Obstetric risk factors for symptomatic prolapse: A population-based approach

doi:10.1016/j.ajog.2005.06.086

American Journal of Obstetrics and Gynecology

Volume 194, Issue 1, January 2006, Pages 75-81

https://doi.org/10.1016/j.ajog.2005.06.086 Get rights and content

Objective

The purpose of this study was to identify obstetric risk factors for symptomatic prolapse.

Study design

This was a population-based case-control study of prolapse prevalence.

Results

Four hundred fifty-four women with self-reported symptomatic pelvic organ prolapse who were identified among 5489 women who participated in a population survey (cases) and 405 control subjects without symptoms were selected randomly from the same survey. All cases and control subjects received a mailed questionnaire with 72 questions about factors that were suspected to be linked to risk and that included obstetric history. The response rate was 76%. Among parous women, the odds for symptomatic pelvic organ prolapse increased with number of childbirths and were 3.3-fold higher among mothers of 4 than among mothers of 1. Indices of excessive stretching and tearing during labor (vaginal lacerations or episiotomies) were associated with increased risk for symptomatic pelvic organ prolapse. Instrumental delivery with forceps or vacuum did not seem to increase the risk of symptomatic pelvic organ prolapse, nor did length of delivery or maternal age at time for delivery. Abdominal deliveries appeared to be protective; the age- and parity-adjusted odds ratio of symptomatic pelvic organ prolapse after ≥1 abdominal deliveries was 0.5 (95% CI, 0.3-0.9), relative to women who had had only vaginal deliveries. A positive association with child birth weight in unadjusted analyses disappeared after adjustments for attained age and parity of the mother.

Conclusion

Excessive stretching and tearing and multiple deliveries seem to be the main predisposing obstetric factors for symptomatic pelvic organ prolapse. Abdominal delivery emerged as a comparably strong protective factor.

Section snippets

Material and methods

In a cross-sectional survey investigation 8000 women, who were 30 to 79 years old and residents of Stockholm, were selected randomly from a computerized and continuously updated Swedish Population Register. A validated 5-item questionnaire with a specificity of 94.2% and sensitivity of 66.5% vis-à-vis POP quantification (POPQ) among the nonconsulting female public was mailed to all selected women.²⁰ The response rate was 69%. We identified 454 women who gave self-reports that were consistent

Results

Of 454 cases and 405 control subjects, 344 cases (76%) and 312 control subjects (77%) returned completed questionnaires. Sixty-four women (7.5%) actively declined participation.

Of the 131 participating women who underwent a gynecologic examination, 1 woman (0.8%) had stage 0 prolapse; 29 women (22%) had stage I prolapse; 82 women (62.6%) had stage II prolapse; 16 women (12%) had stage III prolapse, and 3 women (1.5%) had stage IV prolapse. The corresponding stage distribution among the 79

Comment

Our results suggest that manifestations of excessive stretching and tearing during labor are independent risk factors for symptomatic POP. Histories of any rupture (vaginal or anal sphincter tear) or episiotomy were associated with significantly increased odds of having this condition. Instrumental delivery with forceps or vacuum did not seem to increase the risk nor did length of labor or maternal age at delivery. A moderately weak association between infant weight and POP disappeared after an

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Perineal lacerations could lead to substantial morbidities for women. A reliable prediction model for perineal lacerations has the potential to guide the prevention. Although several prediction models have been developed to estimate the risk of perineal lacerations, especially third- and fourth-degree perineal lacerations, the evidence about the model quality and clinical applicability is scarce.
To systematically review and critically appraise the existing prediction models for perineal lacerations.
Seven databases (PubMed, Embase, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, SinoMed, China National Knowledge Infrastructure, and Wanfang Data) were systematically searched from inception to July 2022. Studies that developed prediction models for perineal lacerations or performed external validation of existing models were considered eligible to include in the systematic review. Two reviewers independently conducted data extraction according to the Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies. The risk of bias and the applicability of the included models were assessed with the Prediction Model Risk of Bias Assessment Tool. A narrative synthesis was performed to summarize the characteristics, risk of bias, and performance of existing models.
Of 4345 retrieved studies, 14 studies with 22 prediction models for perineal lacerations were included. The included models mainly aimed to estimate the risk of third- and fourth-degree perineal lacerations. The top five predictors used were operative vaginal birth (72.7 %), parity/previous vaginal birth (63.6 %), race/ethnicity (59.1 %), maternal age (50.0 %), and episiotomy (40.1 %). Internal and external validation was performed in 12 (54.5 %) and seven (31.8 %) models, respectively. 13 studies (92.9 %) assessed model discrimination, with the c-index ranging from 0.636 to 0.830. Seven studies (50.0 %) evaluated the model calibration using the Hosmer–Lemeshow test, Brier score, or calibration curve. The results indicated that most of the models had fairly good calibration. All the included models were at higher risk of bias mainly due to unclear or inappropriate methods for handling missing data and continuous predictors, external validation, and model performance evaluation. Six models (27.3 %) showed low concerns about applicability.
The existing models for perineal lacerations were poorly validated and evaluated, among which only two have the potential for clinical use: one for women undergoing vaginal birth after cesarean delivery, and the other one for all women undergoing vaginal birth. Future studies should focus on robust external validation of existing models and the development of novel models for second-degree perineal laceration.
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Regional Variation and Temporal Trends in Surgery for Pelvic Organ Prolapse in Canada, 2004-2014
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We sought to examine temporal trends in pelvic organ prolapse (POP) surgery in Canada.
In this observational cross-sectional study, we used diagnostic and procedure codes from all hospitalizations and outpatient clinic visits in Canada (excluding Québec) from 2004 to 2014 to identify and analyze data on POP surgery.
There were 204 301 POP surgery visits from 2004 to 2014, and the rate of POP surgery declined from 19.3 to 16.0 per 10 000 women during this period. The rates of “native tissue reconstructive repair” and “hysterectomy without other procedure” declined from 15.0 to 12.8 per 10 000 women and 2.6 to 1.6 per 10 000 women, respectively. The rate of obliteration increased from 0.1 to 0.3 per 10 000 women (all P values for trend <0.01). Mesh procedures increased from 1.6 per 10 000 women in 2004 to 2.4 per 10 000 women in 2007 and 2008, and then declined to 1.3 per 10 000 women in 2014. Reconstructive mesh surgery using an abdominal open approach declined, while laparoscopic procedures increased over the period examined.
The rates of POP surgery declined in Canada between 2004 and 2014. An increase was observed in obliteration procedures and in laparoscopic vaginal suspension and fixation with mesh.
Nous avons cherché à analyser les tendances temporelles en matière de traitement chirurgical du prolapsus des organes pelviens (POP) au Canada.
Dans le cadre de cette étude transversale observationnelle, nous avons utilisé des codes diagnostiques et d'intervention de toutes les hospitalisations et visites en clinique externe au Canada (à l'exception du Québec) de 2004 à 2014 afin de recenser et d'analyser les données sur le traitement chirurgical du POP.
On a dénombré 204 301 visites de traitement chirurgical du POP de 2004 à 2014, et le taux d'intervention pour cette affection est passé de 19,3 à 16,0 par 10 000 femmes au cours de cette période. Les taux de « réparation avec les tissus natifs » et d’ « hystérectomie sans autre intervention » sont passés de 15,0 à 12,8 par 10 000 femmes et de 2,6 à 1,6 par 10 000 femmes, respectivement. Le taux d'oblitération a augmenté, passant de 0,1 à 0,3 par 10 000 femmes (toutes les valeurs P relatives à cette tendance sont inférieures à 0,01). Le taux d'interventions de treillis a augmenté pour passer de 1,6 par 10 000 femmes en 2004 à 2,4 par 10 000 femmes en 2007 et 2008, pour diminuer à 1,3 par 10 000 femmes en 2014. Le taux d'interventions reconstructives de treillis par voie d'abord ouverte abdominale a diminué, tandis que le taux d'interventions laparoscopiques a augmenté au cours de la période examinée.
Le taux de traitement chirurgical du POP a diminué au Canada entre 2004 et 2014. On a constaté une augmentation du nombre d'interventions d'oblitération et de suspension et fixation vaginales laparoscopiques avec treillis.
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Pelvic organ prolapse (POP) is a major health problem that affects many women with potentially severe physical and psychological impact as well as impact on their daily activities, and quality of life. Several surgical techniques have been proposed for the treatment of POP. The FDA has published documents that refer to concerns about the use of synthetic meshes for the treatment of prolapse, in view of the severe complications that may occur. These led to hesitancy in use of these meshes and partial increase in use of other biological grafts such as allografts and xenografts. Although there seems to be an increasing tendency to use grafts in pelvic floor reconstructive procedures due to lower risks of erosion than synthetic meshes, there are inconclusive data to support the routine use of biological grafts in pelvic organ prolapse treatment.
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: Supported by the Vårdal foundation (www.vardal.se).

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General Obstetrics and Gynecology: GynecologyObstetric risk factors for symptomatic prolapse: A population-based approach

Objective

Study design

Results

Conclusion

Section snippets

Material and methods

Results

Comment

Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Lancet

Lancet

Obstet Gynecol

Obstet Gynecol

Eur J Obstet Gynecol Reprod Biol

Am J Obstet Gynecol

J Clin Epidemiol

Am J Obstet Gynecol

Am J Obstet Gynecol

Obstet Gynecol

Eur J Obstet Gynecol Reprod Biol

Eur J Obstet Gynecol Reprod Biol

Am J Obstet Gynecol

General Obstetrics and Gynecology: Gynecology
Obstetric risk factors for symptomatic prolapse: A population-based approach