Abstract
Introduction and hypothesis
Pregnancy and delivery are well-established risk factors for pelvic floor dysfunction (PFD), but the physiopathology, such as the delivery route, is not well understood. This study evaluated the impact of delivery route on the pelvic floor muscles via 3D ultrasound.
Methods
This review is registered in the PROSPERO database. The criteria for inclusion were prospective studies with 3D translabial ultrasound assessment in primigravida women during pregnancy and postpartum published in English, Spanish or Portuguese between 1980 and 2016. We excluded studies that did not include the topic of urogenital hiatus measurement and literature reviews. The MeSH terms were obstetric delivery, postpartum period, labor, parturition, three-dimensional images, ultrasonography, pelvic floor, and pelvic floor disorders.
Results
The search retrieved 155 articles. After analysis, 6 articles were included. Four studies showed that vaginal delivery (VD) was associated with a larger hiatal area. One study associated the hiatal area with levator ani muscle (LAM) defects in VD. Four articles evaluated the bladder neck, 3 of which showed a significant increase in bladder neck mobility associated with VD and 1 showed decreased bladder neck elevation, not associated with the delivery mode; the first 3 articles all evaluated LAM injuries and showed an association between VD and LAM injury. Women who underwent VD presented defects of the puborectalis muscle.
Conclusions
Vaginal delivery was associated with a higher number of LAM injuries, puborectalis defects, increased bladder neck mobility, and enlargement of the hiatal area.
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References
Dietz HP. Pelvic floor trauma in childbirth. Aust N Z J Obstet Gynecol. 2013;53(3):220–30.
Nygaard I, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008;300(11):1311–6.
Shamliyan T, Wyman J, Bliss DZ, Kane RL, Wilt TJ. Prevention of urinary and fecal incontinence in adults. Evid Rep Technol Assess (Full Rep). 2007;161:1–379.
Progetto Menopausa Italia Study Group. Risk factors for genital prolapse in non-hysterectomized women around menopause. Results from a large cross-sectional study in menopausal clinics in Italy. Eur J Obstet Gynecol Reprod Biol. 2000;93(2):135-40.
Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the Oxford family planning association study. Br J Obstet Gynaecol. 1997;104(5):579–85.
MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. BJOG. 2000;107(12):1460–70.
Kisli E, Kisli M, Agargun H, Altinokyigit F, Kamaci M, Ozman E, et al. Impaired function of the levator ani muscle in the grand multipara and great grand multipara. Tohoku J Exp Med. 2006;210(4):365–72.
Bim CR, Perego AL, Pires-Jr H. Fisioterapia aplicada à ginecologia e obstetrícia. Cesumar. 2002;4(1):57–61.
Lukacz ES, Lawrence JM, Contreras R, Nager CW, Luber KM. Parity, mode of delivery, and pelvic floor disorders. Obstet Gynecol. 2006;107(6):1253–60.
Herbert J. Pregnancy and childbirth: the effects on pelvic floor muscles. Nurs Times. 2009;105(7):38–41.
Staer-Jensen J, Siafarikas F, Hilde G, Bø K, Engh ME. Ultrasonographic evaluation of pelvic organ support during pregnancy. Obstet Gynecol. 2013;122:329–36.
Dietz HP. Levator function before and after childbirth. Aust N Z J Obstet Gynaecol. 2004;44(1):19–23.
Otcenasek M, Krofta L, Baca V, Grill R, Kucera E, Herman H, et al. Bilateral avulsion of the puborectal muscle: magnetic resonance imaging-based three-dimensional reconstruction and comparison with a model of a healthy nulliparous woman. Ultrasound Obstet Gynecol. 2007;29(6):692–6.
Jou IM, Lai KA, Shen CL, Yamano Y. Changes in conduction, blood flow, histology, and neurological status following acute nerve-stretch injury induced by femoral lengthening. J Orthop Res. 2000;18(1):149–55.
Dietz HP, Wilson PD. Childbirth and pelvic floor trauma. Best Pract Res Clin Obstet Gynaecol. 2005;19(6):913–24.
Shek KL, Dietz HP. Pelvic floor ultrasonography: an update. Minerva Ginecol. 2013;65(1):1–20.
Dixit P, Shek KL, Dietz HP. How common is pelvic floor muscle atrophy after vaginal childbirth? Ultrasound Obstet Gynecol. 2014;43(1):83–8.
Shek KL, Dietz HP. Intrapartum risk factors for levator trauma. BJOG. 2010;117(12):1485–92.
DeLancey JO, Morgan DM, Fenner DE, Kearney R, Guire K, Miller JM, et al. Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse. Obstet Gynecol. 2007;109:295–302.
Dietz HP, Simpson JM. Levator trauma is associated with pelvic organ prolapse. BJOG. 2008;115(8):979–84.
Schwertner-Tiepelmann N, Thakar R, Sultan AH, Tunn R. Obstetric levator ani muscle injuries: current status. Ultrasound Obstet Gynecol. 2012;39(4):372–83.
Moher D, Liberati A, Tetzlaff J, Altman DG. Systematic reviews and meta-analyses: the PRISMA statement. Annu Intern Med. 2009;151(4):264–9.
Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomized studies of interventions. BMJ. 2016;355:i4919.
Staer-Jensen J, Siafarikas F, Hilde G, Benth JS, Bo K, Engh ME. Postpartum recovery of levator hiatus and bladder neck mobility in relation to pregnancy. Obstet Gynecol. 2015;125(3):531–9.
Siafarikas F, Staer-Jensen J, Hilde G, Bø K, Ellström Engh M. The levator ani muscle during pregnancy and major levator ani muscle defects diagnosed postpartum: a three- and four-dimensional transperineal ultrasound study. BJOG. 2015;122(8):1083–91.
Van Delft K, Sultan AH, Thakar R, Schwertner-Tiepelmann N, Kluivers K. The relationship between postpartum levator ani muscle avulsion and signs and symptoms of pelvic floor dysfunction. BJOG. 2014;121(9):1164–71. discussion 1172
Chan SSC, Cheung RYK, Yiu KW, Lee LL, Chung TKH. Pelvic floor biometry in Chinese primiparous women 1 year after delivery: a prospective observational study. Ultrasound Obstet Gynecol. 2014;43(4):466–74.
Toozs-Hobson P, Balmforth J, Cardozo L, Khullar V, Athanasiou S. The effect of mode of delivery on pelvic floor functional anatomy. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(3):407–16.
Peschers U, Schaer GN, DeLancey JO, Schussler B. Levator ani function before and after childbirth. Br J Obstet Gynaecol. 1997;104:1004–8.
Dietz HP, Bernardo MJ, Kirby A, Shek KL. Minimal criteria for the diagnosis of avulsion of the puborectalis muscle by tomographic ultrasound. Int Urogynecol J. 2011;22(6):699–704.
Jelovsek JE, Barber MD. Women seeking treatment for advanced pelvic organ prolapse have decreased body image and quality of life. Am J Obstet Gynecol. 2006;194(5):1455–61.
Braekken IH, Majida M, Ellstrøm-Engh M, Dietz HP, Umek W, Bø K. Retest and intra-observer repeatability of two-, three- and four-dimensional perineal ultrasound of pelvic floor muscle anatomy and function. Int Urogynecol Pelvic Floor Dysfunct. 2008;19(2):227–35.
Glazener C, Elders A, Macarthur C, Lancashire RJ, Herbison P, Hagen S, et al. Childbirth and prolapse: long-term associations with the symptoms and objective measurement of pelvic organ prolapse. BJOG. 2013;120(2):161–8.
Yousuf AA, DeLancey JO, Brandon CJ, Miller JM. Pelvic structure and function at 1 month compared to 7 months by dynamic magnetic resonance after vaginal birth. Am J Obstet Gynecol. 2009;201(5):514.e1–7
Tunn R, DeLancey JO, Howard D, Thorp JM, Ashton-Miller JA, Quint LE. MR imaging of levator ani muscle recovery following vaginal delivery. Int Urogynecol J Pelvic Floor Dysfunct. 1999;10(5):300–7.
Svabik K, Shek KL, Dietz HP. How much does the puborectalis muscle have to stretch in childbirth? Ultrasound Obstet Gynecol. 2008;32:395.
Shek KL, Kruger J, Dietz HP. The effect of pregnancy on hiatal dimensions and urethral mobility: an observational study. Int Urogynecol J. 2012;23(11):1561–7.
Wijma J, Potters AE, de Wolf BT, Tinga DJ, Aarnoudse JG. Anatomical and functional changes in the lower urinary tract following spontaneous vaginal delivery. BJOG. 2003;110(7):658–63.
Shek KL, Dietz HP, Kirby A. The effect of childbirth on urethral mobility: a prospective observational study. J Urol. 2010;184(2):629–34.
Dietz HP, Lanzarone V. Levator trauma after vaginal delivery. Obstet Gynecol. 2005;106(4):707–12.
Notten KJB, Vergeldt TFM, van Kuijk SMJ, Weemhoff M, Roovers JWR. Ultrasound for the assessment of levator ani defects and levator ani biometry in women with pelvic organ prolapse: a systematic review. Female Pelvic Med Reconstr Surg. 2017;23(6):420–8.
Yan Y, Dou C, Wang X, Xi Y, Hu B, Ma L, et al. Combination of tomographic ultrasound imaging and three-dimensional magnetic resonance imaging-based model to diagnose postpartum levator avulsion. Sci Rep. 2017;7(1):11235.
Funding
We are grateful to Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) for the support of this study with a post-graduate scholarship to one of the authors (CCA), and Fundação de Amparo a Pesquisa do Estado de São Paulo (FAPESP 2016/24065-2).
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de Araujo, C.C., Coelho, S.A., Stahlschmidt, P. et al. Does vaginal delivery cause more damage to the pelvic floor than cesarean section as determined by 3D ultrasound evaluation? A systematic review. Int Urogynecol J 29, 639–645 (2018). https://doi.org/10.1007/s00192-018-3609-3
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DOI: https://doi.org/10.1007/s00192-018-3609-3