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
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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?
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THIS PT GOT….
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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.”
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6 weeks after Delivery
• 3C laceration
• Fecal Urgency
• FI with liquid stool
• Pain with defecation and sitting
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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
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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
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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)
74/86 (86%) 3.3 years 28% continent
23% incontinent to flatus only
49% incontinent of stool
Halverson 2002
(USA)
49/71 (69%) 5.8 years 14% continent
32% incontinent to flatus only
54% incontinent of stool
Bravo Guitierrez 2004
(USA)
130/191 (71%) 10.3 years 6% continent
18% incontinent to flatus only
60% incontinent of solid stool
Trowbridge 2007
(USA)
59/86 (70%) 5.6 years 10% continent
15% incontinent to flatus only
75% incontinent of solid stool
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Was my repair done right?
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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)
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No difference at 3 years
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No difference
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6 Trials
No difference at 3 years for AI
Less fecal urgency in overlap group
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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
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8.2% vs 24.1%
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7.3%, most within 2 weeks
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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
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Perineal body length < 2 cm is risky
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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
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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.
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Granulation tissue and scar tissue causing dyspareunia
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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
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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
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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
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Fistula in Ano
• Drain• Leave open• Seton placement• Bowel History
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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
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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