*Małgorzata Kołodziejczak1, Przemysław Ciesielski1, 2, Fabian Kamiński3, 4
A surgeon in the delivery room
Chirurg na sali porodowej
1Warsaw Proctology Centre, Saint Elizabeth’s Hospital, Mokotów Medical Centre
Head of Centre: Associate Professor Małgorzata Kołodziejczak, PhD
2Department of General Surgery, County Hospital in Wołomin
Head of Department: Krzysztof Górnicki, MD, PhD
3Department of General Surgery, Hospital in Białystok
Head of Department: Professor Janusz Kuźmiuk, MD, PhD
41st Department of General and Endocrine Surgery, University Teaching Hospital, Białystok, General Surgery Unit of Ministry of the Interior and Administration Hospital in Białystok
Head of Department: Professor Jacek Dadan, MD, PhD
Streszczenie
Większość położniczych uszkodzeń krocza ginekolodzy zaopatrują sami i chirurg rzadko proszony jest o konsultację na salę porodową. Najczęściej ma to miejsce w sytuacji dużych uszkodzeń zwieraczy odbytu oraz ściany odbytnicy, czyli w przypadku pęknięcia krocza IV stopnia. Szczególnie w szpitalach wieloprofilowych, w których istnieje zarówno oddział ginekologiczno-położniczy, jak i chirurgiczny, może zaistnieć konieczność sprostania powyższej sytuacji. W artykule autorzy przypominają zasady doraźnego zaopatrzenia położniczych uszkodzeń mięśni zwieraczy, w oparciu o aktualne wytyczne postępowania w tym zakresie opracowane przez Royal College Obstetricians and Gynaecologists oraz o najnowsze piśmiennictwo. Przekazują też własne obserwacje praktyczne z przeprowadzania operacji rekonstrukcyjnych po uszkodzeniach położniczych zwieraczy odbytu. Prawidłowo przeprowadzona doraźna rekonstrukcja zwieraczy w większości przypadków nie pozostawia trwałych ubytków czynnościowych u pacjentki, natomiast źle zaopatrzone pęknięcie krocza III i IV stopnia może dać powikłania w postaci: gorszego trzymania gazów i stolca, przetoki odbytowo-pochwowej, przetoki odbytniczo-pochwowej, krwiaka, infekcji rany, ropnia, a w krańcowych przypadkach doprowadzić do ciężkich powikłań septycznych.
Summary
Most of perineal tears are managed by gynaecologists, who rarely consult with surgeons. Consultation most often takes place in the case of extensive damage to the anal sphincters and rectal wall, i.e. fourth-degree perineal tears. This situation is particularly likely in multispeciality hospitals featuring both gynaecological/obstetric and surgical departments. The paper discusses the guidelines for urgent management of perineal sphincter tears based on the current guidelines developed by the Royal College Obstetricians and Gynaecologists as well as recent literature. We also wish to share our practical observations from reconstructive surgeries after obstetric anal sphincter injuries. In most cases, a correctly performed anal sphincter repair causes no permanent dysfunctions, whereas inappropriately managed third- or fourth-degree perineal tears may lead to complications, such as poor gas and faecal continence, anovaginal or rectovaginal fistula, haematoma, wound infection, abscess and, in extreme cases, severe septic complications.
Introduction
According to WHO reports, the incidence of anal sphincter injury during vaginal delivery ranges between 4% and 6.6% (1). A thorough American meta-analysis in a group of 22,741 women showed the incidence of obstetric anal sphincter injuries (OASIS) of 4.9%, including 3.6% for vaginal delivery and up to 24% for vacuum-assisted vaginal delivery (2). For comparison, there has been a 3-fold increase in the number of OASIS cases between 2000 and 2012 in England (1.8 vs. 5.9%), including 6.1% in primigravidas and 1.7% in multiparas (mean 2.9%) (3). The rates of obstetric anal sphincter injuries are 6.6% in Sweden, 3.6% in Denmark, 4.1% in Norway and 0.6% in Finland (4-6). The 2011 data from Austria indicates the incidence of third-degree and fourth-degree perineal tears of 1.5 and 0.1%, respectively (7). In Germany in 2012, the incidence of third-degree and fourth-degree perineal tears was 0.95 and 0.09%, respectively (with no significant differences between primigravidas and multiparas) (8).
Surprisingly, sphincter damage is reported to account for only 0.4% of deliveries in Poland (9). This is uncommon compared to the above mentioned data from Western countries. However, it should be noted that these findings not necessarily reflect the actual scale of the problem in a given country and may indicate better or worse diagnosability of sphincteric trauma.
Risk factors
Researchers are not unanimous on the grading of risk factors for obstetric anal sphincter injuries.
According to the 2015 Guidelines of the Royal College of Obstetricians and Gynaecologists, the risk factors for third- and fourth-degree perineal tear include (10):
– asian origin,
– primiparity (relative risk),
– birth weight greater than 4 kg,
– shoulder dystocia,
– persistent occiput posterior foetal position,
– prolonged second stage of delivery,
– instrument-assisted delivery.
According to the authors of one of the Polish studies, increased rates of perineal tear may be due to invasive delivery completion, the second stage of delivery lasting more than 1 hour and prostaglandin-induced delivery (9). Our study showed that (11) third- and fourth-degree perineal tear was the most important risk factor for postpartum incontinence.
Anatomical predisposing factors of sphincter damage in women include a particularly thin anterior circumference of the external anal sphincter (EAS) (about 90% of women lack the deep part of the external sphincter on the anterior circumference). If, additionally, the patient presents with the so-called low perineum, i.e. small distance between the vagina and the rectum, sphincter damage is more likely to occur.
The current classification of obstetric tears is the one developed by Sultan and Fernando, which was accepted during the 2012 Conference held by the College of Obstetricians and Gynaecologists (12, 13):
– first degree perineal tear – only the skin of the perineum is involved,
– second-degree tear – perineal muscles are involved, but intact anal sphincter,
– third-degree tear – injury to perineum involving the anal sphincter complex (classification suggested by Fernando and Sultan):
– 3a is a tear involving less than 50% of the EAS muscle,
– 3b is a tear involving more than 50% of the EAS muscle,
– 3c is a tear involving the whole EAS muscle and the internal anal sphincter muscle,
– fourth-degree tear is a tear involving perineum, the anal sphincter complex (external and internal sphincter) and rectal mucosa.
Interestingly, some authors distinguish a fifth-degree tear, when the anal sphincters are intact, but the anal mucosa is torn (14).
In the case of doubts about the extent of anal sphincter damage, higher classification group should be assumed (overdiagnosis is better than underestimation).
A surgeon in the delivery room – the proposed management
Most of perineal tears are managed by gynaecologists, who rarely consult with surgeons. Consultation most often takes place in the case of extensive damage to the anal sphincters and rectal wall, i.e. fourth-degree perineal tears. This situation is particularly likely in multispeciality hospitals featuring both gynaecological/obstetric and surgical departments.
In most cases, a correct urgent sphincter repair causes no permanent dysfunctions, whereas inappropriately managed third- or fourth-degree perineal tears may lead to serious complications, such as poor gas and faecal continence, anovaginal or rectovaginal fistula, haematoma, secondary wound infection, abscess and, in extreme cases, severe life-threatening septic complications.
The management in anal sphincter injury during vaginal delivery
Powyżej zamieściliśmy fragment artykułu, do którego możesz uzyskać pełny dostęp.
Mam kod dostępu
- Aby uzyskać płatny dostęp do pełnej treści powyższego artykułu albo wszystkich artykułów (w zależności od wybranej opcji), należy wprowadzić kod.
- Wprowadzając kod, akceptują Państwo treść Regulaminu oraz potwierdzają zapoznanie się z nim.
- Aby kupić kod proszę skorzystać z jednej z poniższych opcji.
Opcja #1
24 zł
Wybieram
- dostęp do tego artykułu
- dostęp na 7 dni
uzyskany kod musi być wprowadzony na stronie artykułu, do którego został wykupiony
Opcja #2
59 zł
Wybieram
- dostęp do tego i pozostałych ponad 7000 artykułów
- dostęp na 30 dni
- najpopularniejsza opcja
Opcja #3
119 zł
Wybieram
- dostęp do tego i pozostałych ponad 7000 artykułów
- dostęp na 90 dni
- oszczędzasz 28 zł
Piśmiennictwo
1. World Health Organization: International Classification of Diseases (ICD). Geneva (CG) 2015. http://www.who.int/classifications/icd/en (data dostępu: 15.09. 2015).
2. Ramm O, Woo VG, Hung YY et al.: Risk Factors for the Development of Obstetric Anal Sphincter Injuries in Modern Obstetric Practice. Obstet Gynecol 2018; 131(2): 290-296.
3. Gurol-Urganci I, Cromwell DA, Edozien LC et al.: Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG 2013; 120: 1516-1525.
4. Waldenström U, Ekèus C: Risk of obstetric anal sphincter injury increases with maternal age irrespective of parity: a population-based register study. BMC Pregnancy Childbirth 2017; 17(1): 306. DOI: 10.1186/s12884-017-1473-7.
5. Ekeus C, Nilsson E, Gottvall K: Increasing incidence of anal sphincter tears among primiparas in Sweden: a population-based register study. Acta Obstet Gynecol Scand 2008; 87: 564-573.
6. Laine K, Gissler M, Pirhonen J: Changing incidence of anal sphincter tears in four Nordic countries through the last decades. Eur J Obstet Gynecol Reprod Biol 2009; 146: 71-75.
7. Oberaigner W, Leitner H, Kölle D: Innsbruck: Eigenverlag 2011. Geburtenregister Tirol – Bericht über die Geburtshilfe in Tirol 2010.
8. Statistisches Bundesamt Deutschland Gesundheitsberichterstattung des BundesOnline: http://www.gbe-bund.de/oowa921-install/servlet/oowa/aw92/WS0100/_XWD_FORMPROC?TARGET=&PAGE=_XWD_106&OPINDEX=3&HANDLER=_XWD_CUBE.SETPGS&DATACUBE=_XWD_134&D.001=1000001&D.946=32202.
9. Malinowska-Polubiec A, Knaś M, Czajkowski K et al.: Okołoporodowe urazy dróg rodnych. Perinatol Neonatol Ginekol 2009; 2(3): 195-202.
10. Royal College of Obstetricians and Gynaecologists: The Management of Third- and Fourth-Degree Perineal Tears. Green-top Guideline No. 29 June 2015.
11. Kołodziejczak M: Okołoporodowe uszkodzenia zwieraczy odbytu. Badanie prospektywne. Praca habilitacyjna. II Wydział Lekarski, Akademia Medyczna w Warszawie 2006.
12. Sultan AH, Kettle C: Diagnosis of perineal trauma. [In:] Sultan AH, Thakar R, Fenner DE (eds.): Perineal and anal sphincter trauma. 1st ed. Springer-Lerlag, London 2009: 13-19.
13. Sultan AH, Thakar R: Third and fourth degree tears. [In:] Sultan AH, Thakar R, Fenner DE (eds.): Perineal and anal sphincter trauma. 1st ed. Springer-Lerlag, London 2009: 33-51.
14. Fernano RJ, Sultan AH: Risk factors and management of obstetric perineal injury. Curr Obstet Gyn 2002; 14: 320-326.
15. Buppasiri P, Lumbiganon P, Thinkhamrop J, Thinkhamrop B: Antibiotic prophylaxis for third- and fourth-degree perineal tear during vaginal birth. Cochrane Database Syst Rev 2014; (10): CD005125. DOI: 10.1002/14651858.CD005125.pub4.
