Skip to main content

2D pelvic floor ultrasound imaging in identifying levator ani muscle trauma agrees highly with 4D ultrasound imaging

Abstract

Introduction and hypothesis

The objective was to evaluate the agreement between 2D and 4D translabial ultrasound (TLUS) technique in showing levator ani muscle (LAM) states after vaginal birth.

Methods

In a prospective observational cohort study between March 2017 and April 2019 we evaluated LAM states (intact, hematoma, partial, complete avulsion) of primiparous women having given birth vaginally with singletons in vertex presentation ≥ 36+0 gestational weeks by using 2D and 4D TLUS within 1–4 days postpartum (assessment A1) and again 6–10 weeks postpartum (assessment A2). Cohen’s Kappa analysis was performed for each side separately to evaluate the test agreement between the two ultrasound techniques at every assessment period.

Results

A total of 224 women participated at A1 and 213 at A2. The agreement between the two ultrasound techniques was good to very good at A1 (Cohen`s kappa right-sided 0.78, left-sided 0.82) and very good at A2 (Cohen`s kappa both sides 0.88). The agreement was best when assessing an intact LAM or a complete avulsion (Cohen`s kappa between 0.78–0.92 for complete avulsions).

Conclusions

The comparison between 2D and 4D TLUS showed a good to very good agreement in LAM trauma immediately after birth as well as 6–10 weeks postpartum. Therefore, 2D ultrasound could also be a valuable method for demonstrating a LAM abnormality and could be used in settings where 3D/4D ultrasound equipment is not available.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

References

  1. Dietz H, Lanzarone V. Levator trauma after vaginal delivery. Obstet Gynecol. 2005;106:707–12.

    Article  Google Scholar 

  2. Dietz HP. Pelvic floor trauma in childbirth. Aust N Z J Obstet Gynaecol. 2013;53(3):220–30.

    Article  Google Scholar 

  3. Albrich S, Laterza R, Skala C, Salvatore S, Koelbl H, Naumann G. Impact of mode of delivery on levator morphology: a prospective observational study with three-dimensional ultrasound early in the postpartum period. BJOG. 2012;119:51–61.

    CAS  Article  Google Scholar 

  4. Schwertner-Tiepelmann N, Thakar R, Sultan AH, Tunn R. Obstetric levator ani muscle injuries: current status. Ultrasound Obstet Gynecol. 2012;39:372–83.

    CAS  Article  Google Scholar 

  5. Horak TA, Guzman-Rojas RA, Shek KL, Dietz HP. Pelvic floor trauma: does the second baby matter? Ultrasound Obstet Gynecol. 2014;44(1):90–4.

    CAS  Article  Google Scholar 

  6. Dietz HP, Simpson JM. Levator trauma is associated with pelvic organ prolapse. BJOG. 2008;115(8):979–84.

    CAS  Article  Google Scholar 

  7. Dietz HP, Schierlitz L. Pelvic floor trauma in childbirth—myth or reality? Aust N Z J Obstet Gynaecol. 2005;45(1):3–11.

    CAS  Article  Google Scholar 

  8. Weemhoff M, Vergeldt TF, Notten K, Serroyen J, Kampschoer PH, Roumen FJ. Avulsion of puborectalis muscle and other risk factors for cystocele recurrence: a 2-year follow-up study. Int Urogynecol J. 2012;23(1):65–71.

    Article  Google Scholar 

  9. Skinner EM, Barnett B, Dietz HP. Psychological consequences of pelvic floor trauma following vaginal birth: a qualitative study from two Australian tertiary maternity units. Arch Women Ment Health. 2018;21(3):341–51.

    Article  Google Scholar 

  10. Skinner EM, Dietz HP. Psychological and somatic sequelae of traumatic vaginal delivery: a literature review. Aust N Z J Obstet Gynaecol. 2015;55(4):309–14.

    Article  Google Scholar 

  11. Kimmich N, Burkhardt T, Kreft M, Zimmermann R. Reducing birth trauma by the implementation of novel monitoring and documentation tools. Acta Obstet Gynecol Scand. 2019;98:1223–6.

    Article  Google Scholar 

  12. Kimmich N. Improving birth attendance by prevention and correct diagnosis of birth trauma. Acta Obstet Gynecol Scand. 2020;99(5):680.

    Article  Google Scholar 

  13. Dietz HP, Shek C. Validity and reproducibility of the digital detection of levator trauma. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(8):1097-1101. https://doi.org/10.1007/s00192-008-0575-1. Erratum in: Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(11):1589.

    CAS  Article  PubMed  Google Scholar 

  14. Kruger JA, Dietz HP, Budgett SC, Dumoulin CL. Comparison between transperineal ultrasound and digital detection of levator ani trauma. Can we improve the odds? Neurourol Urodyn. 2014;33(3):307–11. https://doi.org/10.1002/nau.22386.

    Article  PubMed  Google Scholar 

  15. Kamisan Atan I, Lin S, Dietz HP, Herbison P, Wilson PD, ProLong Study Group. Levator ani muscle avulsion: digital palpation versus tomographic ultrasound imaging. Int J Gynaecol Obstet. 2021;156(2):270–275. https://doi.org/10.1002/ijgo.13721.

    Article  PubMed  Google Scholar 

  16. Lammers K, Kluivers KB, Vierhout ME, Prokop M, Fütterer JJ. Inter- and intraobserver reliability for diagnosing levator ani changes on magnetic resonance imaging. Ultrasound Obstet Gynecol. 2013;42(3):347–52. https://doi.org/10.1002/uog.12462.

    CAS  Article  PubMed  Google Scholar 

  17. Dietz HP, Shek C, Clarke B. Biometry of the pubovisceral muscle and levator hiatus by three-dimensional pelvic floor ultrasound. Ultrasound Obstet Gynecol. 2005;25:580–5.

    CAS  Article  Google Scholar 

  18. Valsky DV, Lipschuetz M, Bord A, et al. Fetal head circumference and length of second stage of labour are risk factors for levator ani muscle injury, diagnosed by 3-dimensional transperineal ultrasound in primiparous women. Am J Obstet Gynecol. 2009;201(91):e1–7.

    Google Scholar 

  19. Dietz HP. Pelvic floor ultrasound: a review. Am J Obstet Gynecol. 2010;202(4):321–34.

    Article  Google Scholar 

  20. Dietz HP, Moegni F, Shek KL. Diagnosis of levator avulsion injury: a comparison of three methods. Ultrasound Obstet Gynecol. 2012;40:693–8.

    CAS  Article  Google Scholar 

  21. Garcia-Mejido JA, Gutierrez-Palomino L, Borrero C, Valdivieso P, Fernandez-Palacin A, Sainz-Bueno JA. Factors that influence the development of avulsion of the levator ani muscle in eutocic deliveries: 3–4D transperineal ultrasound study. J Matern Fetal Neonatal Med. 2016;29(19):3183–6.

    Article  Google Scholar 

  22. Salsi G, Cataneo I, Dodaro G, Rizzo N, Pilu G, Gascón MS, Youseef A. Three-dimensional/four-dimensional transperineal ultrasound: clinical utility and future prospects. Int J Womens Health. 2017;9:643–56.

    Article  Google Scholar 

  23. Notten KJ, Kluivers KB, Futterer JJ, et al. Translabial three-dimensional ultrasonography compared with magnetic resonance imaging in detecting levator ani defects. Obstet Gynecol. 2014;124:1190–7.

    Article  Google Scholar 

  24. Dietz HP, Bernardo MJ, Kirby A, Shek KL. Minimal criteria for the diagnosis of avulsion of the puborectalis muscle by tomographic ultrasound. Int Urogynecol J. 2011;22(6):699–704.

    Article  Google Scholar 

  25. Dietz HP, Shek KL. Levator defects can be detected by 2D translabial ultrasound. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20(7):807–11.

    CAS  Article  Google Scholar 

  26. Zhou M, Du H, Ying T, Shui W, Dou C. Value of high-frequency two-dimensional ultrasound on evaluating puborectalis muscle. Arch Gynecol Obstet. 2020;301(5):1347–52.

    CAS  Article  Google Scholar 

  27. Kreft M, Cai P, Furrer E, Richter A, Zimmermann R, Kimmich N. The evolution of levator ani muscle trauma over the first 9 months after vaginal birth. Int Urogynecol J. 2022. https://doi.org/10.1007/s00192-021-05034-z.

    Article  PubMed  Google Scholar 

  28. Dietz HP, Shek KL. Tomographic ultrasound imaging of the pelvic floor: which levels matter most? Ultrasound Obstet Gynecol. 2009;33(6):698–703.

    CAS  Article  Google Scholar 

  29. Dietz HP, Garnham AP, Guzman RR. Is it necessary to diagnose levator avulsion on pelvic floor muscle contraction? Ultrasound Obstet Gynecol. 2017;49(2):252–6.

    CAS  Article  Google Scholar 

  30. Bland M. An introduction to medical statistics. Oxford: Oxford University Press. 2015; p. 319.

    Google Scholar 

  31. Van Delft K, Thakar R, Shobeiri SA, Sultan AH. Levator hematoma at the attachment zone as an early marker for levator ani muscle avulsion. Ultrasound Obstet Gynecol. 2014;43(2):210–7.

    Article  Google Scholar 

Download references

Funding

The study was supported by GE Healthcare, Zipf, Austria, which provided the ultrasound device (Voluson S10) and probes for the ultrasound examinations during the whole study period. The Heartbay Foundation (Vaduz, Liechtenstein) supported the project financially. The supporters had no role in the planning or implementation of the study, or in the analysis or writing process.

Author information

Authors and Affiliations

Authors

Contributions

M. Kreft: study conception, ultrasound performance, data acquisition and management, manuscript writing; P. Cai: statistical analysis, manuscript editing; E. Furrer: statistical analysis, manuscript editing; A. Richter: data acquisition, manuscript editing; R. Zimmermann: study conception, manuscript editing; N. Kimmich: study conception, ultrasound performance, data acquisition and management, manuscript editing.

Corresponding author

Correspondence to Martina Kreft.

Ethics declarations

Conflicts of interest

None.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Kreft, M., Cai, P., Furrer, E. et al. 2D pelvic floor ultrasound imaging in identifying levator ani muscle trauma agrees highly with 4D ultrasound imaging. Int Urogynecol J (2022). https://doi.org/10.1007/s00192-022-05198-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s00192-022-05198-2

Keywords

  • Avulsion
  • Levator ani
  • Pelvic floor
  • 2D and 4D translabial ultrasound
  • Vaginal birth