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Anal Sphincter lesions after delivery
Finnish Society Of Gynecological Surgery 22-23.9.2005
Karl Møller BekAarhus University Hospital
Skejby SygehusDenmark
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Risk factors for having obstetric anal sphincter rupture
• Episiotomy • Primi parity• Heavy infant• Instrumental delivery • Long second stage of delivery
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What about episiotomy
Restrictive use of episiotomy has a number of benefits compared with routine episiotomy especially there are less posterior trauma in the restrictive group
Routine episiotomy rate : 73 %
Restrictive episiotomy rate : 28 %
Cochrane review (Carroli & Belizan: Episiotomy for vaginal birth 2004)
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Risk of having an episiotomy depending on the midwife at charge
Henriksen, Bek, Hedegaard, Secher: Br J Obst Gynecol 1992
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Henriksen,Bek,Hedegaard,Secher:Br J Obst Gynec 1994
before sept. 1990 No: 1669
after sept. 1990 No: 2250
Indication of episiotomyProphylactic 462(28%) 463(21%)
Shortening 153(9,2%) 222(9,9%)
Perineal status
Episiotomy 615(37%) 685(30,5%)
Intact 533(32%) 792(35%)
Grade I - II 49% 49%
Grade III a – b 32(1,9%) 50(2,2%)
Grade III c + IV 17(1%) 23(1%)
Heriksen, Bek,Hedegaard, Secher: Br J Obst Gynecol 1994
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Changing in the rate of episiotomy at Aarhus University Hospital
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Thorp et all : Obstet Gynecol 1987Obstet
Restrictive Liberal
Number of
deliveries 113 265
+ epis - epis + epis - epis
16 (14%) 97 168 (63%) 97
Sphincter
Rupture 2 (0,9%) 0 37 (14%) 0
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Frequency of anal sphincter rupture at delivery in Sweden and Finland.Pirhonen et all. Acta obst Scandinavia 1998
Malmö Turku p
Deliveries 14.678 16.255
Cesarean section 9.1% 16.2% < 0.001
Ventous 5.4% 6.2% < 0.001
Forceps 0.8% 0.7% NS
Episiotomy 24.3% 37.2% < 0.001
Lacerations 2.69% 0.36% < 0.001
Partial sphincter 2.45% 0.35% < 0.001
Support to fetal
head passive active
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Parnell, Langhoff-Roos, Møller
90 cases with sphincter tears, 164 referents
A reduction in the incidence of sphincter tears may be accomplished by improved obstetric care in terms of easing the perineum over the caput as it advanced
Acta Obstet Gynecol 2001
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ConclusionPrevention of sphincter tears
Avoid instrumental deliveries if possible
Only use episiotomy when needed !!
Look upon the basic obstetrics practices
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Reported anal incontinence following obstetric anal sphincter rupture
Number Time Gas Liq/Solid
total
Sørensen 25 6 år 25% 17% 42%
Hadeem 59 3,4 år 25% 7% 29%
Nielsen 24 18 md 29% 13% 29%
Bek-Laurberg 121 1-13 år 16% 3% 16%
Tetzschner 72 3mdr 14% 4% 18%
Tetzschner 72 2-4 år 25% 17% 39%
Sultan 34 6mdr 47%
Craword 35 9-12m 17% 3% 13%
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Anal incontinence score – Wexner – Modification
• Wexner scoreIncontinence Never Rarely Sometimes Weekly DailySolid stool 0 1 2 3 4Liquid stool 0 1 2 3 4Gas 0 1 2 3 4Need to wear pad 0 1 2 3 4Lifestyle alteration 0 1 2 3 4 Max: 20
• Modification
Soiling 0 1 2 3 4
No YesConstipating med. 0 2Urgency (less than 15 minutes) 0 4 Max: 30
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Primary suture of obstetric anal sphincter tearInternal sphincter
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Primary suture of obstetric anal sphincter tearExternal sphincter
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Treatment of III and IV perineal dehiscence after primary repair.Should we do a colostomy and do a later repair?
• Hankins et all. (Obst Gynecol 1990) Treated 22 patients with dehiscence of a primary sutured III or IV perineal laceration with wound preparation for 4 – 10 days followed by early secondary suture. One had a pinpoint rectovaginal fistula
• Arona et all (Obst Gynecol 1995) treated 23 patients with dehiscence of a primary sutured III or IV perinal tear using the same procedure and had simmilary results.
• Colostomy in sphincter repair is unnecessary – it gives no benefit in terms of wound healing or functional outcome, and it is a source of morbidity (Hasegawa et all. Dis Colon Rectum ;2000)
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Transanal ultrasound of a patient with misdiagnosed Grad IIIc perineal tear at delivery.
Five days after delivery and five months after early secondary suture
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Results of early secondary or delayed repair within first week in 19 patients with sphincter rupture and gross anal incontinence from
1994 -04Parity 17 para 0, one earlier caesarian sectio,
one para 2 with earlier sphincter rupture
Age mean 33 years (26 – 40)
Type of 2 forceps, 8 vacuum, 9 spontaneus delivery
Classifications Grade I : 2 ptt. Grade II: 2 ptt, Grade IIIa: 1 pt, at delivery Grade IIIb: 9 ptt, Grade IIIc: 1 ptt, Grade IV : 4 pt
Symptoms leading Anal incontinence only: 8 ptt. Haematoms: 5 ptt.to reoperation Infections: 4 ptt. Fistula to vagina/perineum: 2 ptt.
Classifications Grade IIIb: 10 ptt, Grade IIIc: 3 ptt, Grade IV : 6 pttat reoperation
Time of re-op 6 days (1 – 14) after delivery
Postop. 1 had minor defect in perineum that healed spontaneously. 2 had hypergranulations tissue
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Functional results after 6 months
Incontinence to gass: 4 patients
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Functionel results after 1 – 14 years
2 had incontinence to solid stool (One rarely and one weekly)
4 had incontinence to liquid stool (two rarely, 2 weekley)
17 had incontinence for gas(five dayly, six weekly,six somtimes and one
rarely)
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If you don't make an early secondary suture this patient may look like this after a some years
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Number of acute obstetrics anal sphincter repairs done by coloproctologists, obstetricians and trainees In U.K 2002
number of repair coloproctologists obstetricians trainees
None 54(60%) 69(0,3%) 16(10,8%)
Less than 5/years 27(30%) 290(43.2%) 89(60,1%)
5 – 10 / year 3(3.3%) 168(25%) 34(23%)
10 / years 6(6.7%) 145(21.5%) 9(6.1%)
Fernando RJ,Sultan AH,Radley S,Jones PW,Johanson RB.BMC Health services Research.2002
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Delayed secondary suture is difficult and only 80% will become continent to feces. The result deteriorate by timeMalouf et all: Lancet 2000,Rothbarth et all. Dig Surg 2000
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Conclusion
• Primary suture of Grad III and IV perineal lacerations should be done by obstetricians
• Good educations is necessary• Patients with anal incontinence following a delivery
should have an endoanal ultrasound. • Early secondary suture of a III´th or IV´th perineal tear
can be done within the first 2 weeks with good results
• Late secondary repair is difficulty and only 80% become continent for feces. The result deteriorate by time
• Patients should bee offered clinical control some month after delivery
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Following deliveries : Vaginal or Caesarian section?
• 2,1% without episiotomy• 10,6% with episiotomy
• 21,4 % with episiotomy and instrumentel
735 ptt with prior sphincter rupture
Peleg obst & Gynecol 1999
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Following deliveries : Vaginal or Caesarian section?
• 10% with anal sphincter rupture at 2. delivery have had a prior sphincter ruptur
• The risk of having sphincter rupture in the following delivery is four fold increased
OR 4.3 (3.8 – 4.8)• Absolut risk for Re-ruptur 1,3% for Birth Weight <3000 g men 23.3% for Birth Weight > 5000g
• 486.463 fødsler
• Spydslaug et al.Obst Gynecol 2005
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Anal incontinence after the next delivery in 52 patients with
prior sphincter rupture • Anal incontinence after
sphincter rupture• 23 patients
Anal incontinence after the following delivery without sphincter rupture
9 patients
Bek KM, Laurberg S
• No Anal incontinence after sphincter rupture
• 29 patients
Anal incontinence after the following delivery without sphincter rupture
2 patients
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59 nulliparous Fynes, Lancet 1999
39 no defect after first delivery
7 asymtomatic defect after first delivery
13 symptomatic defect after first delivery
39 had no defect during second pregnancy
12 had an 5 asymptomatic defect during second pregnancy
8 had a symptomatic defect during second pregnancy
37 had no defect after second delivery
7 had an asymptomatic defect after second dellivery
15 had a symptomatic defect after second delivery 2 + 5
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Recommendation
• Clinical examination after 5 months
• The risk of repeat sphincter rupture in the next delivery is similar to that of primipara.
• Vaginal delivery in patients without symptoms
• Caesarian section in patients with symptoms