Anal Sphincter lesions after delivery

Finnish Society Of Gynecological Surgery 22-23.9.2005

Karl Møller BekAarhus University Hospital

Skejby SygehusDenmark

Risk factors for having obstetric anal sphincter rupture

• Episiotomy • Primi parity• Heavy infant• Instrumental delivery • Long second stage of delivery

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)

Risk of having an episiotomy depending on the midwife at charge

Henriksen, Bek, Hedegaard, Secher: Br J Obst Gynecol 1992

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

Changing in the rate of episiotomy at Aarhus University Hospital

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

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

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

ConclusionPrevention of sphincter tears

Avoid instrumental deliveries if possible

Only use episiotomy when needed !!

Look upon the basic obstetrics practices

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%

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

Primary suture of obstetric anal sphincter tearInternal sphincter

Primary suture of obstetric anal sphincter tearExternal sphincter

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)

Transanal ultrasound of a patient with misdiagnosed Grad IIIc perineal tear at delivery.

Five days after delivery and five months after early secondary suture

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

Functional results after 6 months

Incontinence to gass: 4 patients

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)

If you don't make an early secondary suture this patient may look like this after a some years

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

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

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

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

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

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

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

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