Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : June | Volume : 17 | Issue : 6 | Page : QC07 - QC11 Full Version

Detection of Occult Anal Sphincter Injuries in Primipara by 2D Transperineal Ultrasound and its Clinical Association: A Cohort Study


Published: June 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/60487.17985
Sakshi Tanwar, Sandhya Jain, Shalini Rajaram, Anupama Tandon, Bindiya Gupta, Kanika Kalra

1. Senior Resident, Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India. 2. Professor, Department of Obstetrics and Gynaecology, University College of Medical Sciences and GTB Hospital, University of Delhi, Delhi, India. 3. Director Professor, Department of Obstetrics and Gynaecology, University College of Medical Sciences and GTB Hospital, University of Delhi, Delhi, India. 4. Director Professor, Department of Radiodiagnosis, University College of Medical Sciences and GTB Hospital, University of Delhi, Delhi, India. 5. Professor, Department of Obstetrics and Gynaecology, University College of Medical Sciences and GTB Hospital, University of Delhi, Delhi, India. 6. Junior Resident, Department of Obstetrics and Gynaecology, University College of Medical Sciences and GTB Hospital, University of Delhi, Delhi, India.

Correspondence Address :
Dr. Sandhya Jain,
Professor, Department of Obstetrics and Gynaecology, UCMS and GTB Hospital, Dilshad Garden, Delhi-110095, India.
E-mail: drsandy2015@gmail.com

Abstract

Introduction: Endoanal Ultrasound (EAUS), the gold standard for the detection of occult Obstetric Anal Sphincter Injuries (OASI) has limited clinical application due to its intrusiveness and need for specialised equipment and personnel. A 2D Transperineal Ultrasound (TPU) is simple, non invasive and shows a high degree of agreement with EAUS. Few studies have evaluated the use of 2D TPU in determining the incidence and clinical outcomes of occult OASI in primigravida.

Aim: To study the incidence, risk factors, and clinical outcome of occult obstetric anal sphincter injury using 2D TPU in primigravida.

Materials and Methods: The present cohort study was conducted in the Department of Obstetrics and Gynaecology in collaboration with the Department of Radiology at Guru Teg Bahadur Hospital, Delhi, India, from November 2018 to April 2020. A total of 200 low risk primigravida ≥36 weeks period of gestation underwent baseline TPU of the anal sphincter complex antenatally and on day 2 postpartum. On the basis of difference between pre and postdelivery measurements, they were divided into group I (n=91): women with occult OASI {(diagnosed as thinning of the internal and External Anal Sphincter (EAS), interruption in the anal sphincter, alteration in mucosa and half-moon sign)} and group II (n=109): no OASI. Group I was followed at two and six weeks postpartum with TPU and clinical tests were applied at six weeks to assess clinical outcomes of sphincter injury. Data was analysed using Chi-square test/Fisher’s-exact test for qualitative parameters, Analysis of Variance (ANOVA) for comparison of predelivery and postpartum measurements; and multiple logistic regression for determining sphincter injury determinants.

Results: Incidence of occult OASI was 91/200 (45.5%). Significant risk factors for OASI were lower baseline thickness of anal sphincter, position of baby (p=0.028), longer duration of second stage of labour (p<0.001), greater length and angle of episiotomy (p<0.001) and greater baby weight (p=0.042). Group I had significantly lower pelvic floor muscle strength testing score (p<0.001), Digital Rectal Examination Scoring System (DRESS) resting (p=0.013) and squeeze scores (p=0.008), weaker muscle contraction (p<0.001), reduced anal sphincter tone, and was more clinically symptomatic at six weeks postpartum.

Conclusion: The technique of 2D TPU is simple and feasible to detect OASI. Women, who sustain OASI, can be followed-up in perineal clinic more meticulously, using TPU for pelvic floor rehabilitation.

Keywords

Delivery, Episiotomy, Incontinence, Pelvic floor

Perineal injuries are extremely common during childbirth. Occult injuries to the anal sphincter, which are often not recognisable, on routine clinical examination, can be seen in as many as 35-41% of primiparous women undergoing vaginal birth, of which about 5% manifest clinically (1),(2). These injuries can have late onset consequences like faecal incontinence, flatulence, dyspareunia, etc., and affects every aspect of a woman’s life. An inadequate repair after delivery, increases the chances of further damage during subsequent deliveries (3). Hence, early recognition and prompt management strategies are essential to achieve effective functional outcomes. Clinical examination is often not sufficient to detect occult injuries immediately after delivery and the reported range of missed tears ranges from 26-87% (4). This warrants the use of ultrasonographic techniques for early detection and subsequent monitoring of women, who sustain anal sphincter injuries during childbirth.

The EAUS is considered the gold standard technique for the assessment of anal sphincter complex (5),(6),(7). However, the limited availability of equipment and trained personnel, the invasive nature of the technique, and discomfort to the patient, particularly in immediate postpartum preclude its routine use. The insertion of the ultrasound probe into the anal canal may distort the normal anatomy, precluding dynamic evaluation of the anal sphincter and mucosa on sphincter contraction, which seems to enhance the definition of the muscular defect (8). The technique of TPU for the study of the anal canal dates back to 1997 but, its use in evaluation of OASI has been under evaluation for a decade or so (Table/Fig 1). The technique shows a high degree of agreement with clinical examination (9) and EAUS (10) for determining the degree of perineal tear after vaginal delivery. The positive and negative predictive value of TPU for OASIs has been estimated to be 91% and 99%, respectively (11) The measurements of the anal sphincter obtained using this technique are reproducible and show high interobserver reliability (12),(13). Given its non invasive nature, ready availability of low cost transducers, and better patient acceptability, TPU appears promising in detecting occult anal injury (8),(14),(15),(16).

Most studies on the utility of TPU in the detection and follow-up of OASI have focussed on 3D and 4D imaging, which allow extensive evaluation along the entire length and breadth of the anal sphincter. However, the availability of these techniques is still limited especially in the Indian scenario. The more readily available transabdominal and transvaginal probes have also been studied in this regard. Ozyurt S et al., screened 201 primigravid women for occult OASI after vaginal delivery and found occult tears in 11.5% of cases. After two months, mild to moderate incontinence (Wexner continence scale) was found in 34.8% of women with occult OASI (1). Timor-Tritsch IE et al., also demonstrated the successful use of transvaginal probes in TPU in the detection of occult OASI to the extent of comparing the quality of imaging to that of Magnetic Resonance Imaging (MRI) (17). Despite this, evidence to date on the use of transvaginal probes for 2D TPU is limited; none in the Indian context. Also, data correlating the findings of 2D TPU with clinical outcomes is sparse. This was a cohort study to determine the risk factors and clinical outcomes of occult anal sphincter injury by 2D TPU using transvaginal probe in primiparous women undergoing vaginal delivery in the Indian scenario.

Material and Methods

The present cohort study was conducted in the Department of Obstetrics and Gynaecology in collaboration with the Department of Radiology at Guru Teg Bahadur Hospital, Delhi, India, from November 2018 to April 2020. The present study was performed in line with the principles of the declaration of Helsinki. Approval was granted by the Institutional Ethical Committee for human research (Dated 26.10.2018/No 36).

Inclusion criteria: Low risk primigravida who underwent vaginal delivery at term were included in the study.

Exclusion criteria: Elderly primigravida (>35 years), women with multifoetal pregnancy, medical disorders such as diabetes, hypertension, cardiac disorders, women who underwent preterm vaginal delivery, still birth and women who suffered third and fourth degree perineal tear were excluded from the study.

Study Procedure

Primigravida at or beyond 36 weeks gestation, who attended the outpatient antenatal clinic in the Department of Obstetrics and Gynaecology at the tertiary care centre were evaluated after obtaining informed and written consent. Antenatal care and delivery were done as per hospital protocol. Socioeconomic status was assessed using Modified Kuppuswamy Scale Consumer Pricing Index 2018 (18).

Antepartum: Patients underwent baseline 2D TPU using a transvaginal probe (7 MHz). It was covered with lubricated condom and kept at 90o on the posterior fourchette and the following structures were visualised:

• Fold of rectal mucosa in the shape of a star.
• Hypoechoic concentric ring of the Internal Anal Sphincter (IAS).
• Hyperechoic ring of the EAS.
• Levator ani appearing as a hammock

Internal and EAS thickness were measured in four quadrants.

Intrapartum: Details of labour patients who underwent vaginal delivery in labour room, were recorded in World Health Organisation (WHO) partogram. Parameters such as details of foetal position and presentation, spontaneous or induced labour, episiotomy angle, and baby weight were noted.

Postpartum: On day 2 postpartum the subjects underwent a repeat scan after the application of 2% lignocaine jelly at local site. The thickness of the external and IAS was measured in four quadrants and the difference between pre and postdelivery values were used to detect thinning of the sphincter.

On the basis of the difference between predelivery and postdelivery measurements, the participants were divided into group I (OASI) (defined as thinning of the internal and EAS, interruption in the internal and EAS, alteration in star shaped mucosal fold and half moon sign) and Group II (no OASI). As the literature doesn’t give any cut-off value for sphincter thickness to define OASI, thinning of more than 0.05 mm on day 2 of postpartum was taken as cases and less than or equal to 0.05 mm as control as it was the median value of 200 subjects. Ultrasound was again repeated for group I at two and six weeks postpartum to follow-up sphincter injury. Furthermore, these subjects were examined at six weeks postpartum in the postnatal clinic and were assessed using the following scores:

• Pelvic Floor Distress Inventory 20 (PFDI 20) (19): It is a composite score of three parameters:
• Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6)
• Colorectal Anal Distress Inventory 8 (CRAD-8)
• Urinary Distress Inventory 6 (UDI-6)

Of the 20 questions in PFDI 20 form, each question response has a yes or no as a potential answers. No response corresponds to a score of 0. If patients answers yes then the response will be based on an ordinal range from 1 to 4 in terms of the bother and severity of the symptoms: 1=not at all; 2=somewhat; 3=moderately; 4=quite a bit.

• Pelvic floor muscle strength testing (oxford grading) (20): The examination was carried out after emptying the bladder in the dorsal position, with the knees semi flexed. Patients were requested to contract the muscles of the pelvic floor lifting up inside, closing of introitus and drawing the anus in and the perineum and labia were observed for any visible contraction, followed by palpation of the vaginal wall with two fingers. A score from 0-5 was given according to the validated Oxford Scale.
• Digital Rectal Examination (DR E) scoring system (21): During DRE separate number was assigned to Resting Pressure (RP) and to maximal Squeeze Pressure (SQ). A score of 3 is normal; a resting score of 5 indicates very high pressures and a tight anal canal, whereas, a score of 0 denotes an open or patulous anal canal at rest with separation of the buttocks. A squeeze score of 5 indicates a very strong squeeze, almost painful to the examiner, while a score of 0 denotes no discernible increase in pressure from rest with maximal patient effort.

Routine pelvic exercises were offered to all women. Study methodology is detailed in the flowchart (Table/Fig 2).

Statistical Analysis

Data was analysed using Statistical Package for Social Sciences (SPSS) version 20. All the qualitative parameters were analysed by Pearson’s Chi-square test and quantitative parameters using repeated Student’s t-test for comparison between two groups and ANOVA for ≥2 groups comparison. Friedman test was applied for comparison of serial measurements of anal sphincter thickness. Multiple logistic regression analysis was used to detect sphincter injury determinants. The p-value of <0.05 was considered significant.

Results

The two groups were comparable with respect to age, Body Mass Index (BMI), educational and socioeconomic status (Table/Fig 3). On review of antenatal sphincter dimensions when the two groups were defined it was observed that during pregnancy mean EAS thickness was significantly less in cases as compared to controls at 12’o clock and 6’o clock position. Whereas, IAS at all four positions i.e. 12, 3, 6, 9’o clock position the thickness was significantly less in cases as compared controls (Table/Fig 4).

Comparison of serial thickness of EAS and IAS in group I are shown in (Table/Fig 5). As compared to baseline thickness of EAS in antenatal period, the EAS became thinner at day 2; however, its thickness remained same subsequently till six weeks, suggesting permanent stretching of muscle fibers. As compared to baseline the IAS became thinner at day 2 postpartum; however, the thickness improved subsequently in all positions, except at 6’o clock position where it reduced further. Apart from thinning, interruption in anal sphincter was observed in 41/91 (45.1%) of cases, half moon sign in 1/91 (1.1%) and alteration in rectal mucosa in 9/91 (9.9%) cases.

Logistic regression analysis of risk factors for occult anal sphincter injury is shown in (Table/Fig 6). The significant risk factors for the occurrence of OASI were length and angle of episiotomy, position of baby, baby weight, duration of the second stage of labour, and instrumental delivery. Various clinical tests that were done and compared between cases and controls at six weeks postpartum are described in (Table/Fig 7). Mean PFDI 20 scores were similar in cases and controls with no statistical difference. Controls had significantly better pelvic floor muscle strength as compared to controls at six weeks postpartum. DRESS resting and squeeze scores were better in controls as compared to cases; although the difference was not statistically significant. Good muscle contraction was seen in 6/91 (6.6%) cases vs 13/109 (11.9%) controls, suggesting greater pelvic floor muscle damage in patients with occult anal sphincter injury. OASI was also seen to be associated with reduced anal sphincter tone in cases as compared to controls.

The most common symptoms experienced by participants in both groups: sense of incomplete evacuation, straining too hard to pass stools, pressure in lower abdomen and heaviness and dullness in pelvic area were significantly more in cases as compared to controls (p<0.001) (Table/Fig 8).

Discussion

2D TPU is largely being studied as a substitute for the more intrusive endo-anal ultrasound for the detection of occult OASIs. The incidence of radiologically diagnosed occult anal sphincter injury in the present study came out to be 45.5% which is in concert with the available literature [1,2]. Both the EAS and IAS thickness reduced significantly from their antepartum values. On serial comparison of postdelivery measurements in women with OASI, the EAS did not seem to recover from the day 2 measurements suggesting permanent stretching and thinning of muscle fibres. Paradoxically, the DRESS squeeze scores were comparable in the two groups at six weeks postpartum. On the other hand, the thickness of IAS gradually improved over six weeks, however still being lesser than the antepartum measurements. Consequentially, these women had reduced anal sphincter tone compared to those who did not sustain OASI. Sticklemann et al., observed that with the natural healing process, it is very probable that the width of third-degree tears and anal incontinence symptoms decrease during the six months after delivery (22). However, in the present study follow-up of the index patients was done only for six weeks. More long term follow-up studies are required to study how OASIs behave over time. Of note is the fact that women with OASI performed poorly on pelvic floor muscle strength testing and PFDI than those who did not. A possible explanation for this is that the factors which play a significant role in the causation of OASI also have damaging effects on the pelvic floor.

In the present study, prolonged duration of the second stage of labour seemed to have an adverse impact on anal sphincter injuries probably due to stretching of sphincter fibres by the head at the perineum. Eventhough, total duration of labour has been shown to be a significant risk factor for OASI in primigravida undergoing vaginal delivery (23), the effect of prolonged second stage of labour is not well studied. In the present study more women who sustained OASI had right occipito anterior position of the baby and lesser number had left occipito-anterior position than those who did not sustain OASI, the difference being statistically significant. Greater baby weights and use of instrumental delivery were also identified to be significant risk factors in incidence of OASIs which has also been confirmed by a meta-analysis. As per available literature, birth weights >4 kg increase the risk of OASI (24) while <4 kg decrease the incidence [25,26]. However, in the present study, the average birth weights were much lesser supporting that perhaps Asian ethnicity is an underlying risk factor for OASI (27). Mediolateral episiotomy has been shown to be protective for OASI [22,28]. The incidence of OASI was similar whether or not an episiotomy was given. However, greater angle and shorter length of episiotomy showed lesser degree of damage to anal sphincter. The above findings could help take timely and accurate decisions to avoid the risk of OASIs especially, in women with history of OASI in prior deliveries. The authors found that, women who sustained OASI had lower thickness of both the external and IASs even in the antenatal period which could explain why some women are at a higher risk of sphincter injuries during childbirth. Till this date, there are no studies on the effect of antenatal thickness of anal sphincter on incidence of OASI. Prior identification of such women could lead to more meticulous delivery practices in this subset of women however, the clinical application of this finding is presumptive and requires more research.

However, the present study is the first ever study to define the baseline thickness of anal sphincter in 200 antenatal women using TPU. It successfully demonstrates the use of TPU in detection of occult OASI in the Indian setting. Further studies correlating the degree of thinning of anal sphincter with symptoms are required to devise appropriate management strategies.

Limitation(s)

The study was conducted only in low risk primigravida at or more than 36 weeks and <35 years of age (inclusion criteria). Thus, the effect of maternal age, prematurity, multifoetal pregnancy, previous vaginal deliveries could not be studied. Due to equipment limitations, 2D transvaginal probe was used to carry out TPU.

Conclusion

The technique of 2D TPU is simple, easily available and feasible to detect OASI. The scope of 2D TPU in identification and monitoring of OASI is ever expanding making it an active area of research. It can be used to identify which injuries are amenable to surgical repair and which by more conservative measures. It could also be useful in objectively defining the anatomical distortions sustained during childbirth which could be helpful in the intraoperative settings. It can be used for prioritising patients who require close follow-up and who do not. If done in the antenatal period, especially in women with prior history of OASI, it could enable meticulous preparation for delivering beforehand or even help in planning the mode of delivery thus, reducing the incidence of OASI. All these practices can actually make childbirth a safe procedure for women without unwanted long lasting consequences.

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DOI and Others

DOI: 10.7860/JCDR/2023/60487.17985

Date of Submission: Sep 27, 2022
Date of Peer Review: Nov 18, 2022
Date of Acceptance: Jan 09, 2023
Date of Publishing: Jun 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Sep 28, 2022
• Manual Googling: Dec 28, 2022
• iThenticate Software: Jan 07, 2023 (10%)

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