The impact of delivery on anorectal function in women with and women without anal incontinence--a prospective study.

A prospective study was carried out to evaluate the effect of delivery on anal physiological parameters in anally incontinent women (n=18) compared with continent women (n=42). Perineal plane, anal manometry, anal mucosa electrosensitivity and pudendal nerve terminal motor latency (PNTML) were all assessed at 26 weeks' gestation and at 3 and 6 months after delivery. No major effect on the incremental changes in anal physiological parameters was seen from 26 weeks of gestation to 3 months after delivery. At 26 weeks of gestation perineal plane and maximal squeeze pressure were impaired in incontinent women (P=0.02 and P=0.06); PNTML was impaired in incontinent women 6 months after delivery (P=0.05). Irrespective of continence status, delivery had an adverse effect on maximal squeeze pressure and PNTML. No major incremental changes were found between incontinent and continent women after delivery. However, there was a tendency to a higher degree of impairment of maximal squeeze pressure among incontinent women. Delivery per se had an adverse effect on maximal squeeze pressure and PNTML irrespective of continence status.

Flatus and faecal incontinence: prevalence and risk factors at 16 weeks of gestation.

OBJECTIVE: To evaluate the prevalence of anal incontinence at 16 weeks of gestation and to identify possible maternal and obstetrical risk factors. DESIGN: Cross sectional study and cohort study. SETTING: Department of Obstetrics and Gynaecology, Aarhus University Hospital, Denmark. PARTICIPANTS: Cross sectional study: 7,557 women attending antenatal care. Cohort study: a subgroup of 1,726 pregnant women with one previous delivery at our department. RESULTS: The prevalence of anal incontinence within the preceding year was 8.6%. Incontinence of liquid and solid stools was reported in 2.3% and 0.6%, respectively. Isolated flatus incontinence at least once a week was reported in 4.2%. The risk of flatus incontinence at least once a week was increased with age > 35 years (OR 1.6; 95% CI 1.1-2.4) and with previous lower abdominal or urological surgery (OR 1.5, 95% CI 1-1-2.1) in a logistic regression model controlling for maternal factors. Increasing parity did not increase the risk. The risk of flatus incontinence was increased after anal sphincter tear and birthweight > 4,000 g in a logistic regression model controlling for maternal and obstetric variables. Episiotomy was insignificantly associated, while spontaneous perineal tear > 3 cm and a number of other intrapartum factors were not associated. CONCLUSION True faecal incontinence is rare among younger women. However, an age > 35 years and previous lower abdominal or urological surgery increased the risk of flatus incontinence in contrast to increasing parity. This suggests that childbirth plays a minor role compared with age. However, when analysing obstetric variables separately, a birthweight > 4,000 g, and anal sphincter tears were significant risk factors for flatus incontinence.

Urinary incontinence: prevalence and risk factors at 16 weeks of gestation.

OBJECTIVE: To evaluate the prevalence of urinary incontinence at 16 weeks of gestation and to identify possible maternal and obstetric risk factors. DESIGN: Cross-sectional study and cohort study. SETTING: Department of Obstetrics and Gynaecology, Aarhus University Hospital, Denmark. POPULATION: Cross-sectional study: 7795 women attending antenatal care. Cohort study: a sub-group of 1781 pregnant women with one previous delivery at our department. RESULTS: Prevalence and maternal risk factors: the prevalence of urinary incontinence within the preceding year was 8.9% among women at 16 weeks of gestation (nulliparae, 3.9%, para 1, 13.8%, para 2+, 16.2%). Stress or mixed incontinence occurred at least weekly in 3% of all the women. After adjusting for age, parity, body mass index, smoking, previous abortions, and previous lower abdominal or urological surgery in a logistic regression model, primiparous women who had delivered vaginally had higher risk of stress or mixed urinary incontinence than nulliparous women (OR 5.7; 95% CI 3.9-8.3). Subsequent vaginal deliveries did not increase the risk significantly. Young age, body mass index > 30, and smoking were possible risk factors for developing urinary incontinence. Obstetric factors: weight of the newborn > 4000 g (OR 1.9; 95% CI 1.0-3.6) increased the risk of urinary incontinence; mediolateral episiotomy in combination with birthweight > 4000 g also increased the risk (OR 3.5; 95% CI 1.2-10.2); a number of other intrapartum factors did not increase the risk of urinary incontinence. CONCLUSIONS: The first vaginal delivery was a major risk factor for developing urinary incontinence; subsequent vaginal deliveries did not increase the risk significantly. Birthweight > 4000 g increased the risk; episiotomy in combination with birthweight > 4000 g also increased the risk.

Closure versus non-closure of peritoneum at cesarean section--evaluation of pain. A randomized study.

OBJECTIVE: To evaluate the effects of leaving the parietal peritoneum open at lower segment cesarean section (LSCS) measured by postoperative pain. DESIGN: A randomized, prospective and double-blind study. SETTING: Department of Obstetrics and Gynecology, Aarhus University Hospital, Denmark. POPULATION: Forty women referred for an elective cesarean section were assigned to one of two groups: peritoneum open (n=21) or peritoneum closed (n=19). METHODS: Pain was evaluated twice a day from the first to the fifth postoperative day by Visual Analog Scales. MAIN OUTCOME MEASURES: Postoperative pain. Other outcomes include usage of analgesics, bowel function, postoperative complications, and hospital stay. RESULTS: We found no overall difference in postoperative pain. A tendency to less pain was found in the non-closure group from the third postoperative day to the fifth postoperative day. No differences were found either in the incidence of postoperative complications, or the time to return of bowel function. Concerning opiate analgesics the non-closure group had a significantly higher use in the second postoperative 24-hour period, but in the remains of the registration period it was significantly lower. For oral analgesics no difference was found in the first 24-hour period, but in the remains of the period the non-closure group had a significantly lower use. CONCLUSIONS: The VAS-scales showed no difference in postoperative pain comparing closure to non-closure of the parietal peritoneum. However, the use of analgesics is lower in the non-closure group. We suggest leaving the parietal peritoneum open when performing LSCS.

Plasminogen activation system in human milk.

BACKGROUND: Plasmin is the major endogenous protease present in milk. The level of plasmin activity is controlled by the availability of the precursor plasminogen and by the levels of plasminogen activators and inhibitors. Recently, a differential distribution of tissue-type plasminogen activator (t-PA) and urokinase-type plasminogen activator (u-PA) has been demonstrated in bovine milk. To assess whether this distribution pattern is a general feature, the occurrence of components of the plasminogen activation system in different fractions of human milk was investigated. METHODS: Milk samples were separated into the following fractions; milk fat, skim milk, and milk cells by centrifugation. The different fractions were detected for the presence of plasminogen and plasminogen activators by immunoblotting and zymography. The distribution of t-PA and u-PA was investigated by ligand binding analysis. t-PA-catalyzed plasminogen activation was examined by a coupled chromogenic assay. RESULTS: A differential distribution of plasminogen, t-PA, and u-PA was found. Casein micelles were found to exhibit t-PA and plasminogen binding activity, whereas the u-PA receptor was identified as the u-PA binding component in the cell fraction. Furthermore, human casein enhanced t-PA-catalyzed plasminogen activation, comparable to the enhancing effect obtained with fibrinogen fragments. CONCLUSION: The finding of a differential distribution of u-PA and t-PA in milk suggests that the two activators may have different physiological functions, which involve protection against invading microorganisms and maintenance of patency and fluidity in the ducts of mammary gland, respectively.

Placental vascular malformation with mesenchymal hyperplasia and a localized chorioangioma. A rarity simulating partial mole.

We here report a case of placental vascular malformation with mesenchymal hyperplasia of the villi and a localized chorioangioma. After an uneventful pregnancy our patient delivered a non-malformed live female infant. The placenta was grossly enlarged, and macroscopically it was characterized by strongly enlarged varicous chorionic vessels. On the maternal plate vesicle-like structures, giving the impression of partial mole, were seen. At microscopy level, areas of normal looking tissue alternated with areas of excessively enlarged villi, in which the ground substance contained large amounts of acid mucopolysaccharide, corresponding to "mesenchymal hyperplasia". Moreover, a localized chorioangioma was found. In none of the histological sections were cisterns, abnormal trophoblastic proliferation, stunted ramification or stromal trophoblastic inclusions observed. In week 15 maternal se-AFP was elevated to 3.03 multiples of the median. Genetic analyses revealed a normal female karyotype and biparental genomic contributions to 7 unlinked loci. Placental vascular malformation with mesenchymal hyperplasia is a differential diagnosis to partial mole which should be considered when vesicle like placental enlargement is observed along with a living fetus.