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Sunday, September 13, 2015

Review of: Postpartum Recovery of Levator Hiatus and Bladder Neck Mobility in Relation to Pregnancy


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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