OBJECTIVE: The aim of this study was to explore the risk of levator ani muscle (LAM) avulsion and enlargement of the levator hiatus following vaginal birth after Cesarean section (VBAC) in comparison with vaginal delivery in primiparous women. METHODS: In this two-center observational case-control study, we identified all women who had a term VBAC for their second delivery at the Departments of Obstetrics and Gynecology at the Faculty of Medicine in Pilsen and the 1st Faculty of Medicine in Prague, Charles University, Czech Republic, between 2012 and 2016. Women with a repeat VBAC, preterm birth or stillbirth were excluded from the study. As a control group, we enrolled a cohort of primiparous women who delivered vaginally during the study period. To increase our control sample, we also invited all primiparous women who delivered vaginally in both participating units between May and June 2019 to participate. All participants were invited for a four-dimensional pelvic floor ultrasound scan to assess LAM trauma. LAM avulsion and the area of the levator hiatus were assessed offline from the stored pelvic floor volumes obtained at rest, during maximum contraction and during Valsalva maneuver. The laterality of the avulsion was also noted. The cohorts were then compared using the χ2 test and Wilcoxon's two-sample test according to the normality of the distribution. P < 0.05 was considered statistically significant. Multivariate regression analysis, controlling for age and body mass index (BMI), was also performed. RESULTS: A total of 356 women had a VBAC for their second delivery during the study period. Of these, 152 (42.7%) attended the ultrasound examination and full data were available for statistical analysis for 141 women. The control group comprised 113 primiparous women. A significant difference was observed between the VBAC group and the control group in age (32.7 vs 30.1 years; P < 0.05), BMI (28.4 vs 27.4 kg/m2 ; P < 0.05) and duration of the first and second stages of labor (293.1 vs 345.9 min; P < 0.05 and 27.6 vs 35.3 min; P < 0.05, respectively) at the time of the index birth. The LAM avulsion rate was significantly higher in the VBAC compared with the control group (32.6% vs 18.6%; P = 0.01). The difference between the groups was observed predominantly in the rate of unilateral avulsion and remained significant after controlling for age and BMI (adjusted odds ratio 2.061 (95% CI, 1.103-3.852)). There was no statistically significant difference in the area of the levator hiatus at rest (12.0 vs 12.6 cm2 ; P = 0.28) or on maximum Valsalva maneuver (18.6 vs 18.7 cm2 ; P = 0.55) between the VBAC and control groups. The incidence of levator hiatal ballooning was comparable between the groups (17.7% and 18.6%; P = 0.86). CONCLUSIONS: VBAC is associated with a significantly higher rate of LAM avulsion than is vaginal birth in nulliparous women. The difference was significant even after controlling for age and BMI. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

• Klíčová slova
• VBAC, ballooning, childbirth trauma, levator ani avulsion, levator hiatus, transperineal ultrasound, urogenital hiatus, vaginal birth after Cesarean,
• MeSH
• anální kanál diagnostické zobrazování   zranění   MeSH
• dospělí MeSH
• komplikace porodu diagnostické zobrazování   etiologie   MeSH
• lidé MeSH
• poranění měkkých tkání diagnostické zobrazování   etiologie   MeSH
• studie případů a kontrol MeSH
• těhotenství MeSH
• ultrasonografie prenatální * MeSH
• vaginální porod po císařském řezu škodlivé účinky   MeSH
• Check Tag
• dospělí MeSH
• lidé MeSH
• těhotenství MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• práce podpořená grantem MeSH

OBJECTIVE: The aim of this multicentric observational study was to explore the impact of the timing of cesarean section (SC) on levator (MLA - levator ani musle) avulsion at the first subsequent vaginal birth. METHODS: All women after term vaginal birth following a cesarean section (VBAC) for their second delivery at the Departments of Gynecology and Obstetrics, Faculty of Medicine, Charles University and University Hospital in Pilsen and the 1st Faculty of Medicine, Charles University and General Hospital in Prague, between 2012 and 2016 were identified. Hospital database and surgical notes were used to collect basic characteristics of the patients including the indication and course of their previous delivery. These women were divided into two groups according to indication of prior SC in the previous delivery to women with elective SC and acute SC. All participants were invited for a 4D pelvic floor ultrasound to assess levator trauma. Levator avulsion and the levator hiatus area were assessed off-line from the stored pelvic floor volumes. Data were statistically assessed. RESULTS: A total of 356 women had a VBAC for their second delivery during the study period. Of these, 152 (42.7%) attended the ultrasound examination and full data were available for 141 women for statistical analyses. These were further divided into 80 women after acute SC and 61 women after elective SC. The levator avulsion rate was higher in the elective SC subgroup, but the difference was not significant (26.3 vs. 41.0%, P = 0.0645). No statistical differences in urogenital hiatus enlargement and ballooning were observed. CONCLUSION: VBAC is associated with a significantly higher rate of levator ani avulsion compared to the first vaginal birth in nulliparous women. However, it seems that risk of levator ani avulsion doesnt depend on the timing of SC in previous labor. More studies are needed to confirm the results of this pilot study.

• Klíčová slova
• 4D transperineal ultrasound, avulsion injury, levator ani muscle, musculus levator ani, pelvic fl oor, pelvic floor, vaginal birth after cesarean section,
• MeSH
• císařský řez MeSH
• lidé MeSH
• onemocnění dna pánevního * etiologie   MeSH
• pánevní dno * diagnostické zobrazování   MeSH
• pilotní projekty MeSH
• těhotenství MeSH
• ultrasonografie MeSH
• vedení porodu metody   MeSH
• Check Tag
• lidé MeSH
• těhotenství MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• multicentrická studie MeSH
• pozorovací studie MeSH

OBJECTIVE: We compared the incidence and type of levator ani avulsion diagnosed by translabial ultrasound evaluation in primiparous women six months after vacuum-assisted or spontaneous vaginal delivery. MATERIAL AND METHODS: This retrospective observational study was performed between January 2011 and December 2013. Primiparous women six months after vacuum-assisted vaginal delivery and after spontaneous vaginal delivery underwent translabial ultrasound evaluation. The distance between the urethra and fibers of the musculus levator ani puborectalis (levator-urethra gap) was measured. A levator-urethra gap >25 mm was considered a musculus levator ani avulsion. RESULTS: In total, 184 women participated in the study. Among them, 92 had vacuum extraction and 92 had uncomplicated spontaneous delivery. A longer levator-urethra gap on both sides of the pubic bone was found in women after vacuum-assisted vaginal delivery (p < 0.0001 for both sides). Musculus levator ani avulsion was identified in 20 women (unilateral in 16 cases and bilateral in four cases). No difference in an incidence of musculus levator ani avulsion was identified in women after vacuum-assisted vaginal delivery [11/92 (12%)] compared to spontaneous delivery [9/92 (10%); p = 0.81]. CONCLUSION: Vacuum-assisted vaginal delivery in primiparous women is associated with a longer levator-urethra gap but not with a higher frequency of avulsion of the musculus levator ani.

• Klíčová slova
• Delivery, pelvic floor, vacuum extraction,
• MeSH
• dospělí MeSH
• epiziotomie MeSH
• index tělesné hmotnosti MeSH
• lidé MeSH
• onemocnění dna pánevního epidemiologie   MeSH
• pánevní dno zranění   MeSH
• parita MeSH
• retrospektivní studie MeSH
• těhotenství MeSH
• ultrasonografie MeSH
• uretra MeSH
• vakuová extrakce porodnická škodlivé účinky   MeSH
• vedení porodu MeSH
• Check Tag
• dospělí MeSH
• lidé MeSH
• těhotenství MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• práce podpořená grantem MeSH

BACKGROUND: There is variation in the reported incidence rates of levator avulsion (LA) and paucity of research into its risk factors. OBJECTIVE: To explore the incidence rate of LA by mode of birth, imaging modality, timing of diagnosis and laterality of avulsion. SEARCH STRATEGY: We searched MEDLINE, EMBASE, CINAHL, AMED and MIDIRS with no language restriction from inception to April 2019. STUDY ELIGIBILITY CRITERIA: A study was included if LA was assessed by an imaging modality after the first vaginal birth or caesarean section. Case series and reports were not included. DATA COLLECTION AND ANALYSIS: RevMan v5.3 was used for the meta-analyses and SW SAS and STATISTICA packages were used for type and timing of imaging analyses. RESULTS: We included 37 primary non-randomised studies from 17 countries and involving 5594 women. Incidence rates of LA were 1, 15, 21, 38.5 and 52% following caesarean, spontaneous, vacuum, spatula and forceps births, respectively, with no differences by imaging modality. Odds ratio of LA following spontaneous birth versus caesarean section was 10.69. The odds ratios for LA following vacuum and forceps compared with spontaneous birth were 1.66 and 6.32, respectively. LA was more likely to occur unilaterally than bilaterally following spontaneous (P < 0.0001) and vacuum-assisted (P = 0.0103) births but not forceps. Incidence was higher if assessment was performed in the first 4 weeks postpartum. CONCLUSIONS: LA incidence rates following caesarean, spontaneous, vacuum and forceps deliveries were 1, 15, 21 and 52%, respectively. Ultrasound and magnetic resonance imaging were comparable tools for LA diagnosis. TWEETABLE ABSTRACT: Levator avulsion incidence rates after caesarean, spontaneous, vacuum and forceps deliveries were 1, 15, 21 and 52%, respectively.

• Klíčová slova
• Assisted birth, birth, caesarean, forceps, hiatus, labour, magnetic resonance imaging, operative, parturition, pelvic floor, perineum, prolapse, transperineal, ultrasound, vacuum, ventouse,
• MeSH
• císařský řez škodlivé účinky   statistika a číselné údaje   MeSH
• incidence MeSH
• lidé MeSH
• onemocnění dna pánevního epidemiologie   etiologie   MeSH
• těhotenství MeSH
• vakuová extrakce porodnická škodlivé účinky   statistika a číselné údaje   MeSH
• Check Tag
• lidé MeSH
• těhotenství MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• práce podpořená grantem MeSH
• systematický přehled MeSH

OBJECTIVE: To compare the efficacy of two standard surgical procedures for post-hysterectomy vaginal vault prolapse in patients with levator ani avulsion. METHODS: This was a single-center, randomized interventional trial, of two standard surgical procedures for post-hysterectomy vaginal vault prolapse: Prolift Total vs unilateral vaginal sacrospinous colpopexy with native tissue vaginal repair (sacrospinous fixation, SSF), during the period from 2008 to 2011. Entry criteria included at least two-compartment prolapse, as well as complete unilateral or bilateral levator ani avulsion injury. The primary outcome was anatomical failure based on clinical and ultrasound assessment. Failure was defined clinically, according to the Pelvic Organ Prolapse Quantification system, as Ba, C or Bp at the hymen or below, and on translabial ultrasound as bladder descent to 10 mm or more below the lower margin of the symphysis pubis on maximum Valsalva maneuver. Secondary outcomes were evaluation of continence, sexual function and prolapse symptoms based on validated questionnaires. RESULTS: During the study period, 142 patients who were post-hysterectomy underwent surgery for prolapse in our unit; 72 of these were diagnosed with an avulsion injury and were offered participation in the study. Seventy patients were randomized into two groups: 36 in the Prolift group and 34 in the SSF group. On clinical examination at 1-year follow-up, we observed one (3%) case of anatomical failure in the Prolift group and 22 (65%) in the SSF group (P < 0.001). Using ultrasound criteria, there was one (2.8%) failure in the Prolift group compared with 21 (61.8%) in the SSF group (P < 0.001). The postoperative POPDI (Pelvic Organ Prolapse Distress Inventory) score for subjective outcome was 15.3 in the Prolift group vs 21.7 in the SSF group (P = 0.16). CONCLUSION: In patients with prolapse after hysterectomy and levator ani avulsion injury, SSF has a higher anatomical failure rate than does the Prolift Total procedure at 1-year follow-up.

• Klíčová slova
• 4D ultrasound, Prolift Total, SSF, levator avulsion, mesh, sacrospinous vaginal colpopexy, ultrasound assessment, vaginal prolapse surgery, vaginal sacrospinous fixation,
• MeSH
• bolest komplikace   diagnostické zobrazování   chirurgie   MeSH
• chirurgické síťky * MeSH
• gynekologické chirurgické výkony metody   MeSH
• hysterektomie vaginální škodlivé účinky   MeSH
• koitus MeSH
• lidé středního věku MeSH
• lidé MeSH
• nemoci anu komplikace   diagnostické zobrazování   chirurgie   MeSH
• pánevní dno chirurgie   MeSH
• pooperační komplikace diagnostické zobrazování   chirurgie   MeSH
• prolaps pánevních orgánů diagnostické zobrazování   etiologie   chirurgie   MeSH
• průzkumy a dotazníky MeSH
• senioři MeSH
• stresová inkontinence moči etiologie   MeSH
• ultrasonografie MeSH
• vagina diagnostické zobrazování   patofyziologie   chirurgie   MeSH
• Valsalvův manévr MeSH
• výsledek terapie MeSH
• Check Tag
• lidé středního věku MeSH
• lidé MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• práce podpořená grantem MeSH
• randomizované kontrolované studie MeSH
• srovnávací studie MeSH

Levator ani avulsion injury is one of the main factors associated with vaginal prolapse of all compartments. Levator avulsion is the main link between vaginal delivery and subsequent vaginal prolapse - cause and sequel. The risk for prolapse is doubled in women with levator injury (RR = 1,9). The risk for prolapse is mainly expressed for anterior and central compartment. In retrospective analysis of women after vaginal repair without use of implants the recurrence rate was 29%. In subanalysis of only of women with recurrence the avulsion injury was detected in 85%. The risk of recurrence of prolapse after native tissue repair is four times higher if the avulsion is present to those where not. Levator avulsion injury is main etiological and risk factor associated with uterine and vaginal prolapse as the sequel of delivery trauma. This injury also increases significantly the risk of prolapse recurrence after native tissue vaginal repair.

• MeSH
• komplikace porodu * MeSH
• lidé MeSH
• pánevní dno zranění   MeSH
• prolaps dělohy etiologie   MeSH
• recidiva MeSH
• rizikové faktory MeSH
• těhotenství MeSH
• Check Tag
• lidé MeSH
• těhotenství MeSH
• ženské pohlaví MeSH
• Publikační typ
• anglický abstrakt MeSH
• časopisecké články MeSH

INTRODUCTION AND HYPOTHESIS: Pregnancy and delivery are commonly associated with ano-rectal dysfunction. In addition, vaginal delivery may impact both the structure and functionality of the pelvic floor. Herein, we systematically reviewed the literature for the potential association between levator ani muscle (LAM) avulsion and ano-rectal function after childbirth. METHODS: We systematically searched the PubMed, EMBASE, CINAHL, Web of Science Core Collection, CENTRAL (Cochrane), Clinicaltrials.gov, and ICTRP databases from inception. We selected studies reporting on the anatomy of the LAM and ano-rectal function within 24 months after childbirth, the former determined by imaging and the latter measured through validated questionnaires or ano-rectal manometry. Meta-analyses were used to pool data from studies reporting on the association between LAM avulsion and ano-rectal function, with subgroup analysis according to the presence or absence of anal sphincter trauma. Summary odds ratio (OR) and mean difference (MD) are reported with 95% confidence intervals. RESULTS: From the 7,621 studies identified, 11 were included, reporting on 2,146 women. Ten studies used transperineal ultrasound (TPUS) and one study used magnetic resonance imaging (MRI) for LAM assessment. Ano-rectal function was assessed through validated questionnaires in all but one study, in which ano-rectal manometry was used. There was no evidence for an association between LAM avulsion and symptoms of incontinence (OR 1.75 [0.74, 4.12]; MD 0.13 [-0.58, 0.85]), including in the subgroup of patients with concomitant anal sphincter injury (OR 1.83 [0.71, 4.71]). CONCLUSIONS: We did not identify an association between LAM avulsion and ano-rectal dysfunction following vaginal childbirth.

• Klíčová slova
• Anal dysfunction, Childbirth, Levator ani muscle, Pelvic floor ultrasound, Postpartum, Puborectalis muscle,
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH

OBJECTIVE: To draw a comparison between spontaneous vaginal delivery and vacuum-assisted vaginal delivery in relation to the incidence and the type of levator ani avulsion in primiparas. DESIGN: Retrospective observational study. SETTIMG: Department of Obstetrics and Gynaecology, University Hospital of Ostrava. METHODOLOGY: In the study, the primiparas who were from 6 to 12 months after spontaneous vaginal delivery (group A, n = 52) or after childbirth with vacuum extraction (group B, n = 51) underwent translabial 3D ultrasound. The obstetric data had been obtained from the hospital database. Translabial 3D ultrasound examination were performed by two sonographists. The monitored parameter was the distance between urethra and fibres of musculus levator ani - levator urethra gap [6]. The distance longer than 25 mm was considered an avulsion injury [6, 22]. Other parameters assessed in relation to the avulsion were: women's age, BMI, epidural analgesia, episiotomy performance, the length of the first and the second stages of labour, and fetal weight. RESULTS: Musculus levator ani avulsion was diagnosed in 10 women - unilateral in 8 cases and bilateral in 2 cases. In group A, women after spontaneous birth, we noticed avulsion injury in 7.7% of cases, whereas in group B, women after vacuum extraction, we recorded avulsion injury in 11.8% of cases. Thus the use of vacuum extraction is not statistically significant risk factor for avulsion musculus levator ani. Statistically significant difference in comparison group A and B was recorded in BMI, the length of the second stages of labour and episiotomy performance. CONCLUSION: We did not prove a statistically significant connection between avulsion injury and delivery with the use of vacuum extraction in comparison to avulsion injury incidence in uncomplicated vaginal delivery group (tab. 1). Vacuum extraction does not appear as a risk factor for avulsion in contrast to forceps delivery.

• MeSH
• anální kanál zranění   MeSH
• dospělí MeSH
• incidence MeSH
• lidé MeSH
• onemocnění dna pánevního epidemiologie   etiologie   MeSH
• retrospektivní studie MeSH
• rizikové faktory MeSH
• těhotenství MeSH
• vakuová extrakce porodnická škodlivé účinky   MeSH
• vedení porodu škodlivé účinky   MeSH
• výsledek těhotenství MeSH
• Check Tag
• dospělí MeSH
• lidé MeSH
• těhotenství MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• Geografické názvy
• Česká republika epidemiologie   MeSH

INTRODUCTION AND HYPOTHESIS: This study seeks to assess the effects of forceps-assisted delivery on the levator hiatus. METHODS: Seventy-six women were investigated 12 months after forceps-assisted delivery. Introital three-/four-dimensional ultrasound measured volumes at rest and during the Valsalva maneuver. Morphological parameters analyzed were angle gamma, hiatal area, pubovisceral angle, and continuity between the muscle and pelvic sidewall. Avulsion was diagnosed by loss of continuity. RESULTS: Forty-eight women had avulsion injuries, 23 had bilateral, and 25 had unilateral. Bilateral avulsion increased hiatal area during straining and at rest and was associated with changes in bladder neck position at rest. Unilateral avulsion injury was associated with a higher pubovisceral angle on the side of the avulsion. CONCLUSION: Forceps-assisted vaginal delivery is associated with levator ani injury. Avulsion of the pubovisceral muscle seems more common after forceps delivery than after spontaneous vaginal delivery. Avulsion alters hiatal shape and area and influences the position and mobility of the anterior compartment.

• MeSH
• dospělí MeSH
• extrakce porodnická škodlivé účinky   MeSH
• lidé MeSH
• pánevní dno diagnostické zobrazování   zranění   MeSH
• pilotní projekty MeSH
• ultrasonografie MeSH
• zobrazování trojrozměrné MeSH
• Check Tag
• dospělí MeSH
• lidé MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• práce podpořená grantem MeSH

• MeSH
• dilatace přístrojové vybavení   MeSH
• lidé MeSH
• pánevní dno * zranění   MeSH
• parita MeSH
• pilotní projekty MeSH
• randomizované kontrolované studie jako téma MeSH
• těhotenství MeSH
• vedení porodu * škodlivé účinky   MeSH
• Check Tag
• lidé MeSH
• těhotenství MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• dopisy MeSH
• komentáře MeSH