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marco soligo
Azienda Ospedaliera
Istituti Clinici di Perfezionamento
Ospedale di rilievo nazionale e di alta specializzazi...
Evento Ostetrico e Perineo
Le lacerazioni perineali
22 articles, 651.934 women included
severe perineal lacerations (III°-...
severe perineal lacerations (III°-IV °)
on 967 consecutive women
III° 3 (2.6%)
IV 0
Memorialuroginecologico
LORENZOSPREAFI...
•Lacerazioni PerinealiLacerazioni Perineali
•Lacerazioni VaginaliLacerazioni Vaginali
Memorialuroginecologico
LORENZOSPREA...
Classification of Perineal Lacerations
First degree:First degree: Injury to perineal skin only
Second degree:Second degree...
““New insights into the pathophysiologyNew insights into the pathophysiology
and management of patients withand management...
ENDOANAL ULTRASOUND
Technical aspect
Mechanical TransducerMechanical Transducer
Rotating Scanning: full 360°Rotating Scann...
Sultan et al Clinical Radiology 1994;49:368-374
Valutazione ecografica Endoanale
Memorialuroginecologico
LORENZOSPREAFICO
...
Ecografia Endoanale
Immagine ecografica: SAE e SAI
Memorialuroginecologico
LORENZOSPREAFICO
MONTECCHIOEMILIA14-15settembre...
Ecografia endoanale 3- D
Aspetti tecnici
Mechanical Transducer
Rotating Scanning: full 360°
Frequency Range 6 - 16 MHz
Mem...
Ecografia endoanale 3- D
Memorialuroginecologico
LORENZOSPREAFICO
MONTECCHIOEMILIA14-15settembre2014
Evento Ostetrico e Pe...
EndoAnal US in 202 consecutive pregnant womenEndoAnal US in 202 consecutive pregnant women
Before, 6 week and 6 months aft...
Difetto SAE e SAI
M.A. Kamm Lancet 1994;344:730-33
Ecografia endoanale
Memorialuroginecologico
LORENZOSPREAFICO
MONTECCHIO...
28% out of 150 Nulliparous women28% out of 150 Nulliparous women
“Occult Anal sphincter defects on
EndoAnal US after vagin...
On multivariate analysis only sphincter
defect on EndoAnal US after Ist delivery
was significantly associated with AI 6
ye...
Memorialuroginecologico
LORENZOSPREAFICO
MONTECCHIOEMILIA14-15settembre2014
Evento Ostetrico e Perineo
Le lacerazioni peri...
EPISIOTOMIA
Memorialuroginecologico
LORENZOSPREAFICO
MONTECCHIOEMILIA14-15settembre2014
Evento Ostetrico e Perineo
Le lacerazioni perineali
22 articles, 651.934 women included
Episiotomy & Severe perineal tears...
“Risk Factors for Obstetric AnalRisk Factors for Obstetric Anal
Sphincter Injury: a prospective study”Sphincter Injury: a ...
Mediolateral episiotomyMediolateral episiotomy
Eogan et al 2006
The role of the Angle on OASISThe role of the Angle on OAS...
Evento Ostetrico e Perineo
Le lacerazioni perineali
• Che fare?Che fare?
Memorialuroginecologico
LORENZOSPREAFICO
MONTECCH...
“Occult anal sphincter injuries (OASIS):
myth or reality?”
254 primipare
Esame obiettivo immediato postpartum
Ostetrica/Me...
“Occult anal sphincter injuries: myth or reality?”
Andrews et al, 2006
RisultatiRisultati Lesioni Sfinteriche Ostetriche
•...
“Risk Factors for Obstetric Anal SphincterRisk Factors for Obstetric Anal Sphincter
Injury: a prospective study”Injury: a ...
“Risk Factors for Obstetric AnalRisk Factors for Obstetric Anal
Sphincter Injury: a prospective study”Sphincter Injury: a ...
Fattori di Rischio per lesioni Ostetriche perinealiFattori di Rischio per lesioni Ostetriche perineali
Andrews et al 2006
...
Repair of OASI
GUIDELINESGUIDELINES
1. Performed by an experienced operator
2. Operating theatre
3. GA or Spinal
4. Grade ...
GUIDELINESGUIDELINES
9. Rectovaginal exam
10. IV antibiotics
11. Foley catheter – 24 hrs
12. Detailed notes
13. Laxatives
...
Technique of of anal sphincter closureTechnique of of anal sphincter closure
OverlapOverlap
End-to-endEnd-to-end
Evento Os...
12 months < risk of faecal urgency &Anal Incontinence
36 months no differences
Evento Ostetrico e Perineo
Le lacerazioni p...
Role of Perineal Clinic
• All women who have had obstetric anal
sphincter repair should be reviewed 6 –12
weeks postpartum...
GrazieGrazie
Evento Ostetrico e Perineo
Le lacerazioni perineali
Memorialuroginecologico
LORENZOSPREAFICO
MONTECCHIOEMILIA...
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Evento Ostetrico e Perineo Le lacerazioni perineali

Evento Ostetrico e Perineo Le lacerazioni perineali

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Evento Ostetrico e Perineo Le lacerazioni perineali

  1. 1. 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 LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014
  2. 2. 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 Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014
  3. 3. severe perineal lacerations (III°-IV °) on 967 consecutive women III° 3 (2.6%) IV 0 Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014 Evento Ostetrico e Perineo Le lacerazioni perineali
  4. 4. •Lacerazioni PerinealiLacerazioni Perineali •Lacerazioni VaginaliLacerazioni Vaginali Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014 Evento Ostetrico e Perineo Le lacerazioni perineali
  5. 5. 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 Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014 Evento Ostetrico e Perineo Le lacerazioni perineali
  6. 6. ““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 Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014 Evento Ostetrico e Perineo Le lacerazioni perineali
  7. 7. ENDOANAL ULTRASOUND Technical aspect Mechanical TransducerMechanical Transducer Rotating Scanning: full 360°Rotating Scanning: full 360° Frequency Range: 5 - 10 MHzFrequency Range: 5 - 10 MHz Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014 Evento Ostetrico e Perineo Le lacerazioni perineali
  8. 8. Sultan et al Clinical Radiology 1994;49:368-374 Valutazione ecografica Endoanale Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014 Evento Ostetrico e Perineo Le lacerazioni perineali
  9. 9. Ecografia Endoanale Immagine ecografica: SAE e SAI Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014 Evento Ostetrico e Perineo Le lacerazioni perineali
  10. 10. Ecografia endoanale 3- D Aspetti tecnici Mechanical Transducer Rotating Scanning: full 360° Frequency Range 6 - 16 MHz Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014 Evento Ostetrico e Perineo Le lacerazioni perineali
  11. 11. Ecografia endoanale 3- D Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014 Evento Ostetrico e Perineo Le lacerazioni perineali
  12. 12. 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 Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014 Evento Ostetrico e Perineo Le lacerazioni perineali
  13. 13. Difetto SAE e SAI M.A. Kamm Lancet 1994;344:730-33 Ecografia endoanale Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014 Evento Ostetrico e Perineo Le lacerazioni perineali
  14. 14. 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 Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014 Evento Ostetrico e Perineo Le lacerazioni perineali
  15. 15. 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 Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014 Evento Ostetrico e Perineo Le lacerazioni perineali
  16. 16. Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014 Evento Ostetrico e Perineo Le lacerazioni perineali
  17. 17. EPISIOTOMIA Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014
  18. 18. Evento Ostetrico e Perineo Le lacerazioni perineali 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) Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014
  19. 19. “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 Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014
  20. 20. 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 Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014 Evento Ostetrico e Perineo Le lacerazioni perineali
  21. 21. Evento Ostetrico e Perineo Le lacerazioni perineali • Che fare?Che fare? Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014
  22. 22. “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 Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014 Evento Ostetrico e Perineo Le lacerazioni perineali
  23. 23. “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%) Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014 Evento Ostetrico e Perineo Le lacerazioni perineali
  24. 24. “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 • Higher birthweight • Mediolateral episiotomy Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014
  25. 25. “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 • 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 • Forceps delivery Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014
  26. 26. 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 Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014 Evento Ostetrico e Perineo Le lacerazioni perineali
  27. 27. 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 Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014 Evento Ostetrico e Perineo Le lacerazioni perineali
  28. 28. 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 Evento Ostetrico e Perineo Le lacerazioni perineali Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014
  29. 29. Technique of of anal sphincter closureTechnique of of anal sphincter closure OverlapOverlap End-to-endEnd-to-end Evento Ostetrico e Perineo Le lacerazioni perineali Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014
  30. 30. 12 months < risk of faecal urgency &Anal Incontinence 36 months no differences Evento Ostetrico e Perineo Le lacerazioni perineali Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014 Overlap vs End-to-end:
  31. 31. 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 Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014
  32. 32. GrazieGrazie Evento Ostetrico e Perineo Le lacerazioni perineali Memorialuroginecologico LORENZOSPREAFICO MONTECCHIOEMILIA14-15settembre2014

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