盆底三维超声观察不同分娩方式对初产女性盆膈裂孔的影响

Effects of different patterns of first delivery on pelvic diaphragm hiatus by transperineal three-dimensional ultrasound

目的采用经会阴盆底实时三维超声观察不同分娩方式的女性产后盆膈裂孔解剖结构的重塑状态。方法选取定期行产前检查并分娩的单胎初产妇82例,于产后6～12周行经会阴盆底三维超声检查。其中阴道分娩组55例,又分为自然分娩组(n=44)和产钳分娩组(n=11);剖宫产分娩组27例。观察各组妇女的盆膈裂孔形态结构及特征,测量其在静息、Valsalva动作和缩肛动作3种状态下的盆膈裂孔参数及膀胱颈最大移动度。结果经会阴盆底三维超声图像显示,产后妇女的盆膈裂孔两侧耻骨直肠肌结构较模糊,部分产妇单侧或双侧耻骨直肠肌从耻骨联合处撕脱。盆膈裂孔内的结构模糊,部分可观察到膀胱回声图像。在缩肛动作状态下,阴道分娩组产妇盆膈裂孔各参数明显大于剖宫产组(P<0.05);而静息和Valsalva动作状态下,两组产后盆膈裂孔各参数基本一致(P>0.05);阴道分娩组的膀胱颈最大移动度明显大于剖宫产组[(15.3±3.8)mmvs(11.7±3.6)mm](P<0.01)。自然分娩组和产钳分娩组的产后盆膈裂孔各参数比较差异无统计学意义(P>0.05);但产钳分娩组的膀胱颈最大移动度明显大于阴道自然分娩组[(21.2±2.9)mmvs(16.1±3.0)mm](P<0.01)。结论不同分娩方式妇女产褥早期静息和Valsalva动作时盆膈裂孔大小无明显差异。阴道分娩妇女缩肛动作时盆膈裂孔明显增大;产钳分娩妇女的膀胱颈最大移动度较其他分娩方式的妇女明显增大,与产后压力性尿失禁有关。

Objective To observe the morphological characteristics of pelvic diaphragm hiatus in postpartum women with different first delivery patterns by transperineal three-dimensional ultrasound. Methods Eighty-two postpartum women were selected,and transperineal three-dimensional ultrasound examinations were performed 6 to 12 weeks after delivery.Fifty-five cases underwent transvaginal delivery(transvaginal delivery group),and the other 27 Cesarean delivery(Cesarean delivery group).Cases in transvaginal delivery group were subdivided into spontaneous transvaginal delivery group(n=44) and forceps transvaginal delivery group(n=11).The morphological characteristics of pelvic diaphragm hiatus in each group were observed,and the parameters of pelvic diaphragm hiatus and maximum bladder neck mobility were measured at rest,with Valsalva maneuver and pelvic floor contraction,respectively. Results Transperineal three-dimensional ultrasound demonstrated that the structure of puborectal muscles on both sides of pelvic diaphragm hiatus was vague,and unilateral and bilateral puborectal muscle avulsion was observed in some cases.The structure inside pelvic diaphragm hiatus was vague,and bladder echo was observed in some cases.With pelvic floor contraction,the parameters of pelvic diaphragm hiatus in transvaginal delivery group were significantly larger than those in Cesarean delivery group(P<0.05).At rest and with Valsalva maneuver,there was no significant difference in the parameters of pelvic diaphragm hiatus between transvaginal delivery group and Cesarean delivery group(P>0.05).The maximum bladder neck mobility in transvaginal delivery group was significantly larger than that in Cesarean delivery group [(15.3±3.8)mm) vs(11.7±3.6)mm](P<0.01).There was no significant difference in the parameters of pelvic diaphragm hiatus between spontaneous transvaginal delivery group and forceps transvaginal delivery group(P>0.05),while the maximum bladder neck mobility in forceps transvaginal delivery group was significantly larger than that in spontaneous transvaginal delivery group [(21.2±2.9)mm vs(16.1±3.0)mm](P<0.01). Conclusion The diameters of pelvic diaphragm hiatus are similar in postpartum women with different delivery patterns at rest and with Valsalva maneuver.Transvaginal delivery may be associated with a significantly larger pelvic diaphragm hiatus with pelvic floor contraction,and forceps transvaginal delivery may lead to a greater degree of bladder neck mobility,which may be related to postpartum stress urinary incontinence.