Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Italy.
Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Italy.
Am J Obstet Gynecol MFM. 2019 Aug;1(3):100037. doi: 10.1016/j.ajogmf.2019.100037. Epub 2019 Aug 21.
Early repair of obstetric anal sphincter injuries is crucial in the prevention of anal incontinence, but the diagnostic accuracy of the clinical examination after delivery is poor. Endoanal ultrasound imaging is now regarded as the gold standard for diagnosing anal sphincter injuries, and it improves the diagnosis of these lacerations. Four-dimensional transperineal ultrasound imaging has been proposed as an effective and less invasive alternative to endoanal ultrasound imaging in the diagnosis of anal sphincter injuries.
The purpose of this study was to evaluate the feasibility and accuracy of the assessment of anal sphincter contraction by dynamic 2-dimensional transperineal ultrasound imaging immediately after delivery and its correlation with anal incontinence at the 4-month follow-up evaluation.
A nonconsecutive series of nulliparous women with low-risk singleton term pregnancies were recruited in the labor room after vaginal delivery for the purpose of this study from January 2017 to July 2017. All enrolled patients had a clinical examination of the perineum by the caregiver that was repeated by an experienced research fellow. For each patient, a further dynamic 2-dimensional transperineal ultrasound imaging were carried out. Before the perineal repair, the women were asked to contract the anal sphincter during 2-dimensional transperineal ultrasound imaging; they were divided in 2 groups according to the sonographic findings: women with sonographic evidence of anal sphincter contraction (group A) and women with no evidence of contraction at ultrasound imaging (group B). A follow-up examination of anal sphincter integrity with 4-dimensional transperineal ultrasound imaging was carried out 4 months after delivery. At this time, the levator ani integrity was evaluated with the use of 4-dimensional transperineal ultrasound imaging, as previously described.
Over the study period 69 women were enrolled. In 55 women (80%), there was evidence of proper anal sphincter contraction (group A); in 14 cases (20%), it was not possible to identify anal sphincter contraction with dynamic 2-dimensional transperineal ultrasound imaging (group B). Obstetric anal sphincter injuries that were detected through clinical examination were significantly more frequent in group B than in group A (13/14 [93%] vs 7/55 [12%]; P<.001). At the 4-month postpartum follow up, the previously recognized obstetric anal sphincter injuries were found to be repaired correctly; a third-degree perineal tear that had not been reported previously was diagnosed by 4-dimensional transperineal ultrasound imaging . Anal incontinence was reported in 8 of 69 patients (11%); it was more frequent in group B when compared with group A (4/14 [29%] vs 4/55 [7%]; P=.047).
Dynamic 2-dimensional transperineal ultrasound imaging is a feasible technique and a useful supporting tool for the assessment of anal sphincter integrity in the labor room before suturing. Anal incontinence at the 4-month follow-up evaluation is more frequent among women with no evidence of anal sphincter contraction at dynamic 2-dimensional transperineal ultrasound imaging after delivery.
在预防肛门失禁方面，早期修复产科肛门括约肌损伤至关重要，但产后临床检查的诊断准确性较差。经肛门超声成像现在被认为是诊断肛门括约肌损伤的金标准，它提高了这些撕裂伤的诊断率。四维经会阴超声成像已被提议作为诊断肛门括约肌损伤的经肛门超声成像的有效且侵入性较小的替代方法。
本研究旨在评估在分娩后立即通过动态二维经会阴超声成像评估肛门括约肌收缩的可行性和准确性，并评估其与产后 4 个月随访时肛门失禁的相关性。
本研究为非连续系列研究，纳入了 2017 年 1 月至 7 月在阴道分娩后的产房内低危单胎足月妊娠的初产妇。所有入组患者均由护理人员进行会阴临床检查，该检查由有经验的研究员重复进行。对于每一位患者，均进行进一步的动态二维经会阴超声成像。在会阴修复之前，嘱产妇在二维经会阴超声成像时收缩肛门括约肌；根据超声检查结果将患者分为两组：有超声证据表明肛门括约肌收缩的患者（A 组）和无超声证据表明收缩的患者（B 组）。在分娩后 4 个月进行经会阴四维超声成像的肛门括约肌完整性随访检查。此时，使用四维经会阴超声成像评估肛提肌完整性，如前所述。
在研究期间，共纳入 69 名女性。在 55 名（80%）女性中，有适当的肛门括约肌收缩证据（A 组）；在 14 例（20%）中，无法通过动态二维经会阴超声成像识别肛门括约肌收缩（B 组）。在 B 组中，通过临床检查发现的产科肛门括约肌损伤明显比 A 组更常见（13/14 [93%] vs 7/55 [12%]；P<.001）。在产后 4 个月的随访中，先前识别的产科肛门括约肌损伤被正确修复；通过四维经会阴超声成像诊断了先前未报告的三度会阴撕裂。69 例患者中有 8 例（11%）报告有肛门失禁；与 A 组相比，B 组更为常见（4/14 [29%] vs 4/55 [7%]；P=.047）。
动态二维经会阴超声成像技术是一种可行的技术，是分娩室在缝合前评估肛门括约肌完整性的有用辅助工具。与分娩后行动态二维经会阴超声成像未见肛门括约肌收缩的患者相比，在产后 4 个月随访时报告有肛门失禁的患者更为常见。
