Anal sphincter injury after forceps delivery: myth or reality? A prospective ultrasound study of 93 females.

PURPOSE: This study was designed to estimate the prevalence of anal sphincter injury after forceps delivery in a large population of females managed by trained obstetricians in a French hospital and to identify factors predictive for anal sphincter injury. METHODS: We performed a prospective study of healthy females older than 18 years with no history of anal incontinence, anorectal abnormalities, or anorectal surgery after their first vaginal delivery. All females were interviewed using a standardized questionnaire concerning intestinal transit and continence status. Physical examination and endoanal ultrasonography were performed after delivery. RESULTS: Between November 1999 and November 2000, 93 females were included in the study after their first forceps delivery. Eleven patients (11.8 percent) had a partial defect involving the external sphincter, visible on ultrasonography. One patient (1.1 percent) had a partial defect of external sphincter with complete defect of internal sphincter (sequelae of primary repair of a third-degree perineal tear). Seventeen patients (18.2 percent) had flatus incontinence, and four patients (4.3 percent) had liquid stool incontinence. A high daily number of stools was significantly associated with sphincter defect visible on ultrasonography (P=0.02). The development of anal incontinence was not related to sphincter defect on ultrasonography. There was a strong association between perineal tear and sphincter defect visible on ultrasonography (odds ratio, 4.5 (range, 1.2-16.7)). CONCLUSIONS: Anal sphincter injury after forceps delivery was identified in <13 percent of our large population of healthy females. Our study does not confirm previous observations that anal sphincter injury is common after forceps delivery; previously published studies may have overestimated the prevalence of this condition. The only factor with significant predictive value for anal sphincter injury was perineal tear. Anal endosonography should be recommended after obstetric perineal tear.

[Rupture of a scarred gravid uterus at 28 weeks of amenorrhea. Conservative surgical management and results]. / Rupture utérine à 28 semaines d'aménorrhée d'un utérus cicatriciel gravide. Attitude chirurgicale conservatrice et résultats.

Rupture of a scarred uterus during pregnancy is unusual, but remains a complication with serious consequences for both mother and fetus. It usually occurs towards the term of gestation and the case reported here is of interest because, atypically, the rupture of the uterus occurred some time before term in a scarred uterus and the immediate care provided was conservative surgery. The rest of the pregnancy proceeded to a successful outcome at term under clinical and obstetrical follow-up. The authors also highlight the additional precautions required in medically-assisted pregnancies in patients over 40 years of age.

[A case of cervico-isthmic pregnancy with delayed development]. / A propos d'un cas de grossesse cervico-isthmique à développement tardif.

This is the case of a para three, gravida three, who had a caesarean section for her first pregnancy and a normal delivery for the second one. During her third pregnancy the patient is hospitalised for first trimester bleeding. Ultrasounds show two liquid compartments separated by placenta. The lower one in cervico-isthmic position contains the foetus. During the 24th week gestation the pregnancy is complicated by severe metrorrhagia that leads to abdominal exploration and total hysterectomy. The pathology conclusions confirmed the per-operative impression of cervico-isthmic pregnancy. The authors emphasise the rarity of the cervico-isthmic pregnancy (1 for 10,000 pregnancies) and wonder about atypical evolution of this case and about the possibilities of saving the uterus by an earlier intervention in view of ultrasonographic data.