American Journal of Obstetrics and Gynecology, 2016

The association between maternal age at first

delivery and risk of obstetric trauma
Siti Farihah, 30101407331
Dr. Philip Rahmanou, MD, MRCOG, Dr.
Pembimbing Klinik : dr. Sutrisno, Sp. OG Jessica Caudwell-Hall, MD, Dr. Ixora Kamisan
Ataan, MD, Prof. Hans P. Dietz, PhD
Department of Urogynecology, Sydney Medical School Nepean,
University of Sydney, Penrith, New South Wales, Australia
Abstrak
• Latar Belakang
▫ Semakin bertambahnya usia ibu saat persalinan, ada risiko untuk
meningkatnya trauma obstetri, namun belum ada penelitian khusus
• Tujuan
▫ Menilai hubungan antara pertambahan umur ibu dengan cedera dasar
panggul menggunakan Translabial USG 3/4 D pada wanita primipara yang
kehamilannya aterm
Abstrak
• Metode
▫ Sub-Analisis dari sebuah penelitian intervensi oleh uroginekologis
▫ Semua wanita primipara menjalani pemeriksaan TLUS pre dan post natal
▫ Penilaian berupa Avulsi Levator Ani, Overdistensi Hiatus >25cm, dan
Trauma Sfingter Ani Externa
▫ Faktor-factor seperti penggunaan alat Forceps dan Vakum disertakan dalam
analisis
Abstrak
• Dari 660 wanita :
▫ 375 wanita melakukan persalinan secara pervaginam
▫ 174 wanita mengalami paling tidak satu buat jenis trauma dasar panggul
• Pertambahan usia meningkatkan risiko adanya trauma, dengan odds
ratio 1.064 untuk tiap satu tahun penambahan umur, setelah 18 tahun
(p=0,003)
• Hasil meningkat dengan penggunaan alat, dengan vakum meningkatkan
risiko terjadinya cedera sfingter ani eksterna secara khusus
Abstrak
• Kesimpulan
▫ Adanya peningkatan risiko terjadinya cedera dasar panggul sesuai
bertambahnya umur.
Pendahuluan
• Adanya peningkatan rata-rata umur ibu saat hamil di beberapa negara
berkembang. Pertambahan umur ini menyebabkan risiko terjadinya
gangguan obstetri.
• Belum adanya studi yang meneliti secara prospektif hubungan umur ibu
dan trauma dasar panggul
• Penelitian ini bertujuan untuk menilai hubungan antara bertambahnya
umur ibu dengan cedera dasar panggul pada wanita primipara yang
kehamilannya aterm
Bahan & Metodologi
• Penelitian berlangsung Januari 2007 s/d September 2013, di 2 rumah
sakit tersier Australia
• Peserta menjalani pemeriksaan yang terstandar, USG, serta skoring
Pelvic Organ Prolaps Quantification International Continence Society
• Assesor dilakukan blinding terhadap data klinis
• Semua diagnosis Avulsi Levator, Hiatal Overdistention, serta Cedera
Sfingter Ani Externa berdasarkan USG.
Bahan & Metodologi
• Faktor-faktor yang ikut dianalisis meliputi
▫ Umur Kehamilan
▫ BMI
▫ BBL
▫ Lingkar kepala
▫ Metode persalinan
• Signifikan jika p<0,05
Hasil
Data Hasil
First Gestational Age Recruitment 35,8 (SD 0,75, range 31,6-37,6)
Follow Up Time (498/660) 5 month (SD 2,5, range 1,8-24,3)
Delivery Method SC (112) & VD (375)
Age 30,5 (SD 5,1, range 18,8-42,5)
BMI 27,9 (range 18,0-27,6 kg/m2)
Delivery GA 39,7 (range 36,3-42,2)
Birth Weight 3,41 (2,2-4,7 kg)
Race 80% Caucasian
Instrumental(From 375 women) 269 NVD, 69 VE, 37 Forceps
Dietz, Hans Peter; Pelvic Floor
Muscle Trauma; Expert Rev. Obstet.
Gynecol. 5(4), 479–492 (2010)
Figure 1. Tomographic ultrasound imaging of
the puborectalis muscle:
Complete right sided levator avulsion on
tomographic ultrasound imaging (TUI) of
the puborectalis muscle indicated by
The volume data used for this
representation was acquired translabially
in the midsagittal plane, on pelvic floor
muscle contraction.
Figure 2. Translabial Ultrasound for the
assessment of hiatal dimensions on Valsalva
Hiatal overdistension (microtrauma) as
seen in the midsagittal plane (left, A) and
a rendered volume in the axial plane
(right, B) in a patient with significant
cystocele. (A) The plane of minimal
dimensions is shown byarrows between
symphysis pubis (SP) and the anorectal
angle in the midsagittal plane at
maximum valsalva. (B) The levator hiatus
is outlined by the dotted line. SP =
symphysis pubis, C = cystocele, L = levator
ani, LH = levator hiatus.
Figure 3. Assessment of the external anal
sphincter on Tomographic ultrasound imaging.
A significant external anal sphincter (EAS)
defect is diagnosed in the presence of a
gap in its circumference of >=30 degree in
a least four tomographic ultrasound
imaging (TUI) slices bracketing the EAS.
This defect is indicated by angle
measurements, which are all >30
degrees.
Figure 4. Estimated probability of any major
injury and each type of trauma:
Estimated probability of
A) Any major injury
B) Levator ani avulsion
C) Hiatal over-distension and
D) OASIS, as a function of age for each
mode of vaginal delivery.
Diskusi
• Pertambahan usia meningkatkan risiko adanya trauma, dengan odds
ratio 1.064 untuk tiap satu tahun penambahan umur, setelah 18 tahun
(p=0,003)
• Forceps>Vacuum>Vaginal Delivery dalam menimbulkan trauma.
• Belum dapat diaplikasikan di semua etnis, karena 80% peserta adalah
ras Kaukasia
Diskusi
• Penjelasan yang mungkin atas hubungan umur ibu dan risiko trauma,
adalah berkurangnya elastisitas jaringan lunak
• Penjelasan yang lain adalah berkurangnya densitas tulang, sehingga
menyebabkan fungsi biomekanis os. pubis dan m. puborectalis
terganggu, yang dinamakan “enthesis”
Kesimpulan
• Adanya peningkatan yang signifikan antara cedera dasar panggul
dengan meningkatnya umur ibu, yang berhubungan dengan perubahan
biomekanis jaringan seiring meningkatnya umur.
Critical Appraisal
P I C O

Older Women First Vaginal Delivery Younger Women Pelvic Floor Trauma

In older women patients, does first vaginal delivery compared to younger

women,increasing risk for pelvic floor trauma?
Validity
 Question
Yes Can t tell No
Were there clearly defined groups of patients, similar ✔
in all important ways other than exposure to the
treatment or other causes?

Were treatments/exposures and clinical outcomes  ✔    

measured in the same way for both groups?

Was the assessment of outcomes either objective or  ✔    

blinded to exposure?
Validity
 Question
Yes Can t tell No
Was the follow-up of study patients sufficiently long ✔
for the outcome to occur?

Do the results of the harm study fulfil some of the    ✔  

diagnostic tests for causation?
Importance

How strong is the association between exposure and

outcome, i.e. the estimate of risk? 1,064

How precise is the estimate of risk? P=0,003 

Applicability
 Question
Yes Can t tell No
Is my patient so different from those included in the ✔
study that its results don t apply?

What is my patient s risk of the adverse event/potential

benefit from therapy?
Pelvic Floor Trauma 
What are my patient s preferences, concerns and
expectations from this treatment?
Minimally Trauma 
What alternative treatments are available?
Sectio Caessaria