Thubert T, Cardaillac C, Fritel X, Winer N, Dochez V
Service de gynécologie-obstétrique, hôpitaux de Nantes, CHU Hôtel-Dieu, 38, boulevard Jean-Monnet, 44000 Nantes, France; Université de Nantes, 1, rue Gaston-Veil, 44000 Nantes, France; GMC-UPMC 01, GREEN (Groupe de recherche clinique en neurourologie), 4, rue de la Chine, 75020 Paris, France.
Service de gynécologie-obstétrique, hôpitaux de Nantes, CHU Hôtel-Dieu, 38, boulevard Jean-Monnet, 44000 Nantes, France; Université de Nantes, 1, rue Gaston-Veil, 44000 Nantes, France.
Gynecol Obstet Fertil Senol. 2018 Dec;46(12):913-921. doi: 10.1016/j.gofs.2018.10.028. Epub 2018 Oct 29.
The aim of this review was to agree on a definition of the obstetric anal sphincter injuries (OASIS), to determine the prevalence and risk factors.
A comprehensive review of the literature on the obstetric anal sphincter injuries (OASIS), establishment of levels of evidence (NP), and grades of recommendation according to the methodology of the recommendations for clinical practice.
To classify obstetric anal sphincter injuries (OASIS), we have used the WHO-RCOG classification, which lists 4 degrees of severity. To designate obstetric anal sphincter injuries, we have used the acronym OASIS, rather than the standard French terms of "complete perineum" and "complicated complete perineum". OASIS with only isolated involvement of the EAS (3a and 3b) appears to have a better functional prognosis than OASIS affecting the IAS or the anorectal mucosa (3c and 4) (LE3). The prevalence of women with ano-rectal symptoms increases with the severity of the OASIS (LE3). In the long term, 35-60% of women who had an OASIS have anal or fecal incontinence (LE3). The prevalence of an OASI in the general population is between 0.25 to 6%. The prevalence of OASIS in primiparous women is between 1.4 and 16% and thus, should be considered more important than among the multiparous women (0.4 to 2.7%). In women with a history of previous OASIS, the risk of occurrence is higher and varies between 5.1 and 10.7% following childbirth. The priority in this context remains the training of childbirth professionals (midwives and obstetricians) to detect these injuries in the delivery room, immediately after the birth. The training and awareness of these practitioners of OASIS diagnosis improves its detection in the delivery room (LE2). Professional experience is associated with better detection of OASIS (LE3) (4). Continuing professional education of obstetrics professionals in the diagnosis and repair of OASIS must be encouraged (Grade C). In the case of second-degree perineal tear, the use of ultrasound in the delivery room improves the diagnosis of OASIS (LE2). Ultrasound decreases the prevalence of symptoms of severe anal incontinence at 1 year (LE2). The diagnosis of OASIS is improved by the use of endo-anal ultrasonography in post-partum (72h-6weeks) (LE2). The principal factors associated with OASIS are nulliparity and instrumental (vaginal operative) delivery; the others are advanced maternal age, history of OASIS, macrosomia, midline episiotomy, posterior cephalic positions, and long labour (LE2). The presence of a perianal lesion (perianal fissure, or anorectal or rectovaginal fistula) is associated with an increased risk of 4th degree lacerations (LE3). Crohn's disease without perianal involvement is not associated with an excess risk of OASIS (LE3). For women with type III genital mutilation, deinfibulation before delivery is associated with a reduction in the risk of OASIS (LE3); in this situation, deinfibulation is recommended before delivery (grade C).
It is necessary to use a consensus definition of the OASIS to be able to better detect and treat them.
本综述旨在就产科肛门括约肌损伤（OASIS）的定义达成共识，确定其患病率及危险因素。
全面回顾关于产科肛门括约肌损伤（OASIS）的文献，根据临床实践指南的方法确定证据级别（NP）和推荐等级。
为对产科肛门括约肌损伤（OASIS）进行分类，我们采用了世界卫生组织-皇家妇产科学院（WHO-RCOG）分类法，该分类列出了4级严重程度。为命名产科肛门括约肌损伤，我们使用了首字母缩写词OASIS，而非标准法语术语“完全会阴裂伤”和“复杂完全会阴裂伤”。仅累及外括约肌（EAS）的OASIS（3a和3b）似乎比累及内括约肌（IAS）或肛门直肠黏膜的OASIS（3c和4）具有更好的功能预后（证据级别3）。肛门直肠症状女性的患病率随OASIS严重程度增加而升高（证据级别3）。从长远来看，35%至60%发生过OASIS的女性存在肛门或大便失禁（证据级别3）。一般人群中OASI的患病率在0.25%至6%之间。初产妇中OASIS的患病率在1.4%至16%之间，因此应比经产妇（0.4%至2.7%）更受重视。有既往OASIS病史的女性，产后发生OASIS的风险更高，在5.1%至10.7%之间。在此背景下，首要任务仍是培训分娩专业人员（助产士和产科医生），以便在分娩后立即在产房发现这些损伤。对这些从业者进行OASIS诊断的培训和提高认识可改善产房对其的检测（证据级别2）。专业经验与更好地发现OASIS相关（证据级别3）（4）。必须鼓励对产科专业人员进行OASIS诊断和修复方面的继续职业教育（C级推荐）。对于二度会阴撕裂，在产房使用超声可改善OASIS的诊断（证据级别2）。超声可降低1年后严重肛门失禁症状的患病率（证据级别2）。产后（72小时至6周）使用肛门内超声可改善OASIS的诊断（证据级别2）。与OASIS相关的主要因素是初产和器械助产（阴道手术分娩）；其他因素包括产妇年龄较大、有OASIS病史、巨大儿、会阴正中切开术、胎头后位和产程延长（证据级别2）。肛周病变（肛裂、肛门直肠瘘或直肠阴道瘘）的存在与四度撕裂风险增加相关（证据级别3）。无肛周受累的克罗恩病与OASIS额外风险无关（证据级别3）。对于三度女性生殖器切割的女性，分娩前解除纤维环与降低OASIS风险相关（证据级别3）；在这种情况下，建议分娩前解除纤维环（C级推荐）。
有必要采用OASIS的共识定义，以便更好地检测和治疗这些损伤。
