University of Oslo, Faculty of Medicine, Division Akershus University Hospital, Oslo, Norway.
Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway.
Ultrasound Obstet Gynecol. 2024 Jul;64(1):112-119. doi: 10.1002/uog.27599. Epub 2024 Jun 5.
To assess the evolution of levator ani muscle (LAM) avulsion from 1 year to 8 years after first delivery in women with and those without subsequent vaginal delivery. In addition, to assess whether women with full or partial avulsion 8 years after first delivery have larger LAM hiatal area and more symptoms of pelvic organ prolapse compared to women with normal LAM insertion.
In this single-center longitudinal study, 195 women who were primiparous at the start of the study were included and underwent transperineal ultrasound examination 1 year and 8 years after first delivery. Muscle insertion was assessed by tomographic ultrasound imaging in the axial plane. Full LAM avulsion was defined as abnormal muscle insertion in all three central slices. Partial LAM avulsion was defined as abnormal muscle insertion in one or two central slices. Eight years after the first delivery, LAM hiatal area was assessed at rest, during maximum pelvic floor muscle contraction and on maximum Valsalva maneuver. To assess symptoms of pelvic organ prolapse, the vaginal symptoms module of the International Consultation on Incontinence Questionnaire was used.
At 1-year follow-up, 25 (12.8%) women showed signs of LAM avulsion, of whom 20 fulfilled the sonographic criteria of full avulsion and five of partial avulsion. Eight years after the first delivery, 35 (17.9%) women were diagnosed with avulsion, of whom 25 were diagnosed with full avulsion and 10 with partial avulsion. No woman with partial or full avulsion at 1 year had improved avulsion status at 8-year follow-up. Of the 150 women who had subsequent vaginal delivery, 21 (14.0%) women were diagnosed with partial or full LAM avulsion 1 year after first delivery, and 31 (20.7%) women were diagnosed with partial or full avulsion 8 years after first delivery. Of the 45 women without subsequent vaginal delivery, one woman with partial avulsion 1 year after first delivery was diagnosed with full avulsion at 8-year follow-up. All women with full avulsion at 1-year follow-up were diagnosed with full avulsion at 8-year follow-up regardless of whether they had subsequent vaginal delivery. At 8-year follow-up, women with full avulsion had statistically significantly larger LAM hiatal area compared to women with normal muscle insertion. Mean ± SD vaginal symptom scores ranged between 5.5 ± 5.7 and 6.0 ± 4.0 and vaginal symptom quality of life scores ranged between 0.9 ± 1.4 and 1.5 ± 2.2 and did not differ significantly between women with normal muscle insertion and women with partial or full avulsion at 8-year follow-up.
More LAM avulsions were present 8 years compared with 1 year after first delivery in women with subsequent vaginal delivery. Except for one primipara, all women without subsequent vaginal delivery had unchanged LAM avulsion status between 1 year and 8 years after their first delivery. Larger LAM hiatal area was found in women with full avulsion compared to those with normal muscle insertion at 8-year follow-up. Vaginal symptoms scores were low and did not differ between women with normal muscle insertion and those with partial or full avulsion at 8-year follow-up. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
评估首次分娩后 1 年至 8 年期间，有和没有随后阴道分娩的女性中，肛提肌（LAM）撕裂的演变。此外，评估首次分娩 8 年后完全或部分撕裂的女性与 LAM 插入正常的女性相比，LAM 裂孔区是否更大，以及是否有更多的盆腔器官脱垂症状。
这是一项单中心纵向研究，共纳入 195 名初产妇，在研究开始时接受经会阴超声检查，分别在首次分娩后 1 年和 8 年进行。采用断层超声成像技术在轴向平面评估肌肉插入情况。完全 LAM 撕裂定义为所有三个中央切片的异常肌肉插入。部分 LAM 撕裂定义为一个或两个中央切片的异常肌肉插入。首次分娩 8 年后，在休息、最大盆底肌收缩和最大valsalva 动作时评估 LAM 裂孔区。为了评估盆腔器官脱垂的症状，使用国际尿失禁咨询问卷的阴道症状模块。
在 1 年随访时，25 名（12.8%）女性出现 LAM 撕裂的迹象，其中 20 名符合完全撕裂的超声标准，5 名符合部分撕裂的超声标准。首次分娩 8 年后，35 名（17.9%）女性被诊断为撕裂，其中 25 名被诊断为完全撕裂，10 名被诊断为部分撕裂。首次分娩 1 年后部分或完全撕裂的女性中，没有女性在 8 年随访时撕裂状况得到改善。在 150 名有后续阴道分娩的女性中，21 名（14.0%）女性在首次分娩后 1 年被诊断为部分或完全 LAM 撕裂，31 名（20.7%）女性在首次分娩后 8 年被诊断为部分或完全撕裂。在 45 名没有后续阴道分娩的女性中，1 名首次分娩后部分撕裂的女性在 8 年随访时被诊断为完全撕裂。所有在首次分娩 1 年后完全撕裂的女性，无论是否有后续阴道分娩，在 8 年随访时均被诊断为完全撕裂。在 8 年随访时，与肌肉插入正常的女性相比，完全撕裂的女性 LAM 裂孔区明显更大。平均±标准差阴道症状评分范围为 5.5±5.7 至 6.0±4.0，阴道症状生活质量评分范围为 0.9±1.4 至 1.5±2.2，在 8 年随访时，肌肉插入正常的女性与部分或完全撕裂的女性之间没有显著差异。
与首次分娩后 1 年相比，有后续阴道分娩的女性在首次分娩后 8 年时 LAM 撕裂的发生率更高。除了 1 名初产妇，所有没有后续阴道分娩的女性在首次分娩后 1 年至 8 年期间 LAM 撕裂的情况没有变化。与肌肉插入正常的女性相比，在 8 年随访时，完全撕裂的女性 LAM 裂孔区更大。阴道症状评分较低，在 8 年随访时，肌肉插入正常的女性与部分或完全撕裂的女性之间没有差异。
