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Int Urogynecol J (2012) 23:1561–1567

DOI 10.1007/s00192-012-1795-y


The effect of pregnancy on hiatal dimensions and urethral

mobility: an observational study
Ka Lai Shek & Jenny Kruger & Hans Peter Dietz

Received: 17 January 2012 / Accepted: 11 April 2012 / Published online: 15 May 2012
# The International Urogynecological Association 2012

Abstract Conclusion Both hiatal dimensions and urethral mobility

Introduction and hypothesis Childbirth is an established were markedly higher in women in late pregnancy and at
risk factor of pelvic floor dysfunction. The role of pregnan- 4 months after prelabour/1st stage caesarean section com-
cy is, however, not fully understood. This study was pared to nulliparous controls. The hormonal and mechanical
designed to evaluate the potential effect of pregnancy on changes of pregnancy may have an irreversible effect on the
pelvic floor function. The hypothesis was: Pregnancy has no pelvic floor.
effect on urethral mobility and levator hiatal dimensions.
Methods This was a reanalysis of the translabial 3D/4D Keywords Childbirth . Levator hiatus . Pelvic organ
ultrasound volume data of 688 nulliparous pregnant prolapse . Pregnancy . Ultrasound . Urethral mobility
women seen in the late 3rd trimester and again 4 months
postpartum and that of 74 nulliparous, nonpregnant vol-
unteers in previously reported studies. Hiatal dimensions Introduction
and urethral mobility were determined as the outcome
parameters. Multivariate regression analysis was per- Childbirth is an established risk factor of pelvic floor dys-
formed after adjusting for age and BMI between the function [1, 2]. Women with one child were 4.0 times and
pregnant and nonpregnant cohorts. with two, 8.4 times more likely to require hospital admis-
Results Comparison of 3rd trimester data of the pregnant sion for prolapse [1]. While vaginal delivery has been
cohort with that of the nonpregnant nulliparae revealed a shown to confer a higher risk of stress urinary incontinence
27 % and 41 % increase in hiatal area at rest and on Valsalva and pelvic organ prolapse than caesarean section [3, 4], the
and an increase in segmental urethral mobility by 64 % to effect of pregnancy itself on pelvic organ support is not well
91 % in late pregnancy. About 70 % of this difference in studied. In the rat, mean linear stiffness (ability to resist
hiatal dimensions, but virtually identical differences in ure- distension) of the vagina and supportive tissues decreases
thral mobility, were observed when comparing nonpregnant in pregnancy. Four weeks after vaginal delivery, all biome-
controls with women 4 months after prelabour or 1st stage chanical characteristics returned to at least virgin values [5].
caesarean section. These findings suggest maternal tissue adaptation in prepa-
ration for mammalian parturition. In some species, such
adaptation can take rather drastic forms, such as ‘pubioly-
sis’, that is, partial absorption of the os pubis in preparation
K. L. Shek (*) : H. P. Dietz
for childbearing [6]. Work investigating such changes in
Nepean Clinical School, Nepean Hospital, University of Sydney,
Nepean Campus, other mammalian species led to the discovery of relaxin
Sydney, NSW 2750, Australia (described in Stewart, 1984). While the effect of human
e-mail: relaxin on pelvic organ and joint mobility in pregnancy
has not yielded any positive results [7], it seems that women
J. Kruger
Auckland Bioengineering Institute, University of Auckland, in early pregnancy have more mobile pelvic organs than
Auckland, New Zealand age- matched nonpregnant controls [8].
1562 Int Urogynecol J (2012) 23:1561–1567

In order to elucidate the effect of pregnancy on the pelvic the help of proprietary postprocessing software similar to a
floor and pelvic organ support, women should ideally be DICOM viewer (4D View 5.0 and 7.2, GE Kretz Ultra-
assessed before, during, and after pregnancy, but unfortu- sound, Zipf, Austria), and analysis of postnatal datasets
nately there are significant practical problems in implement- had been performed blinded against delivery mode. Blind-
ing such a study design. We have therefore undertaken an ing against pregnancy status was impossible due to the
observational study to evaluate the potential role of preg- presence of the fetal presenting part in the volume data.
nancy on pelvic organ support. This study was designed to Hiatal area and urethral motion profile (UMP), a measure
test the hypothesis ‘Pregnancy has no effect on urethral of urethral mobility, were used as the outcome parameters,
mobility and levator hiatal dimensions’. according to our previously described methodology [9, 15].
Hiatal areas at rest and on Valsalva have been shown to be
associated with symptoms and signs of pelvic organ descent
Methods both in symptomatic and asymptomatic populations [15,
16]. Urethral mobility, in particular midurethral mobility,
This study utilised the data of 688 nulliparous pregnant has been found to be associated with stress urinary inconti-
women who had been seen between 35 to 38 weeks and nence and urodynamic stress incontinence [17].
again 4 months postpartum in the context of two previously Hiatal area was measured at the plane of minimal hiatal
reported studies [9, 10] for re-analysis. Participants had been dimension as defined in the mid-sagittal plane, evident as
recruited from the antenatal clinics of 2 tertiary hospitals in the minimal distance between the hyperechogenic posterior
Sydney. The selection criteria were identical for both stud- aspect of the symphysis pubis and the hyperechogenic an-
ies: singleton pregnancy in cephalic presentation; maternal terior border of the levator ani muscle just posterior to the
age older than 18; and no previous pregnancy more than anorectal muscularis (represented by the oblique white line
20 weeks. Women with incomplete antepartum and postpar- in Fig. 1a). This plane is defined in the mid-sagittal orthog-
tum datasets were excluded from analysis, as were those of onal plane, which then allows representation of exactly this
the intervention arm of one of the two studies [10]. Ultra- cross-section of the volume in the axial plane for measure-
sound volume datasets were compared with those of healthy, ment of hiatal dimensions (Fig. 1b).
nulliparous and nonpregnant volunteers seen in the context For UMP determination the urethral length of each pa-
of two other previously published studies [11, 12]. To eval- tient was digitally traced on 2D ultrasound images in the
uate the effect of pregnancy on pelvic organ support, the midsagittal plane, both at rest and on maximum Valsalva.
study was divided into 2 parts. First, statistical analysis was This traced length was divided into 5 segments with 6
performed between the nonpregnant cohort and the entire equidistant points from Point 1 (bladder neck) to Point 6
pregnant cohort in order to evaluate the mechanical and (external urethral meatus). The vertical (x coordinate) and
hormonal effects of late pregnancy on pelvic organ support. horizontal distances (y coordinate) of the 6 points relative to
Secondly, we compared the ultrasound volume data of the inferoposterior margin of the pubic symphysis were then
women acquired at approximately 4 months after prelabour measured using a semiautomated programme as previously
or 1st stage caesarean section with the nonpregnant cohort described [9]. Urethral mobility was described by vectors of
to estimate irreversible effects of pregnancy. In another movement from rest to maximum Valsalva of these 6 equi-
study comparing hiatal area between 4 months and 2 years distant points using the formula SQRT((xvalsalva − xrest)2 +
after 1st delivery no significant reduction in hiatal area at (yvalsalva − yrest)2). Volume datasets obtained at rest and
2 years was found, suggesting 4 months postpartum should during the most effective Valsalva manoeuvre were used
be a reasonable time to assess the long term effects of for numerical evaluation (Fig. 2).
pregnancy on the pelvic floor [13]. The means of hiatal area at rest and on Valsalva as well as
Statistical analyses were performed after adjusting for segmental urethral mobility were compared between the
age and BMI in multivariate regression analysis. All partic- nulliparous group and the antepartum and postpartum data
ipants had undergone a 3D/4D translabial ultrasound exam- of the pregnant cohort after adjusting for age and BMI.
ination in the supine position after voiding on Valsalva All individual studies had been approved by the local
manoeuvre according to a previously published protocol ethics committee. No ethics approval was sought for re-
[14]. Seven trained researchers performed the scans for the analysis of the data, since its purpose was covered by
4 studies, all trained by and/ or under the supervision of the previous individual approvals. Minitab V. 13 (Minitab Inc.,
senior author for at least 100 cases. The ultrasound devices State College, PA, USA) and SPSS v 17 for Windows (SPSS
and probes used were GE Kretz Voluson 730/730 Expert Inc., Chicago, IL, USA) were used for statistical analysis.
systems (GE Kretztechnik GmbH, Zipf, Austria) with 8– Two sample t tests were used to compare the means of age
4 MHz tranducers. Ultrasound volume datasets obtained on and BMI between the pregnant and non pregnant cohorts
maximum Valsalva manoeuvre were used for analysis with and Chi square test was used for ethnicity. Multivariate
Int Urogynecol J (2012) 23:1561–1567 1563

Fig. 1 The plane of minimal hiatal dimensions, defined as the minimal the right image is identical to the horizontal line on the left, both
distance between the posterior aspect of the symphysis pubis and the representing the midsagittal minimal hiatal diameter. Hiatal area was
hyperechogenic anterior border of the levator ani muscle just posterior measured in the axial plane shown in (b), see dotted line . S 0
to the anorectal angle, as represented by the oblique line in the mid- Symphysis pubis, U 0 urethra, A 0 anal canal, R 0 rectum, L 0 Levator
sagittal plane on the left (a). Representation of this cross-section of the ani muscle, B 0 bladder, V 0 vagina
volume is shown in the axial plane on the right (b). The vertical line in

regression analysis was used to compare the means of hiatal compared to the nonpregnant controls. The ethnic composi-
areas and segmental urethral mobility adjusting for age and tion was comparable (93 % vs 95 % were Caucasian, P00.55).
BMI between the 2 cohorts. A P<0.05 was considered For the first part of the study, comparison of the 3rd
statistically significant. trimester data of the pregnant cohort with that of the non-
pregnant nulliparae revealed a 27 % increase in hiatal area at
rest (15.11 cm2 vs 11.90 cm2) and 41 % increase in hiatal
area on Valsalva (21.55 cm2 vs 15.31 cm2). There was also a
Results generalised increase in segmental urethral mobility by 0.67
to 1.01 cm corresponding to 64 % to 91 % increase in late
Out of 688 datasets of pregnant cohorts, the ultrasound pregnancy (Tables 2 and 3).
volume data of 393 were analysed after excluding 175 For the second part of the study we compared 105 wom-
who did not attend follow-up, 93 who were part of an en after prelabour or 1st stage caesarean section with 63
intervention arm which may confound results, and in 27 nonpregnant controls in order to study the irreversible effect
cases data was missing (Table 1). The pregnant cohort was of pregnancy on the pelvic floor (see Table 1). The ethnic
on average older (27 years vs 23.2 years, P<0.001) and had composition was comparable (85 % vs 92 % were Cauca-
a higher pre-pregnant BMI (25.2 vs 23.4, P < 0.001) as sian). The median postpartum follow up interval was

Fig. 2 Translabial ultrasound images in the mid-sagittal plane at rest mobility vector of Point 1 is calculated using the formula SQRT
(Left) and on Valsalva (Right). The urethra was traced from the bladder ((xvalsalva − xrest)2 + (yvalsalva − yrest)2). Similar measurments and
neck (Point 1) to the external urethral meatus (Point 6). The vertical (x) calculations are performed for Point 2 to 6 to determine the mobility
and horizontal distances (y) of Point 1 relative to the posterior inferior vectors. S 0 Symphysis pubis, B 0 bladder, V 0 vagina, R 0 rectum, L
margin of the pubic bone at rest and on Valsalva are shown. The 0 Levator ani muscle
1564 Int Urogynecol J (2012) 23:1561–1567

Table 1 Breakdown of populations for the assessment of pregnancy effect on the pelvic floor and pelvic organ support

4.1 months (Interquartile range 3.7-5.2 months) for the was observed when comparing nonpregnant controls with
pregnant cohort.Thirty-four of them were breastfeeding at women after caesarean section (3.20 vs 2.24 cm2 for difference
follow up (33 %). Urethral mobility and hiatal dimensions in mean hiatal area at rest and 6.24 vs 4.25 cm2 for difference in
were not statistically different between those who breastfed mean hiatal area on Valsalva, see Tables 2 and 4). Urethral
and those who did not (all P>0.09). Seventy percent of the mobility, however, was much higher in women after elective/
difference in hiatal dimensions seen during late 3rd trimester prelabor caesarean section compared to nonpregnant women

Table 2 Hiatal dimensions at rest and on Valsalva in nonpregnant and were obtained in an unadjusted analysis. Data are mean (± standard
pregnant cohorts in late 3rd trimester. *Estimates from multivariate deviation) in cm or cm2 unless specified otherwise. The two sample t
regression model that adjusts for BMI and age. Very similar results test was used for analysis

Nulliparous Late 3rd trimester Estimate for 95 % Confidence interval for P

(n063) (n0393) difference* difference* value*

Midsagittal diameter rest 4.64 (±0.68) 5.47 (±0.72) −0.72 ±0.19 <0.001
Transverse diameter rest 3.62 (±0.45) 3.96 (±0.47) −0.30 ±0.13 <0.001
Hiatal area at rest 11.90 (±2.3) 15.10 (±3.2) −2.64 ±0.83 <0.001
Midsagittal diameter on Valsalva 4.91 (±0.89) 6.34 (±1.16) −1.29 ±0.31 <0.001
Transverse diameter on Valsalva 4.04 (±0.55) 4.47 (±0.60) −0.39 ±0.16 <0.001
Hiatal area on Valsalva 15.31 (±5.35) 21.55 (±6.67) −5.40 ±1.76 <0.001
Int Urogynecol J (2012) 23:1561–1567 1565

Table 3 Segmental urethral mobility in nonpregnant and pregnant obtained in an unadjusted analysis. Data are mean (±standard devia-
cohorts in the late third trimester. *Estimates from multivariate regres- tion) in cm unless specified otherwise. The two sample t test was used
sion model that adjusts for BMI and age. Very similar results were for analysis

Nulliparous Late 3rd trimester Estimate for 95 % Confidence interval for P

(n063) (n0393) difference* difference* value*

Point 1 (Bladder neck) 1.58 (±0.86) 2.59 (±0.97) −0.96 ±0.26 <0.001
Point 2 1.39 (±0.70) 2.32 (±0.83) −0.90 ±0.22 <0.001
Point 3 1.17 (±0.57) 2.06 (±0.70) −0.86 ±0.19 <0.001
Point 4 0.96 (±0.48) 1.78 (±0.58) −0.79 ±0.16 <0.001
Point 5 0.81 (±0.43) 1.55 (±0.52) −0.70 ±0.14 <0.001
Point 6 (External urethral meatus) 0.80 (±0.45) 1.47 (±0.52) −0.64 ±0.15 <0.001

(difference in mean segmental urethral mobility ranged collagen production and reorganization, while stimulating
between 0.81 to 1.01 cm) , and this difference was similar to increased collagen degradation [24]. This anti-fibrotic effect
the one observed between nonpregnant and pregnant cohorts may impair the ability of the pelvic floor to repair itself in
(difference in mean segmental urethral mobility ranged the post-partum period, thereby resulting in pelvic floor
between 0.67 to 1.01 cm, see Tables 3 and 5). Similar results dysfunction [25]. In view of the heated debate surrounding
were obtained after adjusting for BMI and age. caesarean section on patient request, research into the effects
of pregnancy itself (rather than delivery mode) should have
a high priority. Clearly, caesarean section may be able to
Discussion prevent delivery-related pelvic floor damage, but it will not
influence irreversible effects of pregnancy itself.
The mechanical and hormonal effects of pregnancy may In this observational study a 27 % and 41 % increase in
induce biomechanical, neurological or neuromuscular hiatal area at rest and on Valsalva were observed in the late
changes to the pelvic floor and pelvic organ supports [18, 3rd trimester as compared to a nonpregnant cohort. There
19] and may contribute to pelvic floor dysfunction, inde- was also a generalised increase in segmental urethral mobil-
pendent of delivery mode. Weidner et al. have demonstrated ity (64 %–91 % for different urethral segments) in late
that pregnancy has a negative effect on the electromyo- pregnancy, suggesting a very substantial mechanical and/or
graphic activity of the urethral rhabdosphincter. This may hormonal effect of pregnancy on the pelvic floor. Lack of
imply a negative effect of pregnancy on the neuromuscular early pregnancy data in this study precludes an evaluation of
integrity of the urethral sphincter [20]. Progesterone recep- the relative contribution of hormonal and mechanical factors
tors have been demonstrated in the pelvic floor muscle and on the observed changes. However a significant increase in
urogenital ligaments [21]. It is plausible that progesterone, a bladder neck mobility on Valsalva in early pregnancy has
smooth muscle relaxant [22], may alter the biomechanical been reported by one of the authors in the past, using a
properties of pelvic floor structures that contain a significant similar (if less sophisticated) methodology: vertical bladder
amount of smooth muscle fibres among the connective neck mobility was found to be 17.6 mm in age matched
tissue making up the bulk of the structures [23]. Relaxin, nonpregnant control; 21.3 mm between 10–17 weeks and
another reproductive hormone, has been shown to limit 22.8 mm between 32–39 weeks [8]. This data agrees well

Table 4 Hiatal dimensions at rest and on Valsalva in nonpregnant and obtained in an unadjusted analysis. Data are mean (± standard devia-
post- caesarean delivery cohort. *Estimates from multivariate regres- tion) in cm or cm2 unless specified otherwise. The two sample t test
sion model that adjusts for BMI and age. Very similar results were was used for analysis

Nulliparous Post Caesarean section Estimate for 95 % Confidence interval for P

(n063) (n0105) difference* difference* value*

Midsagittal diameter at rest 4.64 (±0.68) 5.16 (±0.75) −0.26 ±0.26 0.04
Transverse diameter at rest 3.62 (±0.45) 3.94 (±0.48) −0.29 ±0.17 0.001
Hiatal area at rest 11.93 (±2.32) 14.17 (±3.04) −1.32 ±1.01 0.01
Midsagittal diameter on Valsalva 4.91 (±0.89) 5.82 (±0.99) −0.54 ±0.34 0.002
Transverse diameter on Valsalva 4.04 (±0.55) 4.42 (±0.65) −0.28 ±0.23 0.02
Hiatal area on Valsalva 15.31 (±5.35) 19.56 (±6.28) −2.37 ±2.15 0.03
1566 Int Urogynecol J (2012) 23:1561–1567

Table 5 Segmental urethral mobility in nonpregnant and post- caesar- unadjusted analysis. Data are mean (±standard deviation) in cm unless
ean delivery cohorts. *Estimates from multivariate regression model specified otherwise. The two sample t test was used for analysis
that adjusts for BMI and age. Very similar results were obtained in an

Nulliparous Post Caesarean section Estimate for 95 % Confidence interval for P

(n063) (n0105) difference* difference* value*

Point 1 (Bladder neck) 1.58 (±0.86) 2.59 (±0.92) −1.04 ±0.32 <0.001
Point 2 1.39 (±0.70) 2.32 (±0.77) −0.94 ±0.28 <0.001
Point 3 1.17 (±0.57) 2.05 (±0.64) −0.86 ±0.22 <0.001
Point 4 0.96 (±0.48) 1.79 (±0.52) −0.79 ±0.18 <0.001
Point 5 0.81 (±0.43) 1.62 (±0.48) −0.73 ±0.17 <0.001
Point 6 (External urethral meatus) 0.80 (±0.45) 1.63 (±0.54) −0.76 ±0.19 <0.001

with the results of the current study showing total bladder parity [29]. Furthermore our findings are in concordance
neck mobility of 15.8 mm in nonpregnant women and with epidemiological studies showing that caesarean
25.9 mm in late gestation. section is not completely protective against stress uri-
Wijma et al. have observed widening of the angle of the nary incontinence [3]. The difference in the effect of
urethro-vesical junction during pregnancy on Valsalva from pregnancy and vaginal delivery on urethral support [9]
76.6 degrees at 12–16 weeks to 83.6 degrees at 28–32 weeks and levator ani muscle [27] may be a possible explana-
to 84.9 degrees at term compared to 73.5 degrees in the tion for the difference between the epidemiology of
nonpregnant control group [26]. These observations of a stress urinary incontinence and pelvic organ prolapse
substantial increase in bladder neck mobility in early preg- [3, 30].
nancy may imply that the effects of pregnancy hormones on To date there is limited data in the literature regarding the
pelvic floor function may be more important than mechan- effect of pregnancy on pelvic organ support. This observa-
ical effects due to the enlarging uterus. Future studies should tional study has added to our knowledge. Despite the
assess the effect of pregnancy on pelvic organ mobility by absence of power calculations due to the retrospective study
recruiting nonpregnant women and following them through design, it clearly had sufficient power. To adjust for poten-
gestation. Such a study design may also allow elucidation of tial confounders age and BMI were adjusted in multivariate
a possible link between changes in pelvic organ support on analysis showing consistent results. It is however acknowl-
the one hand and luteal and /or placental hormones on the edged that such a study design has obvious methodological
other hand. Such work may even have potential therapeutic weaknesses in that unknown confounders may not be
implications. adjusted for. Furthermore its retrospective design is also a
Our comparison of nulliparous women with a post- weakness. Optimally, a study assessing the effect of preg-
caesarean section cohort revealed that about 70 % of the nancy on the pelvic floor should recruit nonpregnant women
pregnancy-related increase in hiatal distensibility is retained and follow them through gestation. Lastly, as most partic-
at a median follow-up of 4 months postpartum. These find- ipants were Caucasian, our findings may not be applicable
ings suggest that pregnancy may have a permanent effect on to other ethnic groups.
pelvic floor structures, independent of delivery mode. While In conclusion, this study compared data of nulliparous
caesarean section may protect a woman from levator trauma controls, pregnant women in the late 3rd trimester, and
secondary to vaginal delivery as demonstrated previously women after a prelabour/1st stage caesarean section. Both
[27, 28] it may not be protective against such irreversible hiatal dimensions and urethral mobility were markedly
effects of pregnancy on the pelvic floor. higher in late pregnancy compared to nulliparous controls.
While about 30 % of the effect of late pregnancy on Seventy percent of this difference in hiatal dimensions was
hiatal dimensions was reversible, this was not the case still observed when comparing nonpregnant controls with
for segmental urethral mobility. The marked increase women after caesarean section, which may suggest both a
observed for segmental urethral mobility in late gesta- reversible and an irreversible effect of pregnancy on hiatal
tion was found to persist in women after caesarean dimensions. The marked differences in urethral mobility
section. These findings suggest that the effect of preg- observed on comparing nonpregnant nulliparae with women
nancy on urethral support may be irreversible. Future seen in the 3rd trimester, however, persist when comparing
studies should determine whether such effects of preg- nulliparae with women after caesarean section, suggesting
nancy may be cumulative, as suggested by a previously that the effect of pregnancy on urethral support may be
observed association between bladder neck mobility and irreversible.
Int Urogynecol J (2012) 23:1561–1567 1567

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