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COMPARATION BETWEEN LEVATOR ANI AVULSION AND SIZE OF GENITAL

HIATUS-PERINEAL BODY COMPLEX ON SPONTANEUS DELIVERY


Soryadharma A, Armawan E,Purwara BH, Sasotya RMS, Sukarsa MRA, Ahmad ED, Rinaldi A
Obstetrics and Gynecology Department, Medical Faculty of Padjadjaran University/
Hasan Sadikin Hospital, Bandung
ABSTRACT
Objective: Levatorani plays an important role in the integrity of the anatomy of pelvic organs. Avulsion of the
levatorani can be caused by vaginal delivery. Genital Hiatus -Perineal Body (GH-PB) complex size can be used
as an indicator of pelvic fascia interference. The purpose of the study is to assess the correlation between the
size of the GH-PB complex with avulsion of the levatorani.
Method: The study design is cross sectional with analytic correlative method of 110 female subjects are
primiparous of 40 days or more post vaginal delivery. Characteristics homogeneity of the subjects test of age
20-35 years old (p=0.150), body mass index 18-30 kg/m2 (p=0.213), birth weight 2500-3500 grams (p=0.413)
with the Mann Whitney test. Inspection is done by measuring the GH-PB complex and 2D translabial
ultrasound in Bandung HasanSadikin Hospital.
Result: Data analysis uses the Mann-Whitney test. Forty subjects with avulsion of the levatorani median size
GH-PB complex is 6 cm and 70 subjects without levatorani avulsion the median size of the GH-PB complex is
5.25 cm (p=0.01).
Conclusion: Complex GH-PB can be used as an indicator of avulsion of the levatorani after vaginal delivery.
Keywords: GH-PB complex, levatorani avulsion, translabial ultrasonography.
Correspondence :Arry Soryadharma. Obstetrics and Gynecology Department, Medical Faculty of Padjadjaran
University/ Hasan Sadikin Hospital Bandung. Phone: 08112008021, Email: arry_soryadharma@hotmail.com.

INTRODUCTION
POP prevalence in the general
population ranges from 5-10%, according
to the 3rd International Consultation on
Incontinence Research (ICI). Women's
Health Intiative (WHI) reported that, 41%
of women aged 50-79 years had some kind
of POP around 34% is cystocele, rectocele
as many as 19% and 14% for uterine
prolapse. [1, 2]
Several
epidemiological
studies
reported a population of women who have
POP dominated by white women. Fenner
(2008) stated that white women have twice
the prevalence of POP than black women,
Thom reported that the prevalence of POP
occurred in Hispanic women (36%),

followed by whites(30%), blacks(25% ),


andasian-american race(19%). [3, 4]
POP Incidence increases along with
age, so does the average surgery for
treatment. Weberet al (2006) found the
average age of patients with uterine
prolapse is around 61.5 years and more
than 50% aged 60 years or more. [1, 5] we
have no accurate data in Indonesia, to
reveal the incidence of POP, however, the
annual report from Departement of
Obstetrics and Gynecology Hasan Sadikin
Hospital in 2013 reported there were 45
cases of uterine prolapse from 1,762
gynecologic cases treated. [6]
POP recurrence after surgical correction
is one of the adverse problems in pelvic
reconstruction surgery. Around 30% of all

urinary incontinence and prolapse surgery


performed in the United States is repiring
the recurrence problem. [7, 8] The
prevalence of reoperation in the
communities in the United States,showed a
greater incidence, which is 43%-56%. [8,
9]
The risk of recurrent prolapse surgery
assessed by several studies. The risk of
recurrent operations is age older than 60
years, who have advanced stages of
prolapse and histroy of prolapse. [7-9]
Dietz et al have reported a conflicting
results, avulsion of the levator ani and the
widening of the levator hiatus proved to be
a risk factor of recurrent prolapse surgery.
[10, 11] Dietz further studies reveal that
the levator ani trauma is a risk factor for
prolapse, so that the operation can develop
a specific techniques to reduce avulsion of
the levator ani (risk-specific repair) to
prevent recurrence. [11]
Over the last decade we have
recognized that physiological changes
occur during pregnancy and childbirth can
cause pelvic floor dysfunction. Pelvic floor
dysfunction involving muscle damage,
nerve tissue, connective tissue and tissue
advocate on the pelvic floor. Pelvic floor
dysfunction is generally associated with
damage during vaginal delivery, especially
in the first delivery. [12-14]
While this has been successfully
demonstrated that it is the opinion of one,
through some other research,found that
vaginal
delivery
was
significantly
associated with the incidence of levator ani
avulsion. [15-21] Nurdiawanet alin one
study from Hasan Sadikin Hospital in
2013 said the same thing, avulsion levator
ani during delivery with forceps extraction

is more common than vacuum extraction.


[22]
Puboviseral muscle avulsion occurs in
20-30% of vaginal delivery, estimated to
be an important cause in cases of uterine
prolapse after vaginal delivery. The
relationship between dysfunction of the
pelvic floor and vaginal delivery has been
widely studied epidemiologically in the
last three decades. [23] In a study among
of 180 subjects, the levator ani avulsion
detected in 45 women, as many as
8(13.3%) of 60 women withnormal
delivery without episiotomy, and in 37 of
60(61.7%) women with forceps extraction.
Avulsion of the levator ani occurs more
often in cases with extraction forceps
delivery compared with spontaneous labor,
odds ratio(OR) 10:47(95% CI, 4.2-25.9).
[16] In a study of 157 women, comparing
the incidence of avulsion of the levator ani
between vaginal delivery compared to
Caesarean section, showed 81 women
(51.6%) vaginal delivery (spontaneous
parturition were 70 women and 11 female
operative vaginal delivery), and 76 women
(48.4%) gave birth by Caesarean section
(as many as 55 women under going
elective surgery and 21 women underwent
emergency surgery). Levator ani avulsion
associated with vaginal delivery compared
with cesarean section, the relative risk
(relative risk (RR)is : 7.5(p <0.001). [15]
Trauma of levator ani muscles lead to the
pelvic floor dysfunction, which may lead
to prolapse of the pelvic organ. Cases of
pelvic floor dysfunction requiring surgery
occurred as many as 400,000 cases
annually in the United States. [24]
Avulsion of the levator ani can be
detected either by three-dimensional /four
dimensional
ultrasonography
(3D

ultrasound/4D), [15, 17] but not all health


facilities have these tools, and its not easy
to use this tool, meanwhile twodimensional
ultrasonography
almost
possessed
by
every
obstetricians.
According to Dietz and Shek, levator ani
defects can be detected using 2D
ultrasound. [25]
POP-Q system made measurements at 9
different locations in the vagina and
vulva,centimeter from the the hymen. [26]
POP-Q system is more detailed and
important for clinical care. [27] Since the
introduction of the POP-Q system, many
clinicians began using this method. [11]
Research in South Korea showed that
Asian women have standard measures
POP-Q smaller than western women. [28]
POP-Q normal sizes make diagnosis of the
anterior and posterior prolapse is more
common,while uterine prolapse is less
common. [28]
Measurement of genital hiatus(GH) and
perineal body (PB) is part of the POP-Q
system,
measurements
of
GH-PB
complexes associated with abnormal
ballooning or hiatal distensibility. [11, 26,
27, 29] GH-PB complex measurement
associated with the avulsion and can be a
useful predictor for the diagnosis of
avulsion of the levator ani. [11] GH-PB
complex sized 8.5cm or more is an
avulsion of the levator ani clinical
predictors (sensitivity:70% and specificity:
70%). [11] The size of the GH-PB
complexhas been demonstrated to be
correlated for the levator ani function. [30]
Theoretically by anatomical measurement,
if the levator ani avulsion occurs then there
is an increase in the size of the GH-PB
complex.

METHODS
This study is a cross sectional analytic
study, avulsion of the levator ani compared
to the size of GH-PB complex research
subjects who met the inclusion criteria and
exclusion criteria are not included.
Research subjects are divided into two
groups, the levator ani avulsion and group
without avulsion of the levator ani.
Inclusion criteria were:
1.
2.
3.
4.
5.
6.

primiparous
Women aged 20-35years
Head spontaneous vaginal delivery
More than 40 days postpartum
Infants birth weight 2500-3500 grams
Body Mass Index between 18 and 30

Every woman who met the inclusion


criteria and are not included in the
exclusion criteria, get a detailed
explanation of the research procedures and
voluntarily signed a consent to participate
in the study. Subjects were divided into
two groups.
Data analysis was performed with the
independent test, when the data were not
normally distributed then the MannWhitney test was performed. Data analysis
was performed using SPSS for Windows
version 21.0 at the 95% confidence level
with a value p0,05.

RESULTS
This research was conducted during May
to July 2014. During this period we
obtained 110 research subjects who meet
the inclusion criteria and no exclusion
criteria included, consisting of 40 subjects
for the group of patients who have avulsed
levator ani and 70 subjects without levator
ani avulsion. Research subjects derived
from primiparous patients who gave birth

in Hasan Sadikin hospital, and network of


hospitals which met the inclusion criteria

and no exclusion criteria included, then


ultrasound examination was performed.

Tabel 4.1 Characteristic of Subject


Characteristic
Age (yr)
Median
Range
Infant Weight (kg)
Median
Range
BMI (kg/m2)
Median
Range

Avulsion
(n= 40)

No avulsi
(n= 70 )

25
16

26
15

0,150

3000
1000

2975
1000

0.213

20,9
12,9

21,8
13,1

0.471

Uji Mann Whitney. p>0,05

We
Found
no
significant
differences for age range for both groups,
p=0.150 (p>0.05), no significant difference
was found for the baby's weight range for

both research groups p=0.213 (p>0.05) and


also we found no significant difference for
the BMI range of both research groups
p=0.471 (p>0.05).

Tabel 4.2 Corelation of levatoraniAvusionto the GH-PBcomplexes measurement


Levator ani

Size GH-PB complex (cm)


MEdian

Range

Avulsion

40

6,0

5,0-7,0

Without avulsion

70

5,25

4,0-6,0

0,01*

Uji Mann-Whitney. p<0,05

Table 4. 2 shows that the average size


of the GH-PB complex on the subject with
levator avulsion greater than patients
without levator ani avulsion. With the
known value of p = 0.01(p <0.05), then it
shows that there are differences in the size
of the GH-PB complex between group
with avulsion of the levator ani and
patients without avulsion of the levator
ani. (Table 4.2).
From table 4.2 we found significant
results, and then the to measure the size

difference of the GH-PB complex between


grup with and without avulsed levator ani,
we measure ROC curve. From the
calculation results of the ROC curve cut
points GH-PB complex measurement that
can be used as predictors of the occurrence
of avulsion of the levator ani is more than
5.5cm, then the point of intersection of the
value from the 2x2 table can be created as
follows in Table 4.3.

Tabel 4.3 3 Relationship between Intersection of measurement GH-PB Complex With


TheOccurrence of LevatorAni Avulsion
Measurement GH-PB complex
Levator ani

> 5,5 cm

5,5 cm

Avulsion

21 (52,5 %)

19 (47,5%)

0,002*

Without avulsion

16 (22,9 %)

54 (77,1%)

Note :

X2 =

10,020, p<0,01, POR (IK 95%): 2,18 (1,35-3,52)

Table 4.4 shows the relationship


between the size of th ecut point value of
the GH-PB complex with the events of
levator ani avulsion. With p=0.002, so
there is known that there is a significant
difference between the size of the complex
GH-PB more than 5,5 cm with the levator
ani avulsion events. In the table GH-PB
complex sized more than 5.5cm can be a
predictor of avulsion of the levator ani
with a sensitivity of 52.5% and a

DISCUSSION
Severalstudies,
including
epidemiological
data,support
the
hypothesis that age is a risk factor for
pelvic organ prolapse with or without
including parity as variables. [31-33]
Studies conducted by Weemhoff, Shek and
Dietz on 375 subjects in which
transperineal ultrasound were performed,
stated that there is a weak correlation
between age of subjects with strength and
pelvic floor muscle morphometry(r =-0.25,
p<0.01). [34] Santoso report on 182
subjects, age ranged from 24 to 27 years is
the highest among all subjects (39,42%),
the mean age of the study subjects was
about 25 years on the levator ani avulsion
group and 27 years in the group without
avulsion of the levator ani, stated that there
was no statistically significant difference
between the two. [35]

specificity of 77.1%, with an accuracy of


up to 68.2%. Calculating for the risk from
the odds ratios, we obtained 2.18, so that
the risk of avulsion of the levator ani in
GH-PB complex in size more than 5.5 cm
was 2.18 times higher. With 95%
confidence intervals estimated in the
population, avulsion of the levator ani in
GH-PB complex sized morethan 5.5cm is
approximately 1.35 to 3.52 times.

Infant birth weight also affect the


incidence of levator ani avulsion. In
research conducted by Santoso,infant
weight over 3325 grams is at risk for
avulsion of the levator ani. Mean weigh
tinfants in the group with avulsion of the
levator ani in this study is 3027 grams
while the levator ani group without
avulsion is 2976 grams. Group with
avulsion of the levator ani with having a
mean birth weight higher than the group
without avulsion of the levator ani. Median
values between the two groups is the same,
that is 3000 grams. Range of infants
weight in both groups are around 25003500 grams. It also reduces the bias that
may occur in this study. Research
conducted by Santoso showed that birth
weight may be a predictor factor in
damage to the levatorani(OR=5.3695%
CI: 1.08 to 26.59) and there is a significant
correlation between the two (p=0.003), the

ROC curve determined that the point of


intersection birth weight is 3325 grams or
more. [35, 36]
Obesity is expected to complicate the
process of spontaneous labor so thus it will
increase the risk of levator ani avulsion. In
research conducted by Nurdiawan, there
was no significant association between
obesity with levator ani avulsion events (p
=0.0821). [22] In this study,body mass
index on the levator ani avulsion group
was 21.3 kg/m2 and the levator ani group
without avulsion was 22.03kg/m2. Median
avulsion of the levator ani group was
21.6kg/m2 and group without levator ani
avulsion was 22.5kg/m2. Body Mass Index
range in both groups are also almost the
same so as to reduce the bias that occurs in
this research.
GH-PB Complex Size is different
among asian women compared to
Caucasian women. [28] Report from
Korean studies, the size of GH-PB
complex in nulliparous in Korea was
4.60.48cm. [28] Research in the United
States report the average GH-PB complex
in nulliparous 0.7cm is 5.8. [37] The size
of the GH-PB complex in multi parous in
Korea was 5.80.84cm, whereas in the
United States mentioned the size of the
GH-PB complex in multiparous was
6.30.05cm. [38]

weeks which were performed ultrasound


examination before birth and after birth 26 months, from 39 subjects who delivered
vaginally, avulsion of the levator ani was
found in 14 subjects (36%, 95%
confidence interval 21-51%). In that study
also noted that there is significant increase
in urinary incontinence stress in subjects
with avulsion of the levator ani (p =0.02).
[18]
Dietz said there is a relationship
between the size of the GH-PB complex
with avulsion of the levator ani, in a study
of 295 women in New Zealand mentioned
that the GH-PB complex size of 8.5 cm
was the cut off point of the levator ani
avulsion with a sensitivity and specificity
of 70%. [11]
CONCLUSION
Avulsion of the levator ani occurred in
36.4% of spontaneous labor. The median
size of the complex GH-PB in spontaneous
labor was 6.0cm. Size GH-PB complexes
with avulsion of the levator ani subjects
are greater than the subjects without
levator ani avulsion. GH-PB complex
sized more than 5.5 cm can be a predictor
of the incidence of levator ani avulsion.
(Sensitivity:52.5%,specificity:
77.1%).
Levator ani avulsion risk for the GH-PB
complex size more than 5.5cm was 2.18
times higher.

Dietz and Lanzarone research on the


levator ani trauma after birth including 61
primigravida with gestational age 36-40
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