complications of pregnancy

In the name of GOD
the beneficent, the merciful
Early and late proctologic
complications of delivery
prevention and treatment
The earliest evidence of severe perineal injury mummy of Henhenit,
22 yrs old Egyptian woman with rupture of the vagina into the
bladder and the lower bowel was found protruding from the anus.
Predisposing factors
Tissue Damage
Nerve Injury
Promoting Factors
Pelvic Floor Disorder
Obstetrical injury
Caucasian race
PF Muscle Stretch during Labour
• During 2nd stage the
PF muscles stretch
x 2-3 of their length
• Maximal stretch
tolerated by
nonpregnant animal
muscle tissue = 1.5
Sequelae of Childbirth
Perineal problems
Perineal pain, perineal haematoma,
perineal wound Infection
Bowel problems
Anal Fissure, haemorrhoids,
Pelvic Organ Prolapse
Cystocele, uterine prolapse. Enetrocele ,
rectocele, rectal mucosal or complete
prolapse, descent of PF
Urinary, fecal (gas, liquid or solid stools)
Recto-vaginal Fistula
Pelvic Organ Prolapse
Injury to the pelvic floor during childbirth
number of vaginal deliveries
macrosomic infant
O’Boyle et al: the POPQ stage signifcantly higher in the third than in the first trimester
Associated co-Risk factors
defective collagen
advancing age
chronic raised intra-abdominal pressure
Childbirth and Pelvic Organ Prolapse
Women’s Health Initiative:
• single childbirth associated
with raised odds of:
– Uterine prolapse (odds ratio 2.1;
95% CI 1.7–2.7)
– Cystocoele (2.2; 1.8–2.7)
– Rectocele (1.9; 1.7–2.2)
• Every additional delivery
increased the risk of
worsening prolapse by
10–20% (Hendrix, Am J Obstet
Gynecol 2002).
Obstructed Defecation
Alterations of anatomic morphology
Obstructed Defecation Syndrome
Obstructed Defecation Syndrome (ODS) is defined as
the normal desire to defecate, but an impaired ability to
satisfactory evacuate the rectum
Causes of ODS
1. Descent (pelvic floor)
2. Rectocele
3. Internal mucosal prolapse
4. Intususception (recto-rectal/recto-anal)
5. Complete prolapse
6. Paradox puborectalis
7. SRU
8. Puborectalis insufficiency
9. Enterocele
11.Genital Prolapse
Principal pathological Mechanisms
Obstructed Defecation
Mechanical Outlet Obstruction
- Dissipation of Force Vectore
rectocele, descent
- Causes Lying inside the Rectum
Intussusception, mucosal or complete prolapse
Functional Outlet Obstruction
Impaired Rectal Filling Sensation
megarectum, Hirshprung
Dissipation of Force Vector
Causes Lying Inside the Rectum
Rectal intussusception
Mucosal prolapse
Complete rectal Prolapse
Rectal redundancy
Rectal prolapse
Rectal mucosal prolapse
Complex Situations
Rectocele ± intussusception ± descent ±
rectal prolapse ± enterocele ± sigmoidocele ± urogenital prolapses
Straining too much and repeatedly
Long standing in toilet
Frequent calls to defecate
Assisted defecation
Incomplete evacuation
Fragmeted defecation
Pelvic pressure
Rectal discomfort
Perineal pain
Laxative or enema user
Lack of continence
Worsen Quality of Life
Treatment Options
Non surgical
Behavioural therapy
Abdominal approach
(rectopexy ± sigmoidectomy, colpopexy, LAR)
Vaginal approach
(posterior coloporrhaphy)
Perineal/Transanal approach
(Altemeir, Delorme, Sleeve mucosal resection, Starr,
Anal sphincter rupture is highly
associated with fecal incontinence
perineal trauma
McCandlish R et al, Br J Obstet Gynaecol 1998
Fecal Incontinence and Parturition
Anal sphincter defects occur at first delivery
• Primips:
• Multips:
Before 0%
Before 40%
After 35%
After 44%
Incontinence associated with defect: p=0.0003
• 23% with defects had postpartum incontinence
Sultan et al. NEJM
Childbirth & Fecal Incontinence
259 consecutive women delivered single unit
31 elective CS no FI
Primaparous delivered vaginally 13% FI
Abromowitz Dis Colon Rectum
549 prospective fecal urgency
vag 7.3% vs CS 3.1%
Chaliha 99 Obstet Gyn
Anal Endosonography before and after Delivery in a Primiparous
Woman with a Postpartum Defect of the External Anal Sphincter
Abdul H. Sultan et al, NEJM, 1993
MRI defects in parous womnen
1. First degree, superficial vaginal birth
– skin and subcutaneous tissue
– vaginal mucosa
– combination of the (multiple superficial lacerations)
2. Second degree, deeper
– superficial perineal muscles (B. spongiosus, T. perineal)
– perineal body.
Suture or not suture
less trauma next deliver
unacceptable aesthetics
less pain and infection
Impaired sexual function
the wound heals faster
Impaired PF muscle strength
Incontinence and prolapse
anatomy training
Identifying 3rd degree tears
Sultan et al. NEJM, 1993
Intact anal sphincter
Partial tear in EAS
Buttonhole tear of rectal mucosa
with an intact EAS
Traditional 3 Layer Suturing
Continuous suturing technique
Endo to end
Repair of third and fourth degree tears
End– to – end
or overlap repair?
Internal sphincter repair
Postoperative management
Bladder catheterisation
Stool softener
Patient information
Midline episiotomy is highly
associated with anal sphincter rupture
Sphincter rupture rate
• No episiotomy: 0 - 6.4%
• Episiotomy: 0 - 23.9%
Thacker. Ob Gyn Survey 38:332;1983
Zetterstrom. Obstet Gynecol 94:21;1999
Hartmann K et al. JAMA 293(17):2141-8;2005
Fitzgerald for PFDN, Obstet Gynecol
Operative delivery is
associated with sphincter rupture
Sphincteric Rupture
Forceps delivery
OP position
Vacuum delivery
Odds Ratio (p value)
6.7 (p<0.001)
3.3 (p<0.001)
2.4 (p=0.002)
2.3 (p=0.001)
Fitzgerald MP for PFDN, Obstet Gynecol 109:29;2007
What Is Recommended Practice?
Interventions to Prevent
Obstetrical Perineal Trauma
Planned Caesarean vs. Planned Vaginal Birth
Exercise in Pregnancy
Antenatal Pelvic Massage
Position during Labor and Birth
Epidural vs. Narcotics Pain Relief
Early vs. Delayed Pushing
Second stage pushing advice
Spontaneous vs. Forceps birth
Water Birth
Asymptomatic Women
Asymptomatic women who have minimal compromise
of their anal sphincter function (satisfactory
pressure measurements and ultrasound
images) should be allowed to have a vaginal delivery.
These women should be counselled that they have a 95% chance of not
sustaining recurrent OASIS9 or developing de novo anal incontinence
following delivery.68 However, the delivery should be conducted by an
experienced doctor or midwife.If an episiotomy is considered necessary, e.g.
because of a thick inelastic or scarred perineum,a mediolateral episiotomy
should be performed.There is no evidence that routine episiotomies
prevent recurrence of OASIS.
The threshold at which these women may be considered for a CS
may be lowered if a traumatic delivery is anticipated, e.g. in the presence of
one or more additional relative risk factors such as a big baby, shoulder
dystocia, prolonged labour, diffi cult instrumental delivery. However,
symptomatic women
All symptomatic women are first treated
Conservative management of anal incontinence
is described in detail in Chapter 11 and is summarised
as follows:
• All women are included in the biofeedback programme
(Chapter 11).
• If muscle contractility is weak or absent, electrical
muscle stimulation is commenced.
• Women with flatus incontinence are given
dietary advice, especially the avoidance of gasproducing
foods such as legumes.
• Women with faecal incontinence are commenced
on a low residue diet and constipating
agents such as loperamide can be used.
Women whose symptoms are adequately controlled
by conservative measures are offered CS in
any subsequent delivery so as to minimise the risk
of further compromise to anal sphincter function.
Women with faecal incontinence in whom
conservative measures have failed should be
offered anal sphincter surgery (Chapter 12A), while
others may need advanced surgical techniques as
described in Chapter 12B. All women who have
undergone successful incontinence surgery should
be delivered by CS.
A management dilemma arises in women who suffer from faecal
incontinence but who wish further pregnancies. These women could avoid a
CS and undergo a vaginal delivery followed by a secondary sphincter repair
at a later date. The only rationale behind this is that most of the
damage that occurs during childbirth occurs with the first vaginal delivery68,70
and therefore the risk of further damage during a subsequent vaginal
delivery is relatively small. However, there is a potentially unquantifi ed risk
of deteriorating pudendal neuropathy.
The Effect of Pregnancy Hormones on Connective Tissue
Connective tissue in the area of the urogenital organs is sensitive to hormones. During
pregnancy, collagen is depolymerized by placental hormones, and the ratios of the
glycosaminoglycans change. (The term ‘proteoglycans’ is used here interchangeably
with ‘glycosaminoglycans’.) The vaginal membrane becomes more distensile, allowing
dilatation of the birth canal during delivery. There is a concomitant loss of structural
strength in the suspensory ligaments. This explains the uterovaginal prolapse so often
seen during pregnancy. Laxity in the hammock may remove the elastic closure force,
causing urine loss on effort. This condition is described as stress incontinence. Loss
of membranous support may cause gravity to stimulate the nerve endings (N) at the
bladder base, so causing premature activation of the micturition reflex, expressed as
symptoms of ‘bladder instability’. This condition is perceived by the pregnant patient
as frequency, urgency and nocturia. Laxity may also cause pelvic pain, due to loss
of structural support for the unmyelinated nerve fibres contained in the posterior
ligaments. The action of gravity on these nerves causes a ‘dragging’ pain. Removal of
the placenta restores connective tissue
Following the advent of endoanal ultrasound (see
Chapter 10), Sultan et al.14 demonstrated that 33%
of women sustained “occult” OASIS that were not
identifi ed at delivery (see Chapter 8 for pathophysiology).
Prospective studies11 have identifi ed
“occult” injuries ranging between 2015 and 41%.
occult or in fact unrecognised at delivery.
It was alarming to find that 87% and 27% of
OASIS were not identified by midwives and
doctors respectively.
Lal et al.20 showed that
signifi cantly more women develop anal incontinence
following a second degree tear than with an
intact perineum (23% vs 3%, P = 0.01).
Benifl a et
al.21 identifi ed a 16-fold increase in anal incontinence
following a second degree tear (P < 0.05).
Both these studies support the fi ndings of Andrews
et al. that a large number of OASIS were undiagnosed
and wrongly classifi ed as second degree
Faltin et al.22 randomised 752 primiparous women
with second degree lacerations to conventional
examination (control group) and additional
postpartum endoanal ultrasound (experimental
group) and demonstrated that a considerable
number of women have full-thickness OASIS that
are not recognised at delivery. However, they
excluded partial-thickness sphincter tears from
their study. On identifying new injuries in the
experimental group, a formal sphincter repair was
performed. Overall, severe faecal incontinence
was signifi cantly reduced from 8.7% in the control
group to 3.3% in the experimental group.
The morbidity associated with perineal injury
related to childbirth constitutes a major health
problem, affecting millions of women worldwide.
In the UK, up to 44% of women will continue
to have pain and discomfort for 10 days following
birth3 and 10% of women will continue to have
long-term pain at 18 months postpartum.4 Furthermore,
23% of women will experience superfi cial dyspareunia at 3 months postpartum;5 up to
10% will report faecal incontinence6 and approximately
19% will have urinary problems.7 The rates
of complications reported by women depend on
the severity of perineal trauma
A treatment during pregnancy
is usually limited to emergency care, consisting of
palliation for symptomatic prolapsing internal
temporizing sclerosing injections for bleeding
hemorrhoids, incision and expression of painful
external anal thromboses and drainage for the relatively
uncommon perianal abscess.
The first description of rectal prolapse is
said to be in the
Ebers papyrus 1500 BC. The first
treatment as outlined by
Hippocrates involved hanging patients by
their heels and
shaking them.10 Obviously, this was rarely
successful in the
long term.The true incidence of rectal
prolapse (mucosal or
complete) is unknown mostly because of
It is associated with long-standing
constipation, chronic
straining, pregnancy, prior surgery, female
gender, aging,
neurologic disease, mental illness (up to
53% in a study by
Vongsangnak et al.), and other pelvic floor
Obstetric trauma is the most important etiologic factor in the pathogenesis of
fecal incontinence in women. There
is evidence that hormonal changes during pregnancy lead to smooth muscle
relaxation attributed to progesterone.
Relaxin is an ovarian hormone that peaks late during pregnancy
and leads to connective tissue remodeling in the pelvic floor.23 With parturition,
there is stretching of the levators, stretching and tearing of the rectovaginal
stretching of the vaginal wall, and compression of the pudendal nerves against
the pelvic side wall. All these factors may contribute to fecal incontinence.
A published study by Sultan et al.24 revealed anal sphincter defects in 30% to
40% of asymptomatic postpartum females. Fortunately, the minority of these
patients were symptomatic (32%). However, these patients may become
symptomatic later in life or with subsequent vaginal deliveries.
In addition, pudendal nerve injury documented by electromyography has been
demonstrated in 42% of postpartum females by Snooks et al.25,26 Sixty percent of
these patients recovered nerve function 2 months after delivery, but 40% did not.
Four percent of 906 postpartum women in a study by MacArthur et al.27 reported
new symptoms of incontinence after childbirth. Sultan et al.28 showed a 1%
incidence of frank fecal incontinence and a 25% incidence
of decreased flatal control at 9 months’ follow-up after vaginal delivery.
The incidence of sphincter injury is higher in patients
with perineal tears. Up to 25% of patients developed fecal
incontinence symptoms after a third degree tear in a study
by Wood et al.29 Third degree tears, involving the sphincter
muscle, occur in approximately 0.6% of all vaginal
deliveries. Episiotomies, similar to tears, are associated with
Sultan et al.31 found episiotomy to be associated
with an increased risk of sphincter injury. Signorello et al.33
showed a threefold increase in fecal incontinence after
midline episiotomy as compared with spontaneous
therefore, a mediolateral episiotomy is recommended
Perineal pain is a common symptom
vaginal delivery, regardless of the
presence of
perineal trauma. However, the severity of
perineal pain is directly proportional to the
of perineal trauma.5,15 Perineal pain occurs
42% of women immediately after delivery
but signifi
cantly reduces to 22% and 10% at 8 and
weeks respectively. Compared to a normal
perineal pain occurs more frequently and
persists for a longer period after assisted
(forceps, vacuum delivery, vaginal breech
Perineal Pain
• Soft tissue trauma
(regardeless of suturing)
Asceptic technique
Poor surgical techniques
Perineal Pain
Often associated with dyspareunia
Local Treatment
Ice packs
Sit baths
Local anestetics
Hydrocortisone 1%
Antenatale perineal massage
Systemic Treatment
Rectal supp
Perineal Pain
Local Treatment
Perineal Haematoma
1 : 500 and 1 : 900 vaginal deliveries.
inability to pass urine
rectal tenesmus within a few hours after delivery
Shock in sopraelevator hematomas
• infralevator (vulval, perineal,vaginal)
• supralevator (in the broad ligament or paravaginal area)
frequently after an episiotomy
But about 20% of cases in apparently intact perineum
A supralevator haematoma forms in the broad
ligament and could be due to an extension of
a tear of the cervix, vaginal fornix or uterus.
Perineal Haematoma
If < 5 cm
• Ice packing
• Pressure
• Analgesics
If > 5 cm expanding
• Incision & drainage
• Conservative with transfusions
• Evacuation of clots and packing for 24 hrs
• Embolising the bleeding vessel
Anal Fissure
Anal fissure is an ulcer in the squamous epithelium of the anus
located just distal to the mucocutaneous junction;
In a prospective study before and after delivery
of 163 consecutive women (84 primiparous),
Abramowitz et al.37 reported anal fi ssures in 15%
during the fi rst 2 months postpartum.
Anal Fissure
Risk factors
• dyschezia (painful defaecation),
• heavier babies,
• long second stage of labour,
• Anal incontinence after delivery,
• primiparity,
• forceps deliveries
• perineal damage
Caesarean section did not appear to be protective against
anal fissure
Anal Fissure
Pain sorness during defecations
Visual examination of anal margine
Small ulcer at the level of mucocutaneous junction
Relief of constipation
sit baths
stool softeners
local analgesics
Botulinium toxin
Management of Anal Fissure
pregnancy and postpartum
Anal fissures in postpartum are associated with low pressure resting tone
Risk factors
• straining at defaecation
• constipation,
• vascular enlargement due to increased intra-abdominal pressure
• erect posture
• heredity
Effect of Pregnancy
high levels of circulating
mechanical obstruction by
the gravid uterus
Smooth muscle inhibition
Effect of Pregnancy
Increased blood volume
by 25–40%
Venous engorgement and dilatation
Risk factors include
• heavier baby
• long second stage of labour
• vaginal delivery
• instrumental delivery
In an observational study of 11,701 women,
MacArthur et al.2 found that 8% reported
of more than 6 weeks’ duration for the fi rst
time within 3 months of birth and an
10% reported these as ongoing or recurrent
Two thirds reported the presence of
1–9 years after delivery. Glazener et al.1
found that 17% of postnatal women reported
haemorrhoids (new and recurrent) when
in hospital, 22% between delivery and 8
weeks postpartum and 15% after 2 months.
intermittent bleeding (most common symptom)
burning sensation
Intermittent bleeding of the anus
varying degrees of leakage of mucus, faeces or flatus
sensation of fullness or a lump
perianal hygienic problems
discomfort and/or pain
Compromission of the quality of life
affecting the activities of everyday life
sitting down
emptying bowels
caring for the family or a new baby
Treatment Haemorrhoids
during pregnancy
Often symptoms will resolve spontaneously after birth, and so any
corrective treatment is usually deferred to some time after birth.
relief of symptoms, especially pain control
Complications of haemorrhoids
acute thrombosis
incarceration of prolapsed internal haemorrhoid
Aggressive treatment such as closed excisional haemorrhoidectomy under
local anaesthetic.
Treatment Haemorrhoids
during pregnancy
Conservative Management
• dietary modifications
high fibre intake, high liquid intake, stool
• stimulants or depressants of the bowel transit
• local treatments
sitz baths, creams, ointments or suppositories
containing anaesthetics, antiinflammatory drugs,
steroids, etc., alone or incombination
• drugs of the flavonoid family such as rutosides
that cause decreased capillary fragility
Treatment Haemorrhoids
during pregnancy
Alternative Management in severe and non-responsive cases
ambulatory interventions that usually do not need anaesthetics, such
• injection sclerotherapy,
• rubber-band ligation
• cryotherapy,
• infrared photocoagulation,
• laser therapy
Injection sclerotherapy has been used effectively during pregnancy.
86% of antenatal patients (24 of 28) became asymptomatic by
means of injection of 5% phenol in almond oil.
Treatment Haemorrhoids
during pregnancy
• excision surgery
• stapled anopexy
no known trials that have specifically evaluated
treatments for severe haemorrhoids during
pregnancy and the postpartumperiod.
Interventions to Prevent
Obstetrical Perineal Trauma
Planned Caesarean vs. Planned Vaginal Birth
Exercise in Pregnancy
Antenatal Pelvic Massage
Position during Labor and Birth
Epidural vs. Narcotics Pain Relief
Early vs. Delayed Pushing
Second stage pushing advice
Spontaneous vs. Forceps birth
Water Birth
Routine Episiotomy to Prevent a Tear
What Type of Episiotomy is Safest
Vacuum vs. Forceps
PerinealSupport: Hand on vs. Hand poised
85% of women who have a vaginal birth will
sustain some form of perineal trauma and up to
69% of these will require stitches.
Spontaneous or surgical
McCandlish R et al, Br J Obstet Gynaecol 1998;
1. First degree, superficial
– skin and subcutaneous tissue of the anterior or posterior perineum
– vaginal mucosa
– combination of the above resulting in multiple superficial lacerations
2. Second degree, deeper
– superficial perineal muscles (bulbospongiosus, transverse perineal)
– perineal body.
Suture or not suture
Not suture: less trauma next delivery, less pain and infection, the wound heals faster
unacceptable aesthetics, sexual function, pelvic floor muscle strength
incontinence and prolapse
four European and one UK RCTs (n = 1,864 primiparous and multiparous women)
continuous subcuticular technique of perineal skin closure, when compared to
interrupted transcutaneous stitches, was associated with less perineal pain
Kettle C et al, The Cochrane Library, Issue 3. Oxford: Update Software, 2003.
Suture materia
wound closure, control bleeding, minimise the risk of infection and expedite
healing, minimal tissue reaction and be absorbed once the wound
has healed
The first mention of the surgical management of
severe perineal injury appears in Avicenna’s
famous Arabic book, Al Kanoun. He recommended
a form of a crossed or bootlace suture for the
repairs of perineal injuries.
However, success rates with primary wound union
of perineal wounds reported in the late 1800s were
in the region of 50–60%.
However, in 1999, Sultan et al, described the overlap
technique of primary repair of the EAS (described by
Parks previously for secondary sphincter repair).
In addition, Sultan et al, highlighted the importance of separate repair of the
freshly torn internal anal sphincter (IAS), responsible for maintaining the
resting tone of the anal sphincter.
Damage to the IAS is associated with incontinence to gas and passive soiling
The prevalence of third and fourth degree tears, collectively referred to
as obstetric anal sphincter injuries (OASIS), appears to be dependent
upon the type of episiotomy practised. In centres where mediolateral
episiotomies are practised, the rate of OASIS is 1.7% (2.9% in
primiparae)9 compared to 12%10 (19% in primiparae)11 in centres
practising midline episiotomy.
End-to-end repair
Thirty-five studies over a 20 yr with follow-up ranging from 1 to 30 mons:
Gas incontinence ranges between 15–61% (n = 35; mean = 39%)
Faecal incontinence ranges between 2–29% (n = 25; mean = 14%)
Thirty-five studies over a 20 yr with follow-up ranging from 1 to 30 mons:
following end-to-end repair
Gas incontinence ranges between 15–61% (n = 35; mean = 39%)
Faecal incontinence ranges between 2–29% (n = 25; mean = 14%)
Risk factorsthird/fourth degree tear
• Forceps delivery
• first vaginal delivery
• large baby
• shoulder dystocia
• persistent occipito-posterior
overlap technique
Metanalysis of 21 studies , with good results ranging from 74% to 100%
Jorge and Wexner et al, Dis Colon Rectum, 1993
55 patients with faecal incontinence good clinical outcome in 80% at 15 months.
Engel et al. Br J Surg 1994
Sultan et al, compared to matched historical controls who had an end-to-end
repair, anal incontinence could be reduced from 41% to 8% using the overlap
technique and separate repair of the internal sphincter
Br J Obstet Gynaecol 1999;106:318–23.
Malouf AJ et al.
Long-term results of overlapping anterior anal-sphincter repair for obstetric trauma.
Lancet 2000;355(9200):260–5.
Kairaluoma et al. Dis Colon Rectum 2004,
31 consecutive women who sustained OASIS (3b and fourth degree).
All had an EAS overlap repair immediately after delivery performed by two
colorectal surgeons. In addition to end-to-end repair of the IAS, they also
performed a levatorplasty to approximate the levators in the midline with
two sutures. At a median follow-up of 2 years, 23% complained of anal
incontinence, 23% developed wound infection, 27% complained of
dyspareunia and one developed a rectovaginal fi stula. Levatorplasty
therefore should be avoided during primary anal sphincter repair.
Poen et al.29 identifi ed 43 women (out of original
cohort of 117) who had subsequent vaginal deliveries
following previous OASIS. The rate of anal
incontinence was 56% compared to 34% in those
who did not subsequently deliver (relative risk
1.6; 95% confi dence interval 1.1–
Sangalli et al.14 studied 177 women some 13
years after OASIS (48 fourth degree tears). Anal
incontinence was signifi cantly more common in
women who had sustained fourth degree tears
compared with those with third degree tears (25
vs 11.5%; P = 0.049). Unlike women with previous
fourth degree tears, those who had sustained a
previous third degree tear did not demonstrate an
increase in anal incontinence symptoms after a
subsequent vaginal delivery.
This is in keeping
with the fi ndings of Fenner et al.,25 who found that
the symptom of worse bowel control was 10 times
higher in women who sustained fourth as opposed
to third degree tears. This could be attributed to
persistent injury of the IAS.
Incontinence when stoma
1. When there is a cloacal injury. Some injuries are so
extensive that the anterior half of the anus and the
lower third of the vagina are one common cavity.
2. When there is an associated rectovaginal fistula. Fistulas
to the vagina can be extremely hard to treat;
• 3. In the presence of Crohn’s disease or prior radiation

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