were assessed by manometer at gestational week 22, and 6 and 12 months postpartum. Comparisons between groups were analyzed using independent samples t test. RESULTS: Twenty-eight and 30 % of the women reported dyspareunia at pre-pregnancy and at gestational week 22 respectively. At gestational week 37, and 6 and 12 months postpartum, the percentages were 40, 45, and 33 respectively. No difference in PFM variables was found between women with and those without dyspareunia. Level of bother was higher postpartum than before and during pregnancy. CONCLUSIONS: Symptoms of dyspareunia were common at all time points. No link could be made between PFM function and dyspareunia. Women suffering from dyspareunia postpartum reported it as being bothersome. Our findings suggest that women should be asked about symptoms of dyspareunia related to pregnancy, and that future research should aim for preventative and therapeutic strategies.

How well can pelvic floor muscles with major defects contract? A cross-sectional comparative study 6 weeks after delivery using transperineal 3D/4D ultrasound and manometer.

OBJECTIVE: To investigate ability to contract, vaginal resting pressure (VRP), pelvic floor muscle (PFM) strength and PFM endurance 6 weeks after vaginal delivery in primiparous women, with and without major defects of the levator ani (LA) muscle. DESIGN: Cross-sectional comparative study. SETTING: Akershus University Hospital, Norway. SAMPLE: A cohort of 175 singleton primiparous women delivering vaginally after more than 32 weeks of gestation. METHODS: Major LA defects were assessed by 3D/4D transperineal ultrasound at maximal PFM contraction, using tomographic imaging. VRP, PFM strength and PFM endurance were measured vaginally by manometer. Data were analysed by independent-samples Student's t test, chi-square test, and standard multiple and simple linear regression. MAIN OUTCOME MEASURES: VRP, PFM strength and PFM endurance. RESULTS: Of the women included in the study, 4% were not able to contract their PFM 6 weeks after delivery. Women with major LA defects (n = 55) had 47% lower PFM strength and 47% lower endurance when compared with women without major LA defects (n = 120). Mean differences were 7.5 cmH2O (95% CI 5.1-9.9, P < 0.001) and 51.2 cmH2O seconds (95% CI 32.8-69.6, P < 0.001), respectively. These estimates were unchanged by adjustment in multivariable linear regression for potentially confounding demographic and obstetric factors. No difference was found regarding VRP (P = 0.670). CONCLUSIONS: Women with major LA defects after vaginal delivery had pronounced lower PFM strength and endurance than women without such defects; however, most women with major LA defects were able to contract the PFM. This indicates a potential capacity by non-injured muscle fibres to compensate for loss in muscle strength, even at an early stage after delivery.

Pelvic floor function is independently associated with pelvic organ prolapse.

OBJECTIVE: To investigate the risk factors for pelvic organ prolapse (POP), including physical activity, clinically measured joint mobility and pelvic floor muscle (PFM) function. DESIGN: One-to-one age- and parity-matched case-control study. SETTING: Akershus university hospital and one outpatient physiotherapy clinic in Norway. POPULATION: Forty-nine women with POP (POP quantification, stage>or=II) and 49 controls (stages 0 and I) were recruited from community gynaecologists and advertisements in newspapers. METHODS: Validated questionnaires, interview and clinical examination, including Beighton's scoring system (joint hypermobility) and vaginal pressure transducer measurements (PFM function), were used. Univariate and multivariate conditional logistic regression analyses for one-to-one matched case-control studies were used, and odds ratios with 95% CIs are reported. MAIN OUTCOME MEASURES: Pelvic floor muscle function (strength, endurance and resting pressure), socioeconomic status, body mass index, heavy occupational work, physical activity, family history, obstetric factors and markers of connective tissue weakness (striae, varicose veins, bruising, diastasis recti abdominis, joint hypermobility). RESULTS: No significant differences were found between groups with regard to postmenopausal status, current smoking, current low-intensity exercise, type of birth (caesarean, forceps, vacuum), birth weight, presence of striae, diastasis recti abdominis and joint hypermobility. Body mass index (OR 5.0; 95% CI 1.1-23.0), socioeconomic status (OR 10.5; 95% CI 2.2-50.1), heavy occupational work (OR 9.6; 95% CI 1.3-70.3), anal sphincter lacerations (OR 4.5; 95% CI 1.0-20.0), PFM strength (OR 7.5; 95% CI 1.5-36.4) and endurance (OR 11.5; 95% CI 2.0-66.9) were independently related to POP. CONCLUSIONS: Body mass index, socioeconomic status, heavy occupational work, anal sphincter lacerations and PFM function were independently associated with POP, whereas joint mobility and physical activity were not.

The impact of BMI on subgroups of uterine cancer.

BACKGROUND: Obesity increases the risk of uterine cancer, but results by histological type have differed. METHODS: We followed 36,755 women for 17.8 years for uterine cancers. RESULTS AND CONCLUSION: Body mass index (BMI) was positively associated with uterine cancers as a whole, particularly for endometrioid adenocarcinomas, for which the relative risk for very obese women (BMI: > or = 40 kg m(-2)) compared with lean (BMI: 20-24 kg m(-2)) women, was 11.1 (95% confidence interval: 5.2-23.8).

Interobserver repeatability of three- and four-dimensional transperineal ultrasound assessment of pelvic floor muscle anatomy and function.

OBJECTIVE: To evaluate the interobserver repeatability of measurement of the pubovisceral muscle and levator hiatus, and the position of related organs, during rest, muscle contraction and Valsalva maneuver using three- and four-dimensional (3D and 4D) transperineal ultrasound. METHODS: Seventeen women were included in the study. The position and dimensions of the pubovisceral muscle and levator hiatus in patients at rest and during contraction and Valsalva were determined from stored 3D and 4D ultrasound volumes. Analyses were conducted offline by two observers blinded to the clinical data and to each others' measurements. RESULTS: Measurements of levator hiatal dimensions at rest demonstrated intraclass correlation coefficient (ICC) values of 0.92 to 0.96. The ICC values for pubovisceral muscle thickness at rest varied between good and very good (ICC, 0.61-0.93), regardless of plane. During contraction, the ICC values for all measured parameters were very good, varying between 0.61 and 0.92. Measurement of the transverse diameter of the levator hiatus during the Valsalva maneuver showed good reliability (ICC, 0.86), but assessment of the anterior and posterior borders of the levator hiatus was only possible in 29% of cases. CONCLUSIONS: 3D and 4D transperineal ultrasound measurement of the pubovisceral muscle and levator hiatus is reliable in women with no or minor symptoms of prolapse at rest and during contraction. The technique for recording during the Valsalva maneuver requires improvement if it is to be useful in the diagnosis of pelvic organ prolapse.

Body mass, diabetes and smoking, and endometrial cancer risk: a follow-up study.

We examined the relationship of body mass index (BMI), diabetes and smoking to endometrial cancer risk in a cohort of 36 761 Norwegian women during 15.7 years of follow-up. In multivariable analyses of 222 incident cases of endometrial cancer, identified by linkage to the Norwegian Cancer Registry, there was a strong increase in risk with increasing BMI (P-trend <0.001). Compared to the reference (BMI 20-24 kg m(-2)), the adjusted relative risk (RR) was 0.53 (95% confidence interval (CI): 0.19-1.47) for BMI<20 kg m(-2), 4.28 (95% CI: 2.58-7.09) for BMI of 35-39 kg m(-2) and 6.36 (95% CI: 3.08-13.16) for BMI>or=40 kg m(-2). Women with known diabetes at baseline were at three-fold higher risk (RR 3.13, 95% CI: 1.92-5.11) than those without diabetes; women who reported current smoking at baseline were at reduced risk compared to never smokers (RR 0.55, 95% CI: 0.35-0.86). The strong linear positive association of BMI with endometrial cancer risk and a strongly increased risk among women with diabetes suggest that any increase in body mass in the female population will increase endometrial cancer incidence.