Post on 21-Jan-2017
marco soligo
Azienda Ospedaliera
Istituti Clinici di PerfezionamentoOspedale di rilievo nazionale e di alta specializzazione convenzionato con l’Università degli Studi di Milano
Ospedale dei Bambini V. BuzziDipartimento della Donna, Mamma e Neonato
Direttore prof. Enrico Ferrazzi
Evento Ostetrico e Perineo Le lacerazioni perineali
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Evento Ostetrico e Perineo Le lacerazioni perineali
22 articles, 651.934 women included
severe perineal lacerations (III°-IV °) 15.366 (2.4%)
from 0,3% in Tel Aviv to 6,8 in USA
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severe perineal lacerations (III°-IV °)
on 967 consecutive women
III° 3 (2.6%)
IV 0
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14Evento Ostetrico e Perineo
Le lacerazioni perineali
•Lacerazioni PerinealiLacerazioni Perineali
•Lacerazioni VaginaliLacerazioni Vaginali
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Classification of Perineal LacerationsFirst degree:First degree: Injury to perineal skin onlySecond degree:Second degree: Injury to perineum involving perineal
muscles but not involving the anal sphincter
Third degree:Third degree: Injury to perineum involving the anal sphincter complex:
3a:3a: Less than 50% of EAS thickness torn.3b:3b: More than 50% of EAS thickness torn.3c: 3c: Both EAS and IAS torn.
Fourth degree:Fourth degree: Injury to perineum involving the anal sphincter complex (EAS and IAS) and
anal epithelium.ICI & RCOG
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““New insights into the pathophysiology and New insights into the pathophysiology and management of patients with faecal management of patients with faecal incontinence have been gained in the past incontinence have been gained in the past three years, largely as a result of new three years, largely as a result of new
ways of imaging anal sphincters, …….”ways of imaging anal sphincters, …….”
ENDOANAL ULTRASOUND
MA Kamm, The Lancet 1994MA Kamm, The Lancet 1994
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ENDOANAL ULTRASOUNDTechnical aspect
Mechanical Transducer Mechanical Transducer Rotating Scanning: full 360° Rotating Scanning: full 360° Frequency Range: 5 - 10 MHzFrequency Range: 5 - 10 MHz
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Sultan et al Clinical Radiology 1994;49:368-374
Valutazione ecografica Endoanale
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Evento Ostetrico e Perineo Le lacerazioni perineali
Ecografia EndoanaleImmagine ecografica: SAE e SAI
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Evento Ostetrico e Perineo Le lacerazioni perineali
Ecografia endoanale 3- D Aspetti tecnici
Mechanical Transducer Rotating Scanning: full 360° Frequency Range 6 - 16 MHz
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Le lacerazioni perineali
Ecografia endoanale 3- D
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EndoAnal US in 202 consecutive pregnant womenEndoAnal US in 202 consecutive pregnant womenBefore, 6 week and 6 months after deliveryBefore, 6 week and 6 months after delivery
“Anal sphincter disruption during Vaginal delivery”
Symptoms after delivery Endoanal US findingsAI/Urgency before delivery after delivery
Nulliparae 13% 0 35%
Multiparae 23% 40% 44%
Strong association (p<0.001) between either symptom and sphincter defects
A. Sultan et al. A. Sultan et al. N Engl J MedN Engl J Med 1993 1993
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Difetto SAE e SAI
M.A. Kamm Lancet 1994;344:730-33
Ecografia endoanale
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28% out of 150 Nulliparous women28% out of 150 Nulliparous women
“Occult Anal sphincter defects on EndoAnal US after vaginal delivery”
Faltin et al. Faltin et al. Obstet Gynecol 2000Obstet Gynecol 2000
33.5% out of 197 Nulliparous women33.5% out of 197 Nulliparous womenDamon et al. Damon et al. Dis Colon Rectum 2005Dis Colon Rectum 2005
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On multivariate analysis only sphincter defect on EndoAnal US after Ist delivery was significantly associated with AI 6 years later (o.r. 10.5; 95% CI, 2.1-52.4)
Damon et al, 2005
Long term consequences of occult anal sphincter defect
Anal Incontinence 6 years after the index vaginal delivery in 54 women
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Le lacerazioni perineali
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EPISIOTOMIAM
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Evento Ostetrico e Perineo Le lacerazioni perineali
22 articles, 651.934 women includedEpisiotomy & Severe perineal tears
(OR 3.69 [95% CI, 1.45–9.38; P < 0.001])
• Median episiotomy (OR 3.82 [95% CI, 1.96–7.42]; P < 0.001)
• Mediolateral episiotomy (OR 1.72 [95% CI, 0.81–3.65]; P = 0.16)
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“Risk Factors for Obstetric Anal Risk Factors for Obstetric Anal Sphincter Injury: a prospective study”Sphincter Injury: a prospective study”
Standard mediolateral episiotomyat least 40° from the midline
Andrews et al 2006
““only 13% intended mediolateral only 13% intended mediolateral episiotomies in our study were, by episiotomies in our study were, by
definition, genuinely definition, genuinely mediolateral”mediolateral”
Angle of episiotomy 26° (13)Angle of episiotomy 26° (13) 37° (16) 37° (16) mean (SD)mean (SD)
α
Anal canal
episiotomy
Vagina
OASISOASIS No OASISNo OASIS
P = 0.01P = 0.01
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Mediolateral episiotomyMediolateral episiotomy
Eogan et al 2006
The role of the Angle on OASISThe role of the Angle on OASIS
• Angle of episiotomy Angle of episiotomy (mean)(mean)
54 Cases 54 Cases 46 Controls 46 Controls (OASIS)(OASIS) vsvs (No OASIS) (No OASIS)
30° 30° (95%, 28-32)(95%, 28-32)
38° 38° (95%, 35-41)(95%, 35-41)
50% relative reduction risk for ever 6 ° away from perineal midline
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Evento Ostetrico e Perineo Le lacerazioni perineali
Evento Ostetrico e Perineo Le lacerazioni perineali
• Che fare?Che fare?
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“Occult anal sphincter injuries (OASIS):
myth or reality?”
254 primipare
Esame obiettivo immediato postpartumOstetrica/Medico
Ecografia EA e Riparazione delle lesioni identificate Aiuto esperto
Andrews et al, 2006
MetodiMetodi
Rivalutazione immediataRicercatore espertoM
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Evento Ostetrico e Perineo Le lacerazioni perineali
“Occult anal sphincter injuries: myth or reality?”
Andrews et al, 2006
RisultatiRisultati Lesioni Sfinteriche Ostetriche
• Esame obiettivo immediato postpartumOstetrica/Medico
• Ecografia EA e Riparazione delle lesioni identificate Aiuto esperto
• Rivalutazione immediataRicercatore esperto
11%
24.5%
+ 1.2%
(lesioni misconosciute: 87% / 28%)
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“Risk Factors for Obstetric Anal Sphincter Risk Factors for Obstetric Anal Sphincter Injury: a prospective study”Injury: a prospective study”
241 nulliparous women included25% sphincter injuries
Andrews et al 2006
Univariate analysisUnivariate analysis
• Forceps delivery• Vacuum extraction• Gestation > 40 weeks• Mediolateral episiotomy• Higher birthweight• Larger head circumference• Longer IInd stage of labour
Independent Risk Factors Independent Risk Factors at multiple logistic at multiple logistic regression analysisregression analysis
• Higher birthweight
• Mediolateral episiotomy
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“Risk Factors for Obstetric Anal Risk Factors for Obstetric Anal Sphincter Injury: a prospective study”Sphincter Injury: a prospective study”
241 nulliparous women includedData re-analyzed on the basis of Accoucheur’s diagnosis
11% sphincter injuries
Andrews et al 2006
Univariate analysisUnivariate analysis
• Forceps delivery• Vacuum extraction• Gestation > 40 weeks• Mediolateral episiotomy• Higher birthweight• Larger head circumference• Longer IInd stage of labour
Independent Risk Factors Independent Risk Factors at multiple logistic at multiple logistic regression analysisregression analysis
• Forceps delivery
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Fattori di Rischio per lesioni Ostetriche perinealiFattori di Rischio per lesioni Ostetriche perineali
Andrews et al 2006
Aspetti criticiAspetti critici
• Studi prospettici con più accurata definizione sia dei
fattori di rischio analizzati che degli outcomes misurati
Ricerca
Clinica
• Rivalutazione delle modalità di esecuzione
dell’episiotomia mediolaterale
• Maggiore accuratezza nella valutazione clinica del
perineo nell’immediato post-partum
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Repair of OASIGUIDELINESGUIDELINES
1. Performed by an experienced operator2. Operating theatre3. GA or Spinal4. Grade injury5. Anal epithelium repaired with Vicryl 3/0 or Vicryl rapide6. IAS end to end7. EAS – end to end or overlap – 2.0 PDS8. Routine perineal repair
Andrews, Sultan and Thakar. Reviews in Gynaecological Practice
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GUIDELINESGUIDELINES9. Rectovaginal exam
10. IV antibiotics
11. Foley catheter – 24 hrs
12. Detailed notes
13. Laxatives
EXPLAIN & DEBRIEFEXPLAIN & DEBRIEFAndrews, Sultan and Thakar. Reviews in Gynaecological Practice.
Repair of OASIEvento Ostetrico e Perineo
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Technique of of anal sphincter closureTechnique of of anal sphincter closure
OverlapOverlap
End-to-end End-to-end
Evento Ostetrico e Perineo Le lacerazioni perineali
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12 months < risk of faecal urgency &Anal Incontinence
36 months no differences
Evento Ostetrico e Perineo Le lacerazioni perineali
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Overlap vs End-to-end:
Role of Perineal Clinic
• All women who have had obstetric anal sphincter repair should be reviewed 6 –12 weeks postpartum by a consultant obstetrician and gynaecologist
• All women should be offered physiotherapy and pelvic-floor exercises for 6 –12 weeks after obstetric anal sphincter repair.
RCOG guidelines March 2007
Evento Ostetrico e Perineo Le lacerazioni perineali
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GrazieGrazie
Evento Ostetrico e Perineo Le lacerazioni perineali
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