Management of levator ani avulsion: a systematic review and narrative synthesis.

PURPOSE: Levator ani muscle (LAM) avulsion affects up to 35% of women. Unlike obstetric anal sphincter injury, LAM avulsion is not diagnosed immediately after vaginal delivery, however, has a profound impact on quality of life. The management of pelvic floor disorders is in growing demand yet the significance of LAM avulsion in the context of pelvic floor dysfunction (PFD) is poorly understood. This study collates information on success of treatment for LAM avulsion to establish the best options for management of women. METHODS: MEDLINE®, MEDLINE® In-Process, EMBASE, PubMed, CINAHL and The Cochrane Library were searched for articles that evaluated the management techniques used to treat LAM avulsion. The protocol was registered with PROSPERO (CRD42021206427). RESULTS: Natural healing of LAM avulsion occurs in 50% of women. Conservative measures, including pelvic floor exercises and pessary use are poorly studied. Pelvic floor muscle training for major LAM avulsions was of no benefit. Post-partum pessary use was only of benefit in the first three months for women. Surgeries for LAM avulsion are poorly researched but studies suggest they may provide benefit for 76-97% of patients. CONCLUSIONS: Whilst some women with PFD secondary to LAM avulsion improve spontaneously, 50% continue to have pelvic floor symptoms 1 year following delivery. These symptoms result in a significant negative impact on quality of life, however, it is not clear whether conservative or surgical methods are helpful. There is a pressing need for research to find effective treatments and explore appropriate surgical repair techniques for women with LAM avulsion.

Surviving hepatic rupture in pregnancy--a literature review with an illustrative case report.

Spontaneous hepatic rupture in pregnancy is a rare condition associated with significant maternal and perinatal mortality. Patients developing pre-eclampsia and especially HELLP syndrome require close monitoring for prompt diagnosis of hepatic rupture. However, the presenting symptoms and signs, e.g. epigastric pain, shoulder pain, nausea and vomiting, are common. Thus a high index of suspicion and early evaluation with imaging is vitally important. The important lesson to be learnt is that a Pfannenstiel incision does not allow for adequate assessment of the liver. If hepatic rupture is suspected a second upper abdominal incision should be performed. Improved survival can be achieved through early recognition and a multidisciplinary approach.