Evento Ostetrico e Perineo Le lacerazioni perineali

marco soligo
Azienda Ospedaliera
Istituti Clinici di Perfezionamento
Ospedale di rilievo nazionale e di alta specializzazione convenzionato con l’Università degli Studi di Milano
Ospedale dei Bambini V. Buzzi
Dipartimento della Donna, Mamma e Neonato
Direttore prof. Enrico Ferrazzi
Evento Ostetrico e Perineo
Le lacerazioni perineali
Memorialuroginecologico
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MONTECCHIOEMILIA14-15settembre2014

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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•Lacerazioni PerinealiLacerazioni Perineali
•Lacerazioni VaginaliLacerazioni Vaginali
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Classification of Perineal Lacerations
First degree:First degree: Injury to perineal skin only
Second 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 pathophysiologyNew insights into the pathophysiology
and management of patients withand management of patients with
faecal incontinence have been gainedfaecal incontinence have been gained
in the past three years, largely as ain the past three years, largely as a
result of new ways of imaging analresult of new ways of imaging anal
sphincters, …….”sphincters, …….”
ENDOANAL ULTRASOUND
MA Kamm, The Lancet 1994MA Kamm, The Lancet 1994
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ENDOANAL ULTRASOUND
Technical aspect
Mechanical TransducerMechanical 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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Ecografia Endoanale
Immagine ecografica: SAE e SAI
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Ecografia endoanale 3- D
Aspetti tecnici
Mechanical Transducer
Rotating Scanning: full 360°
Frequency Range 6 - 16 MHz
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Ecografia endoanale 3- D
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EndoAnal US in 202 consecutive pregnant womenEndoAnal US in 202 consecutive pregnant women
Before, 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 findings
AI/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 19931993
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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 women
Damon 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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EPISIOTOMIA
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22 articles, 651.934 women included
Episiotomy & 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 AnalRisk Factors for Obstetric Anal
Sphincter Injury: a prospective study”Sphincter Injury: a prospective study”
Standard mediolateral episiotomy
at least 40° from the midline
Andrews et al 2006
““only 13% intended mediolateralonly 13% intended mediolateral
episiotomies in our study were, byepisiotomies in our study were, by
definition, genuinelydefinition, 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 episiotomyAngle of episiotomy
(mean)(mean)
54 Cases54 Cases 46 Controls46 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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• Che fare?Che fare?
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“Occult anal sphincter injuries (OASIS):
myth or reality?”
254 primipare
Esame obiettivo immediato postpartum
Ostetrica/Medico
Ecografia EA e Riparazione delle lesioni identificate
Aiuto esperto
Andrews et al, 2006
MetodiMetodi
Rivalutazione immediata
Ricercatore esperto
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“Occult anal sphincter injuries: myth or reality?”
Andrews et al, 2006
RisultatiRisultati Lesioni Sfinteriche Ostetriche
• Esame obiettivo immediato postpartum
Ostetrica/Medico
• Ecografia EA e Riparazione delle lesioni identificate
Aiuto esperto
• Rivalutazione immediata
Ricercatore esperto
11%
24.5%
+ 1.2%
(lesioni misconosciute: 87% / 28%)
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“Risk Factors for Obstetric Anal SphincterRisk Factors for Obstetric Anal Sphincter
Injury: a prospective study”Injury: a prospective study”
241 nulliparous women included
25% 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 FactorsIndependent Risk Factors
at multiple logisticat multiple logistic
regression analysisregression analysis
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“Risk Factors for Obstetric AnalRisk Factors for Obstetric Anal
Sphincter Injury: a prospective study”Sphincter Injury: a prospective study”
241 nulliparous women included
Data re-analyzed on the basis of Accoucheur’s diagnosis
11% sphincter injuries
Andrews et al 2006
Univariate analysisUnivariate analysis
• Vacuum extraction
• Gestation > 40 weeks
• Larger head circumference
• Longer IInd stage of labour
Independent Risk FactorsIndependent Risk Factors
at multiple logisticat multiple logistic
regression analysisregression analysis
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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 OASI
GUIDELINESGUIDELINES
1. Performed by an experienced operator
2. Operating theatre
3. GA or Spinal
4. Grade injury
5. Anal epithelium repaired with Vicryl 3/0 or Vicryl rapide
6. IAS end to end
7. EAS – end to end or overlap – 2.0 PDS
8. Routine perineal repair
Andrews, Sultan and Thakar. Reviews in Gynaecological Practice
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GUIDELINESGUIDELINES
9. Rectovaginal exam
10. IV antibiotics
11. Foley catheter – 24 hrs
12. Detailed notes
13. Laxatives
EXPLAIN & DEBRIEFEXPLAIN & DEBRIEF
Andrews, Sultan and Thakar. Reviews in Gynaecological Practice.
Repair of OASI
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Technique of of anal sphincter closureTechnique of of anal sphincter closure
OverlapOverlap
End-to-endEnd-to-end
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12 months < risk of faecal urgency &Anal Incontinence
36 months no differences
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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
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GrazieGrazie
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Evento Ostetrico e Perineo Le lacerazioni perineali

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