evaluation and management of peri- partum complications...

Evaluation and management of peri-

partum complications of OASIS

Catherine A. Matthews, MD

Professor of Ob/Gyn and Urology

Female Pelvic Medicine and Reconstructive Surgery

Wake Forest Baptist Medical Center

Disclosures

• Grant support from Boston Scientific, Pelvalon,

and AMS

• Consultant for Pelvalon


Objectives

Review:

• Common post partum clinical vignettes for

women with OASIS.

• Evidence for management and follow up of

the presenting symptoms

• Helpful hints for your patients.

How would you manage this and

why did it happen?

• 10 days PP

• Increased pain

• Discharge

• What to do?


THIS PT GOT….


When she should have got….

Birth and Healthy Healing

~ 1 in 10 vaginal births has a PFD symptom in the first 6 months post-partum

Patient quotes

• “I just want my body back.

Will I ever get my body back?

No one ever talks about this

part of being a new mom.”

• “All I know is that everyone

was looking at my bottom

and shaking their heads, I

knew it was something bad.”


6 weeks after Delivery

• 3C laceration

• Fecal Urgency

• FI with liquid stool

• Pain with defecation and sitting


Continence Physiology and Symptoms

Symptoms Component Function of Deficit

Internal •Keeps anal • Fecal soilingAnal Sphincter canal closed • Incontinence

at rest of liquid stool•Allows sampling and flatusof stool content

•Enhances con-tinence of liquidstool and flatus


Continence Physiology and Symptoms

Component Function Symptoms of Deficit

External Provides • Fecal urgency

Anal Sphincter emergency • Urge-related loss

control for of liquid

liquid stool stool and flatus

and flatus

•Puborectalis Maintains • Incontinence of

continence solid stool

of solid stool


Anal Sphincter Repair

•

Author/ YearPatient with

follow-up/(%)

Follow-up

(mean)Outcomes

Malouf 2000

(UK)

38/55 (69%) 6.4 years 0% continent

10% incontinent of flatus only

63% passive soiling

Karoui 2000

(France)


23% incontinent to flatus only

49% incontinent of stool

Halverson 2002

(USA)



54% incontinent of stool

Bravo Guitierrez 2004

(USA)

130/191 (71%) 10.3 years 6% continent


60% incontinent of solid stool

Trowbridge 2007

(USA)



75% incontinent of solid stool


Was my repair done right?


TECHNIQUE OF REPAIR

• Find bleeders first

• Use smallest suture possible

• Interrupted stitches (esp if edema)

• Surgical assistant/ retractors

• Delicate tissue forceps

• Adequate light and visualization

• Technique of sphincter repair?

Technique of Repair• Good lights, appropriate

equipment, aseptic conditions (Ib)

• consider self retaining retractor, e.g. Weislander

• Good anesthesia

• Allows EAS to relax for better access

• Evaluate and grade injury

• Repair

• Document like any other surgery

• Antibiotics

• Give at time of repair

• Commonly prescribed in Europe for one week pp

• No Randomized controlled trials supporting/rejecting

• Anal Epithelium: interrupted 3/0 vicryl with knots in lumen

• Sphincter muscles:

• IAS: end to end with 3/0 PDS

• EAS overlap with 3/0 PDS

• If partially torn, consider end to end with mattress sutures

• Perineal muscles with 2/0 vicryl or Monocryl

• Avoid any sutures in vaginal or perineal skin

• BOWEL REGIMEN !!!

Repair of OASIS

• ACOG

• NO practice bulletin

• Episiotomy: Procedure and Repair Techniques

• Rectal mucosa : 4/0 chromic or vicryl-running or locked, through submucosa, not mucosa

• IAS: no comment, although reference to rectal fascia

• EAS: 2/0 suture

• Vaginal tissue: 3/0 or 2/0

• Skin: 4/0

• RCOG

• EAS: PDS or Vicryl can be used with equivalent outcome (LEVEL Ia and Ib)

• IAS: 3/0 PDS 2/0 Vicryl(LEVEL IV)

• Use abx (BEST PRACTICE)

• Use laxatives (LEVEL IV)

• If available, f/u up of women with OASIS should be in a dedicated perineal clinic with access to endoanal u/s and anal manometry, as this can aid decision on future delivery (LEVEL IV)


No difference at 3 years


No difference


6 Trials

No difference at 3 years for AI

Less fecal urgency in overlap group


SUTURE CHOICE

• WHY PDS?

• 50% tensile strength at 3 months

• Monofilament-less infection risk

• WHY VICRYL?

• 50% tensile strength at 3 weeks

• Vicryl Rapide with fewer side effects of retained suture at post partum visit-appropriate for mucosa

• WHY NOT CHROMIC?

• Painful, Particularly in first three days post-partum.

• Proteolytic dissolving, increased infection risk

• Greater wound dehiscence


8.2% vs 24.1%


7.3%, most within 2 weeks


Follow-up

• 1-2 week wound check

• Examination at 6 weeks in perineal clinic: Learn

outcomes of your repair

• Endoanal ultrasound can provide information

about integrity of IAS and EAS

Common Consultation Questions

• What should I do

for my next

delivery?

• When will the

pain go away?

3-7% risk of repeat OASIS: Most can

be delivered vaginally


Perineal body length < 2 cm is risky


Clinical algorithm

If no fecal Incontinence

- Next vaginal delivery: no Fl

If transient fecal Incontinence

- 17-24% with permanent Fl

- 39% with temporary Fl

If permanent fecal Incontinence

- further deterioration of functionBeck. Br J Obstet Gynecol 1992

Tetzschner Br J Obstet Gynecol 1996Fynes. Lancet 1999


Perineal Pain

• 32 yo G1 P1 presents with pain with

intercourse 8 weeks after a vaginal delivery

complicated by a fourth degree laceration.

• Is this normal?

Complications of perineal laceration repair:

Matthews et al. J Pelvic Med & Surg,

2010.


Granulation tissue and scar tissue causing dyspareunia


Perineal Pain

• “NORMAL”

• 42% of women 10 days pp

• 10% of women 18 months pp

• Larger the tear, longer the pain

• Less pain with spontaneous tears than episiotomies at 10 days and 6 months postpartum

• At 12 weeks post partum, pain more common with women who breast fed

• Most pain resolves within 8 weeks postpartum


Dyspareunia

• Short term dyspareunia and other sexual complaints common

• Decreased libido, difficulty with orgasm, dryness

• Six months from delivery

• One in Five women report dyspareunia

• One in Nine have not resumed sexual activity

• Up to 90% of women resume intercourse within the first 3 months of delivery

• During this period two of three mothers experience at least one problem related to sexual function

• LOOK FOR GRANULATION TISSUE AND SCARRING

Post-repair

• Left labium is

mobilized from the

PB and sutured to

itself

• Perpendicular

plane is created

between vagina

and PB


Vaginal Estrogen and lactation

• SHOULD BE EVALUATED ON A CASE BY CASE BASIS

• No data on Vaginal Estrogen and effect on milk supply

• No randomized controlled trials of adequate size yet done on oral hormones

• Decline in milk volume on combined OCPS

Strauss 1981, Tankeyoon 1984, Truitt 2003

Perineal Pain

• 32 y/o G1P1 s/p NSVD 11 months ago with compound presentation

• Sustained 3rd degree laceration and bilateral sulcal tears

What do you see?

Fistula in Ano

SETON or FISTULOTOMY


Fistula in Ano

• Drain• Leave open• Seton placement• Bowel History


Lessons Learned

• Standardized OASIS repairs

• Less suture is better!

• Maternal birth certificate

• See 3rd and 4th degree lacerations in 2 wks.

• Hand-outs

• Bowel program

• Sitz baths

• Expectations

• Depression screening


CONCLUSIONS

• Do not repetitively treat scarring and

granulation tissue with silver nitrate

• Do not ever perform a colostomy for breakdown

of perineal tears- even when there is lots of

stool everywhere

• Get help from someone who knows how to

repair the IAS and EAS

• Ask post-partum women about bowel function

evaluation and management of peri- partum complications...

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