Ozyurt Sezin, Aksoy Huseyin, Gedikbasi Ali, Yildirim Gokhan, Aksoy Ulku, Acmaz Gokhan, Ark Cemal
Department of Obstetrics and Gynecology, Kayseri Education and Research Hospital of Medicine, Kayseri, Turkey,
Arch Gynecol Obstet. 2015 Oct;292(4):853-9. doi: 10.1007/s00404-015-3708-z. Epub 2015 Apr 10.
Here we aimed to evaluate the incidence of obstetric anal sphincter injuries in spontaneous primigravid deliveries with mediolateral episiotomy beyond 36 gestational weeks.
We performed a prospective, randomized controlled study including 201 primigravid women that delivered vaginally. Anal sphincter anatomy and integrity was evaluated before hospital discharge in all cases with transvaginal sonography (5-9 MHz) (Siemens Sonoline G50 and Voluson 730 Expert). The vaginal ultrasound probe is placed in the fourchette of the vaginal introitus to obtain the transverse section of the anal sphincter.
In the cases with sphincter defect, mean gestational week and second stage of labor were prolonged significantly (p = 0.039 and p < 0.0001, respectively). The mean perineal body distance in cases with sphincter injury, as detected by sonography, 2.18 ± 0.33 cm, is compared to 2.31 ± 2.43 cm in cases without injury. There was a significant difference between the two groups (p = 0.0142). Shoulder dystocia was significantly higher in cases with sphincter injury, compared to cases without injury (p = 0.011). No clinical findings were reported in 11.5 % of cases (Sonography findings 1A∓, 1B∓) and 3.5 % of cases had clinical and sonographic findings (Sonography findings 2A∓, 2B∓). "Occult tears" were considered as those cases not detected clinically, but detected by sonography (11.5 % of all cases). Two months after examination, a moderate incontinence (Wexner continence scale) was found in 71.5 % of cases with overt sphincter tear, which was significantly different to the non-overt sphincter tear group. Multiple logistic regression analyses for sphincter injuries identified prolonged second stage of labor and shoulder dystocia as two independent risk factors.
Here, we found that only a portion of anal sphincter injuries can be detected after physical examination, with many of cases of "occult tears" escaping notice. These cases of occult anal sphincter injury are detectable by sonography with transperineal use of a vaginal probe. Based on these findings, we propose that this technique is convenient for obstetric, gynecologic and proctologic evaluation of sphincter anatomy.
本研究旨在评估孕36周后经会阴侧切的初产妇自然分娩时产科肛门括约肌损伤的发生率。
我们进行了一项前瞻性随机对照研究，纳入201例经阴道分娩的初产妇。所有病例在出院前均采用经阴道超声检查（5 - 9MHz）（西门子Sonoline G50和Voluson 730 Expert）评估肛门括约肌的解剖结构和完整性。将阴道超声探头置于阴道口的阴唇系带处，以获取肛门括约肌的横切面图像。
在存在括约肌缺陷的病例中，平均孕周和第二产程显著延长（分别为p = 0.039和p < 0.0001）。经超声检查，括约肌损伤病例的会阴体平均距离为2.18 ± 0.33cm，无损伤病例为2.31 ± 2.43cm。两组间差异有统计学意义（p = 0.0142）。与无损伤病例相比，括约肌损伤病例的肩难产发生率显著更高（p = 0.011）。11.5%的病例未报告临床发现（超声检查结果为1A∓, 1B∓），3.5%的病例有临床和超声检查发现（超声检查结果为2A∓, 2B∓）。“隐匿性撕裂”被认为是那些临床未检测到但超声检查发现的病例（占所有病例的11.5%）。检查两个月后，71.5%的明显括约肌撕裂病例出现中度失禁（韦克斯纳失禁量表），这与非明显括约肌撕裂组有显著差异。括约肌损伤的多因素逻辑回归分析确定第二产程延长和肩难产为两个独立危险因素。
我们发现，体格检查后仅能检测到部分肛门括约肌损伤，许多“隐匿性撕裂”病例未被发现。经会阴使用阴道探头的超声检查可检测到这些隐匿性肛门括约肌损伤病例。基于这些发现，我们认为该技术便于产科、妇科和直肠科对括约肌解剖结构进行评估。
