Valutazione e.m.g. dell'innervazione dello sfintere anale post parto riva
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TASI-2 Preliminary results Diego Riva - Eleonora Raimondi - Corrado Cescon U.O. Ginecologia - Cantù March 2011
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GLUP_Gardone_Valutazione E.M.G. dell’innervazione dello sfintere anale post-parto – D. Riva
Transcript of Valutazione e.m.g. dell'innervazione dello sfintere anale post parto riva
TASI-2Preliminary resultsDiego Riva - Eleonora Raimondi -
Corrado CesconU.O. Ginecologia - Cantù
March 2011
LISiN
Cagliari
RigaBerlino
Brno
Lubiana
Cantù Vinnitsa
Lodz
Trnava
BassanoTorin
oMoncalieri
Savigliano
Cuneo
Asti
Bassano
Brno
TartuCuneo
Vinnitsa
MariaVitto
ria
Moncalie
ri
Saviglia
no
Berlin
Cagliari
CantùComo
Hildesh
eim
Ljubljana
Riga
0
10
20
30
40
50
60
70
80
90
Before Delivery
After Delivery
Patient recruitment histogram TASI-2 (Total: 20 Hospitals)
Hospital
Nu
mb
er o
f P
atie
nts
Trnava
Ferrara
LodzMolin
ette
Asti
Bassano:1 (0%)
Ljubljana:69 (19%)
Como:1 (0%)
Cagliari:55 (15%)
Trnava:4 (1%)
Berlin:23 (6%)
Brno:5 (1%)MariaVittoria:7 (2%)
Hildesheim:7 (2%)Moncalieri:4 (1%)Vinnitsa:44 (12%)
Savigliano:2 (1%)
Riga:55 (15%)
Tartu:1 (0%)
Cantù:85 (23%)
Number of patients PRE-Partum per partner (total: 363)
Cagliari:27 (21%)
Riga:15 (12%)
Vinnitsa:5 (4%)
Berlin:6 (5%)
Ljubljana:17 (13%)
Cantù:56 (44%)
Number of patients completed (PRE-POST) per partner (total: 126)
0
50
100
150
200
250
300
Nu
mb
er o
f p
atie
nts
stu
die
d
Nov-2009Jun-2010
Sep-2010Jan-2011
Apr-2011
Time (months)Jun-2011
Dec-2011
POST
PRE
Introduction
(spontaneous tears or episiotomy), and subsequent appearance of fecal incontinence in women (Wheeler 2007).
A significant correlation exists between tissue lesions which occur during natural childbirth
L-V
L-DR-D
R-V
D
L
V
R
El.1
El.2
El.3
El.4
El.5
El.6
El.7
El.8El.9
El.10
El.11
El.12
El.13
El.14
El.15
El.16
Definition of Quadrants of the EAS
5 mm
DRP1x16-05-MC
L-V
L-DR-D
R-VR-V
Distribution of Episiotomies (N = 47)
Patient 1 – Example of episiotomy
Pre Partum
(Week 34)
Post Partum
(Week 6)
Motor units and Innervation zones – CKC Decomposition
Rest-MVC-RestEl.1
El.2
El.3
El.4
El.5
El.6
El.7
El.8El.9
El.10
El.11
El.12
El.13
El.14
El.15
El.16
L
D
R
V
ARVmap
Rest-MVC-RestEl.1
El.2
El.3
El.4
El.5
El.6
El.7
El.8El.9
El.10
El.11
El.12
El.13
El.14
El.15
El.16
L
D
R
V
ARVmap
Pre Partum (Week 34)
Post Partum (Week 6)
ARV distribution – MVC
0 10 20 30 40 506
8
10
12
14
16
18
20
22
24
26
Time (s) - Rest-MVC-Rest
AR
V (
V)
34BoAlCa110303170304.sigA)
V L D R V
Int.
Med.
Ext.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48
Barycenter
Mean Spatial ARV Distrib. (V)B)
0
5
10
15
20
25
30uV
Rest-MVC-RestEl.1
El.2
El.3
El.4
El.5
El.6
El.7
El.8El.9
El.10
El.11
El.12
El.13
El.14
El.15
El.16
L
D
R
V
ARVmap
Pre Partum (Week 31)
R-MVC-REl.1
El.2
El.3
El.4
El.5
El.6
El.7
El.8El.9
El.10
El.11
El.12
El.13
El.14
El.15
El.16
L
D
R
V
ARVmap
Post Partum (Week 6)
MUs – IZs distributionARV map
Patient 2 – Example of episiotomy
Rest-MVC-RestEl.1
El.2
El.3
El.4
El.5
El.6
El.7
El.8El.9
El.10
El.11
El.12
El.13
El.14
El.15
El.16
L
D
R
V
ARVmap
Pre Partum (Week 35)
Rest-MVC-RestEl.1
El.2
El.3
El.4
El.5
El.6
El.7
El.8El.9
El.10
El.11
El.12
El.13
El.14
El.15
El.16
L
D
R
V
ARVmap
Post Partum (Week 6)
MUs – IZs distribution ARV map
Patient 3 – Example of episiotomy
Rest-MVC-RestEl.1
El.2
El.3
El.4
El.5
El.6
El.7
El.8El.9
El.10
El.11
El.12
El.13
El.14
El.15
El.16
L
D
R
V
ARVmap
Pre Partum (Week 31)
Rest-MVC-RestEl.1
El.2
El.3
El.4
El.5
El.6
El.7
El.8El.9
El.10
El.11
El.12
El.13
El.14
El.15
El.16
L
D
R
V
ARVmap
Post Partum (Week 6)
MUs – IZs distribution ARV map
Patient 4 – Example of episiotomy
Rest-MVC-RestEl.1
El.2
El.3
El.4
El.5
El.6
El.7
El.8El.9
El.10
El.11
El.12
El.13
El.14
El.15
El.16
L
D
R
V
ARVmap
Pre Partum (Week 33)
Rest-MVC-RestEl.1
El.2
El.3
El.4
El.5
El.6
El.7
El.8El.9
El.10
El.11
El.12
El.13
El.14
El.15
El.16
L
D
R
V
ARVmap
Post Partum (Week 6)
MUs – IZs distributionARV map
Patient 5 – Example of episiotomy
Rest-MVC-RestEl.1
El.2
El.3
El.4
El.5
El.6
El.7
El.8El.9
El.10
El.11
El.12
El.13
El.14
El.15
El.16
L
D
R
V
ARVmap
Pre Partum (Week 31)
Rest-MVC-RestEl.1
El.2
El.3
El.4
El.5
El.6
El.7
El.8El.9
El.10
El.11
El.12
El.13
El.14
El.15
El.16
L
D
R
V
ARVmap
Post Partum (Week 6)
MUs – IZs distributionARV map
Patient 6 – Example of episiotomy
STATISTICAL ANALYSIS
From: Enck P, Franz H, Azpiroz F, Fernandez-Fraga X, Hinninghofen H, Kaske-Bretag K, Bottin A, Martina S, Merletti R: Innervation zones of theexternal anal sphincter in healthy male and female subjects: Preliminary results. Digestion 2004;69:123–130.
Fig. 4. Histograms of the number of innervation zones (IZ) found under each channel in 15 males (left column) and 37 females (right column) at the depth levels of 1and 2 cm.
1
2
3
30
210
60
240
90
270
120
300
150
330
180
0
Normalized IZ distribution - ALL patients pre partum (N = 357)N. patients per group = 6
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 160
0.5
1
1.5
2
Num
ber
of I
Zs
(Nor
mal
ized
val
ues)
Channels
1 2 3 40.5
1
1.5
Num
ber
of I
Zs
(Nor
mal
ized
val
ues)
Quadrant
4 5 6 8 10 15 20 30 40 50 60 80 100 120 150 200
El.1
El.2
El.3
El.4
El.5
El.6
El.7
El.8El.9
El.10
El.11
El.12
El.13
El.14
El.15
El.16
QuadrantL-V L-D R-D R-V
Nu
mb
er
of IZ
(A
.U.)
Nu
mb
er
of IZ
(A
.U.)
Electrodes1 16
Number of patients per group:
Effect of the number of patients on IZ distrib.
Average #MU = 38
0.5
1
1.5
2
30
210
60
240
90
270
120
300
150
330
180
0
Normalized IZ distribution - ALL patients pre partum (N = 357)N. patients per group = 20
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 160
0.5
1
1.5
2
Num
ber
of I
Zs
(Nor
mal
ized
val
ues)
Channels
1 2 3 40.5
1
1.5
Num
ber
of I
Zs
(Nor
mal
ized
val
ues)
Quadrant
4 5 6 8 10 15 20 30 40 50 60 80 100 120 150 200
El.1
El.2
El.3
El.4
El.5
El.6
El.7
El.8El.9
El.10
El.11
El.12
El.13
El.14
El.15
El.16
QuadrantL-V L-D R-D R-V
Nu
mb
er
of IZ
(A
.U.)
Nu
mb
er
of IZ
(A
.U.)
Electrodes1 16
Number of patients per group:
Effect of the number of patients on IZ distrib.
Average #MU = 130
0.5
1
1.5
2
30
210
60
240
90
270
120
300
150
330
180
0
Normalized IZ distribution - ALL patients pre partum (N = 357)N. patients per group = 60
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 160
0.5
1
1.5
2
Num
ber
of I
Zs
(Nor
mal
ized
val
ues)
Channels
1 2 3 40.5
1
1.5
Num
ber
of I
Zs
(Nor
mal
ized
val
ues)
Quadrant
4 5 6 8 10 15 20 30 40 50 60 80 100 120 150 200
El.1
El.2
El.3
El.4
El.5
El.6
El.7
El.8El.9
El.10
El.11
El.12
El.13
El.14
El.15
El.16
QuadrantL-V L-D R-D R-V
Nu
mb
er
of IZ
(A
.U.)
Nu
mb
er
of IZ
(A
.U.)
Electrodes1 16
Number of patients per group:
Effect of the number of patients on IZ distrib.
Average #MU = 381
0.5
1
1.5
2
30
210
60
240
90
270
120
300
150
330
180
0
Normalized IZ distribution - ALL patients pre partum (N = 357)N. patients per group = 100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 160
0.5
1
1.5
2
Num
ber
of I
Zs
(Nor
mal
ized
val
ues)
Channels
1 2 3 40.5
1
1.5
Num
ber
of I
Zs
(Nor
mal
ized
val
ues)
Quadrant
4 5 6 8 10 15 20 30 40 50 60 80 100 120 150 200
El.1
El.2
El.3
El.4
El.5
El.6
El.7
El.8El.9
El.10
El.11
El.12
El.13
El.14
El.15
El.16
QuadrantL-V L-D R-D R-V
Nu
mb
er
of IZ
(A
.U.)
Nu
mb
er
of IZ
(A
.U.)
Electrodes1 16
Number of patients per group:
Effect of the number of patients on IZ distrib.
Average #MU = 657
0.5
1
1.5
2
30
210
60
240
90
270
120
300
150
330
180
0
Normalized IZ distribution - ALL patients pre partum (N = 357)N. patients per group = 150
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 160
0.5
1
1.5
2
Num
ber
of I
Zs
(Nor
mal
ized
val
ues)
Channels
1 2 3 40.5
1
1.5
Num
ber
of I
Zs
(Nor
mal
ized
val
ues)
Quadrant
4 5 6 8 10 15 20 30 40 50 60 80 100 120 150 200
El.1
El.2
El.3
El.4
El.5
El.6
El.7
El.8El.9
El.10
El.11
El.12
El.13
El.14
El.15
El.16
QuadrantL-V L-D R-D R-V
Nu
mb
er
of IZ
(A
.U.)
Nu
mb
er
of IZ
(A
.U.)
Electrodes1 16
Number of patients per group:
Effect of the number of patients on IZ distrib.
Average #MU = 977
0.5
1
1.5
2
30
210
60
240
90
270
120
300
150
330
180
0
Normalized IZ distribution - ALL patients pre partum (N = 357)N. patients per group = 200
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 160
0.5
1
1.5
2
Num
ber
of I
Zs
(Nor
mal
ized
val
ues)
Channels
1 2 3 40.5
1
1.5
Num
ber
of I
Zs
(Nor
mal
ized
val
ues)
Quadrant
4 5 6 8 10 15 20 30 40 50 60 80 100 120 150 200
El.1
El.2
El.3
El.4
El.5
El.6
El.7
El.8El.9
El.10
El.11
El.12
El.13
El.14
El.15
El.16
QuadrantL-V L-D R-D R-V
Nu
mb
er
of IZ
(A
.U.)
Nu
mb
er
of IZ
(A
.U.)
Electrodes1 16
Number of patients per group:
Effect of the number of patients on IZ distrib.
Average #MU = 1296
0.5
1
1.5Mean values of IZ distribution of 4 quadrants
4 5 6 8 10 15 20 30 40 50 60 80 100 120 150 2000
0.1
0.2
0.3
0.4
0.5Standard deviations of IZ distribution in 4 quadrants
Number of patients per group
L-V
L-D
R-D
R-V
L-V
L-D
R-D
R-V
(nor
ma
lized
va
lue
s)(n
orm
aliz
ed v
alu
es)
Effect of the number of patients on IZ distrib.
Cesareans: 34 (27%)
Episiotomies: 47 (37%)
Lacerations: 24 (19%)
Vaginal NO damage: 21 (17%)
Type of delivery and damage (total: 126)
IZ distribution – Caes. Sections (N=34)
L-V L-D R-D R-V0
0.5
1
1.5
2
2.5
3
3.5
Nu
mb
er o
f IZ
s
Quadrant
Caesarean – Pre/Post partum
PRE POST
5 10 150
10
20
30
IZ histogramCesarean PRE partum (34)
Rest
Num
ber
of I
Zs
electrode
20
40
30
210
60
240
90
270120
300
150
330
180
0
5 10 150
5
10
15
20
IZ histogramCesarean PRE partum (34)
Rest-MVC-Rest
Num
ber
of I
Zs
electrode
10
20
30
210
60
240
90
270120
300
150
330
180
0
5 10 150
5
10
15
20
25
IZ histogramCesarean POST partum (34)
Rest
Num
ber
of I
Zs
electrode
20
40
30
210
60
240
90
270120
300
150
330
180
0
5 10 150
5
10
15
20
IZ histogramCesarean POST partum (34)
Rest-MVC-Rest
Num
ber
of I
Zs
electrode
10
20
30
210
60
240
90
270120
300
150
330
180
0
IZ distribution – Caes. Sections (N=34)
IZ distribution – Lacerations (N=24)
L-V L-D R-D R-V0
0.5
1
1.5
2
2.5
3
3.5
Nu
mb
er o
f IZ
s
Quadrant
Lacerations – Pre/Post partum
PRE POST
5 10 150
5
10
15
20
IZ histogramLacerations PRE partum (24)
Rest
Num
ber
of I
Zs
electrode
10
20
30
210
60
240
90
270120
300
150
330
180
0
5 10 150
5
10
15
20
IZ histogramLacerations PRE partum (24)
Rest-MVC-Rest
Num
ber
of I
Zs
electrode
10
20
30
210
60
240
90
270120
300
150
330
180
0
5 10 150
5
10
15
20
IZ histogramLacerations POST partum (24)
Rest
Num
ber
of I
Zs
electrode
10
20
30
210
60
240
90
270120
300
150
330
180
0
5 10 150
5
10
15
IZ histogramLacerations POST partum (24)
Rest-MVC-Rest
Num
ber
of I
Zs
electrode
10
20
30
210
60
240
90
270120
300
150
330
180
0
IZ distribution – Lacerations (N=24)
IZ distribution – Episiotomies (N=47)
L-V L-D R-D R-V0
0.5
1
1.5
2
2.5
3
3.5
Nu
mb
er o
f IZ
s
Quadrant
Episiotomy – Pre/Post partum
*Student T-test
p<0,05
PRE POST
R-V
5 10 150
10
20
30
40
IZ histogramEpisiotomy PRE partum (47)
Rest
Num
ber
of I
Zs
electrode
20
40
30
210
60
240
90
270120
300
150
330
180
0
5 10 150
10
20
30
40
IZ histogramEpisiotomy PRE partum (47)
Rest-MVC-Rest
Num
ber
of I
Zs
electrode
20
40
30
210
60
240
90
270120
300
150
330
180
0
5 10 150
10
20
30
40
IZ histogramEpisiotomy POST partum (47)
Rest
Num
ber
of I
Zs
electrode
20
40
30
210
60
240
90
270120
300
150
330
180
0
5 10 150
10
20
30
40
IZ histogramEpisiotomy POST partum (47)
Rest-MVC-Rest
Num
ber
of I
Zs
electrode
20
40
30
210
60
240
90
270120
300
150
330
180
0
IZ distribution – Episiotomies (N=47)
0
10
20
30
40
50
60
70
80
Nu
mb
er o
f p
atie
nts
stu
die
d
AT1-BerlinAT1-Cagliari
AT1-Cantu
AT1-LjubljanaAT1-RigaAT2-Vinnitsa
AT3-Cuneo
AT3-MariaVittoria
AT3-MoncalieriAT3-Savigliano
Nov-2009Jun-2010
Sep-2010Jan-2011
Apr-2011
Time (months)Jun-2011
Dec-2011
ConclusionsTASI 2 study confirm that I.Z. of E.A.S. can
be analized by surface E.M.G. We can confirm the importance of episiotomy
in I.Z. distribution post-partumFurther analysis could permit correlations
between E.M.G. results and clinical data regarding anal ( and urinary ?) incontinence
