Starr-Jensen J, et al. Obstetrics and Gynecolgy2015;3:531-539.
Cora Huit
Pelvic PT Distance Journal Club Sept 2, 2015
Aim: To determine
the changes in pelvic floor morphology, specifically of the levator hiatus and
the bladder neck, during and after pregnancy for women delivery vaginally and
having cesarean sections.
Design: An observational,
longitudinally study using ultrasonography to exam women’s pelvic floor changes
at 21 and 37 weeks pregnant and 6 weeks, 6 months and 12 months postpartum.
Population: The study included 300 women who had not
previously given birth. For the 37th week ultrasoundography, 274
women were examined. At 6 weeks postpartum, 285 women were examined, 198 women
were examined at 6 months and finally 178 women were examined at 12 months. These
women were invited to enroll in the study when coming to Akershus Univeristy
Hopsital, Lorenskog, Norway, for their second-trimester ultrasound examination
at 18-22 weeks pregnant.
Inclusions: Women included in the
study were above the age of 18, had no prior pregnancy lasting more than 16
weeks, spoke a Scandinavian language, were pregnant with only one child during
the study and had no serious illnesses.
Exclusions: Women excluded from the
study were those who had miscarriages or a stillbirth, those who had premature
delivery before 32 weeks, a new pregnancy of more than 6 weeks or those women
randomized to intervention with pelvic floor muscle training at 6 weeks
postpartum.
Methodology: A
three and four dimensional ultrasonography was conducted on each woman while
they were at rest, while contracting the pelvic floor, and when doing the
Valsalva maneuver. Again, this examination was done at 21 and 37 weeks
pregnant, and 6 weeks, 6 months and 12 months postpartum. All maneuvers of the
pelvic floor were taught to participants by physical therapists and each woman
was examined during the maneuvers by examiners who were blinded to the patient’s
clinical information.
Researchers defined an enlarged levator hiatus as any
levator hiatus with an area of more than 25 cm during the Valsalva maneuver.
Major levator ani muscle defects were investigated when participants were
contracting their pelvic floor at the maximum and a partial defect was defined
when there was abnormal muscle insertion in less than all three central planes
of the muscles.
To compare levator ani muscle defects and an enlarged
levator hiatus over time, the McNemar test was used.
Results:
There were no significant differences found in the
demographics of women who had c-sections or vaginal deliveries. No other
significant demographic differences were found in patients who did or did not
withdraw from the study, other than a slightly larger percentage of women who
were married or cohabitating completing the study.
Vaginal delivery: For women who had a vaginal delivery,
there was found to be a significant decrease in the levator hiatus and bladder
neck mobility from 6 week to 6 months postpartum but no further change from 6
months to 12 month postpartum. This group had a larger levator hiatus and more
bladder neck mobility than the cesarean group during postpartum examinations.14.5
% of vaginal deliveries resulted in a diagnosis of a defect of the levator ani
muscle. This diagnosis was reduced from 6 months to 12 months postpartum.
Cesarean Sections Delivery: There were no significant
changes found at any of the postpartum examinations for women who had cesarean
deliveries and women who had enlarged levator hiatus remained stable throughout
this period. This group had fewer changes in bladder neck mobility and a smaller
levator hiatus postpartum than the vaginal delivery group. There were no major levator
ani muscle defects diagnosed in this delivery group.
Comparing Delivery modes: When comparing both birthing
modes, it was found that women who had delivered vaginally had a significantly enlarged
levator hiatus and increased bladder neck mobility at 6 weeks and 6 months postpartum.
When compared again at 12 months postpartum, the only significant difference
found between both birthing modes was found for the levator hiatus when women
were contracting.
Discussion: Most
of the recovery of the levator ani muscle occurs during the first 6 months
postpartum and most women are able to recover back to their pregnancy level. Recovery
varies based on whether the changes were brought on by the pregnancy itself,
the delivery or both. For example, bladder neck mobility is increased when the
delivery is vaginal and takes about 6 months to recover from but there is no
significantly increased bladder neck mobility in cesarean deliveries. There was,
however, no difference in an increase in levator hiatus during pregnancy and at
one year postpartum for either group. These findings suggest there are some
pregnancy-induced changes to the pelvic floor that are occurring, separate from
the delivery mode. Fortunately, most women are able to recover from the pregnancy
and birthing process, although women should understand that some changes can,
and do, persist. Also, women should be aware that the changes that occur during
pregnancy could create complications if they develop pelvic floor disorders in
the future.
Strengths and
weakness of the study: This study was a longitudinal design, so researchers
were able to assess differences in changes that occurred during pregnancy, as
well as, during delivery. There was a lot of agreement between observers of the
data. There were, unfortunately, no pre-pregnant measures of muscles available
to researchers and not many women in the study that had a cesarean delivery.
The question still remains if physical therapy intervention of modalities and
procedures occurred during the first six months would the levator hiatus
decrease and more stiffness of the levator plate occur therefore reducing the
incidence of prolapse.
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