Long-term ailments due to anal sphincter rupture caused by delivery - a hidden problem

Transcription

1 Eur. J. Obstet. Gynecol. Reprod. Biol., 27 (1988) Elsevier 27 EJO Long-term ailments due to anal sphincter rupture caused by delivery - a hidden problem Knut Haadem, Sten Ohrlander and G6ran Lingman Department of Obstetrics and Gynecology, Helsingborg Hospital, Helsingborg, Sweden Accepted for publication 22 July 1987 Summary Questionnaires concerning ailments were sent postpartum (mean two years) to 62 women with anal sphincter ruptures (ASR), who were compared with a matched control population. The frequency of anal sphincter rupture at the hospital during delivery in the period, , was 0.7% (n=63). Primiparity, instrumental deliveries, abnormal presentation, large babies and oxytocin stimulation were all risk factors. Of 59 women answering the questionnaire 37 (63%) stated that they had had ailments three months postpartum, mainly with pain and involuntary passage of flatus but also with dyspareunia and occasional incontinence of faeces. Long-term symptoms were noted by 28 (48%) of the women, mainly with involuntary passage of flatus but also perineal pain, dyspareunia and occasional incontinence of faeces. Long-term symptoms occurred in 7 (88%) of women with ASR also involving the anal mucosa, but only in 21 (39%) of those with ASR only. Three of the patients subsequently underwent reconstructive surgery, and three complained of psychological problems. Gas incontinence; Dyspareunia; Postoperative controls Introduction Anal sphincter rupture (ASR) is a comparatively rare complication of vaginal delivery, reported frequencies ranging from 0 to 20% [13]. Provided the rupture is discovered and treated surgically, prognosis is believed to be good [2,8,11]. Hence, in this retrospective study, we have tried to determine to what extent the patients Correspondence: Dr. K. Haadem, Helsinborg Lasarett, Helsingborg, Sweden /88/$ Elsevier Science Publishers B.V. (Biomedical Division)

2 28 with ASR suffer from continuing ailments, and to what degree these patients are apprehensive of a new pregnancy or delivery. Materials and methods Of a total of 8542 vaginal deliveries at Helsingborg Hospital during the five year period , 63 (0.73%) resulted in anal sphincter rupture. Rupture was confined to the anal sphincter in 54 cases, but also involved the rectal mucosa in eight cases (only 62 patient records avaible). Information as to the extent of the rupture, parity, fetal presentation, instrumental delivery, oxytocin stimulation, anesthetics, neonatal outcome and birth weight were abstracted from patient records. The findings from the study were compared with the total number of vaginal deliveries at the clinic in the period, 8542, and a control population was selected, matched for parity and age + 5 years. All 62 women in the study group (mean 41 months postpartum, range 11-70) and the 62 in the control group (mean 54 months post-partum, range months) were asked to complete a questionnaire concerning perineal pain, dyspareunia or anal dysfunction, both three months after delivery and at investigation. They were also asked whether they had received any treatment for their ailments, and whether the delivery or the rupture surgery had affected their attitude towards further pregnancies or deliveries. There were 59 respondees in the study group and 48 in the control group. The ruptures were sutured by the doctor on duty and the operation was always performed by a well-trained gynecologist. The operative technique was identical in all patients: careful identification of the torn sphincter muscle, adaptation and single-layer sutures of its ends, and the reconstruction of the whole perineum with single-layer sutures. The suture material used was 2-0 and 3-0 Dexon, a resorbable material. The postoperative care for the ASR women was the same as for the women without rupture. The antibiotic regime for perineal infection was ampicillin and metronidazol given per os, if the bacterial culture was not resistant to the actual antibiotics. The anatomical result was examined on discharge from the hospital and eight weeks afterwards. In the statistical analysis the Fisher Exact Test for 2 2 tables and comparison of proportions according to Armitage [1] were used. Results Of the 62 women in the study group, 54 had ruptured only the anal sphincter whereas eight had also ruptured the rectal mucosa. Table I gives the obstetrical data from the ASR group, who had a mean age of 33 years (range 25-41) and a mean parity of 2.2 (range 1-4); for all the vaginal deliveries at the clinic and the control group the mean age was 27 years (range 17-40) and mean parity 1.6 (range 1-4). Thirty-seven (60%) of the ASR group and 21 (44%) of the control group had been stimulated with oxytocin, either nasally or intravenously (the rate is usually 33% of all deliveries). Mediolateral episiotomy (the method used at this hospital) had been performed in 28 (45%) of the study group, as compared with 26% overall at the clinic. In the

3 , 29 TABLE I The ASR (anal sphincter rupture) study group compared to normal material with respect to parity, mode of delivery, maternal anesthesia, fetal presentation and birth weight of the child Obstetrical data for the control group matched for age and parity against the ASR group are also reported in a separate column. The statistical analysis concerns the ASR group and the normal population. Primiparae Instrumental delivery Women with Control Normal ASR group vaginal deliveries (n = 62) (n = 48) (n = 8 542) 66% (41),*** 23% (14)*** ~ ~ 69% (33) 42% 0% 6.3% Anesthetics Pudendal Epidural Presentation excl. occip, ant. Birth weight (g) ** =2p<0.01" *** =2p< % (42) 11% (7) 13% (18),** 3800 *** 65%-(3i) 60% 6%-(3)... 14% 0% 5% 3490 '~ control group 13 had perineal ruptures needing minimum three stitches, one of whom suffered from dyspareunia at questioning time. Nine in the ASR group and none of the controls developed perineal infection in the wound which required antibiotics. One minute Apgar scores of < 7 were recorded for five of the study group newborns, of which two were stillbirths (one due to multiple malformations, the other to asphyxia in utero). The other three had an uneventful neonatal period. The ailments in the ASR group and controls are given in Table II. Women whose rupture involved the rectum had symptoms more frequently than the others (Table III). In the ASR group, six (10%) had consulted physicians for ailments such as pain and swelling, at some time between three and 24 months postpartum. In three of TABLE II Ailments at 3 months postpartum as stated on the questionnaires, and at investigation, (mean 41 months postpartum) for the ASR (anal sphincter rupture) group and (mean 54 months postpartum) for the controls 3 months Long-term symptoms ASR Controls ASR Controls (n = 59) (n = 48) (n = 59) (n = 48) Perineal pain 14 * * * Dyspareunia 15 * * 2 5 * 0 Occasional incontinence of faeces 9 * Incontinence of gas 17 * * * 0 15 * * * 0 + -p<0.05" *-2p<0.05' **-2p<0.01" ***-2p<0.001.

4 30 TABLE III The frequencies of ailments in the group with ASR (anal sphincter rupture) only, and of those also involving the anal mucosa. ASR not involving the anal mucosa 54 ASR involving the anal mucosa 8 Total Ailments Ailments 3 months at investigation postpartum them residual suture material was removed and the other three were surgically reconstructed within 7.5 months after delivery. Of the latter three one had a rectovaginal fistula and another had suture insufficiency and necrosis. One had a low perineum and wanted the anatomy restored for cosmetic reasons. The anatomical result was regarded as sufficient eight weeks postpartum, on routine examination, except for the two who were planned for reoperation. Three patients in the ASR group expressed a pronounced fear of future deliveries, which deterred them from planning a new pregnancy, compared with none in the control group. Of the women in the study group 13 had undergone 14 new deliveries after the ASR, 12 of which were vaginal deliveries, perineotomy being performed in seven cases. Five women had perineal ruptures not involving the anal sphincter in their subsequent deliveries. Two women underwent cesarean section, one due to fetopelvic disproportion, and one due to psycho-social problems related to the rupture. In the control group 15 women had undergone a further vaginal delivery. Discussion A search of the literature has failed to reveal any previous long-term follow-up studies of women with ruptures either of the anal sphincter alone, or including the rectal mucosa. Ruptures of the anal sphincter constitute a heterogeneous group, involvement ranging from a few fibres of the muscle to complete laceration into the rectum. For the purposes of the study we divided the ASR into two categories, namely rupture involving the m. sphincter ani only, and ASR also involving the rectal mucosa. ASR (anal sphincter rupture) was more often seen among the primiparae and women delivered instrumentally, as also reported by others [13]. With regard to pudendal and epidural anesthesia, there was no significant difference between the groups. The suggestion that anesthesia may affect the rate of laceration, due to maternal lack of participation in the birth process [9], received no support from the present findings. We found higher frequencies of rupture in conjunction with abnormal fetal presentations and higher birth weight, explainable by the increased diameter of the fetus transversing the birth channel, a finding also reported by others [13].

5 Patients stimulated with oxytocin were more frequent in the ASR group, maybe due to the subsequent increase in pressure on the pelvic floor. Another possible indication of oxytocin could be bad progress of the delivery, which might have been caused by inelastic vaginal tissue. The frequency of perineotomy was higher in the ASR group, a feature discussed in a number of reports, as reviewed by Thacker and Banta [13]. Though they criticise studies in which the rate of lacerations in patients who received episiotomy was compared with the rate in those who did not, as not having been carefully randomized, and using control groups not well-matched for risk factors, nevertheless the findings may not be entirely without interest. Some workers maintain that perineotomy per se increases the risk of rupture [10], though there is evidence that it may be beneficial in some cases [6,13]. What is best or most suitable is probably impossible to judge. Except for the two stillbirths all the newborn babies were in good condition as judged from Apgar scores. More women complained of ailments three months postpartum in the study group than in the control population. The predominant ailment was perineal pain and various kinds of anal incontinence. Many of them probably regarded this type of problem as normal soon after delivery, although there is a considerable higher frequency in the study group, indicating a possible hidden problem. Although in the ASR group the long-term symptoms diminished subsequently, there was a persistently increased frequency of involuntary passage of flatus, which is regarded as a discrete functional defect of the m. sphincter ani externus [4]. The four patients with occasional incontinence of faeces did not belong to the group with the most serious ruptures, which suggests that any of a variety of factors may be involved. The ASR group reported more instances of pain, probably due to inadequate repair in the operated area. The frequency of dyspareunia was higher in the ASR group. Beischer [3] reported this symptom to have a low correlation to anatomical repair, which is corroborated by the present findings. It is possible that the women had difficulties in distinguishing between perineal pain and dyspareunia, and subsequently there might exist an overlap in registration of the two symptoms. However, it is surprising that three patients were examined and found normal eight weeks postpartum who later consulted their doctors. Maybe the persisting ailments are not sufficiently known among doctors. There was an increased number of infections in the ASR group, which was expected. The ASR group had a lower number of subsequent pregnancies than the control group, although the difference was small. Women with ruptures also involving the anal mucosa suffered more than the other group, indicating that there is a connection between the extent of the rupture and the probability of subsequent ailments. The reason why women with ASR suffer more might be due to scar tissue, which should be considered at the repair surgery. Wound infection might also increase the amount of scar tissue. A perfect repair, however, does not guarantee an absence of long-term symptoms, although it possibly reduces the complaints considerably. It is therefore important to be accurate in the adaptation of the rupture and to monitor the patients afterwards until they are free of symptoms. Earlier investigations have mentioned the possibility that these patients are too 31

6 32 embarrassed to discuss their symptoms, even with their family doctor [5]. Sphincter control is fundamental human socialization, and its impairment may result in severe emotional and social disruption [12]. Our findings indicate that many women with previous ASR are afflicted with more or less pronounced handicaps. The repair should therefore be done by an experienced surgeon [7]. We believe postoperative follow-up focused on postoperative complications would be valuable, as it would provide such women with the opportunity of mentioning any ailments or discomfort in response to direct questioning. Conclusion Risk factors for ASR during delivery are: primiparity, instrumental delivery, abnormal presentation, large babies and oxytocin stimulation. Repair should be done by an experienced surgeon and regular postoperative check-ups would be of value. Long-term symptoms such as anal dysfunction or dyspareunia commonly occur in women with anal sphincter rupture at delivery, symptoms often hidden by the women. References 1 Armitage P. Statistical interference. In: Statistical Methods in Medical Research, Oxford: Blackwell Scientific Publications, 1980: Barter RH, Parks J, Tyndal C. Median episiotomies and complete perineal lacerations. Am J Obstet Gynecol 1960;80: Beischer NA. The anatomical and functional results of mediolateral episiotomy. Med J Aust 1967;29: Bennet RC, Duthie HL. The functional importance of the internal sphincter. Br J Surg 1964;51: Browning GGP, Motsow RW. Results of Park's operation for faecal incontinence after anal sphincter injury. Br Med J 1983;286: Buekens P, Lagasse R, Dramaix M, Wollast E. Episiotomy and third degree tears. Br J Obstet Gynaecol 1985;92: Coates PM, Chan KK, Wilkins "A, Beard RJ. A comparison between midline and mediolateral episiotomies. Br J Obstet Gynaecol 1980;87: Flemming AR. Complete perineotomy. Obstet Gynecol 1960; 16: Hahn SR, Paige KE. American birth practices: A critical review. In: Parsons J, ed. Psychobiology of sex differences and sex roles. New York: Hemisphere, 1980: Kitzinger S, Walters R. Some women's experiences of episiotomy. London: National Childbirth Trust, O'Leary JL, O'Leary JA. The complete episiotomy. Obstet Gynecol 1964;25: Orbach CE, Bard M, Sutherland AM. Fears and defensive adaptations to the loss of anal sphincter control. Psychoanal Rev. 1957;44: Tacker SB, Banta HD. Benefits and risks of episiotomy: An interpretative review of the English language literature Obstet Gynecol Surv 1983;38: