Prevention of pelvic floor Dysfunctions in peri-partum women. Needed or luxary F.LUTFALLAH, MD, C.PETTENATI, MD, C.LEBACLE, MD, A. PIGNE, MD, Bruno DEVAL, MD, PhD, Gynécology Departement, Geoffroy St Hilaire, Paris, France. 59 Rue Geoffroy Saint Hilaire PARIS 75.015 Corresponding author: bruno.deval@orange.fr
SUI and PREGNANCY FREQUENCY 30 25 24 % 22 % 20 15 10 4,5% 7,5 % 6 % 5 0 Before During Post-Partum Post-Partum 5 years Pregnancy Pregnancy 3 month ARYA (Am J Obstet Gynecol 2001), HVIDMAN (Int UroGynecol J 2002), VIKTRUP ( Am J Obstet Gynecol 2001) et WIJMA (Br J Obstet Gynecol 2001)
RISK FACTORS OF POST-PARTUM SUI HVIDMAN, Int Uro Gynecol J 2002 Age + Multiparity + Maternal weight + Vomits during pregnancy NS Foetal weight NS SUI before pregnancy ++ SUI during other pregnancies +++
RATE OF PER PARTUM REHABILITATION BO K, Int Urogynecol J 2006 - N = 467 32-36 SA - Answer rate 84% - Rate of SUI 24% - Rate of women, rehabilitation 1 once / week Before pregnancy 7% 1 er trimestry 13% 2 ème trimestry 18% 3 ème trimestry 17% Conclusion : Per partum rehabilitation is not enough realised.
RCT Per Partum rehabilitation vs Placebo WOLDRINGH C, Int Urogynecol J 2006 Etude Hollandaise 264 patientes ayant une IUE pendant la grossesse 3 séances 23-30 SA + 1 séance post-partum + info écrite (n = 112) Vs 152 contrôles Pas de bénéfice de la rééducation à 1 an
RCT Per Partum rehabilitation vs Placebo MORKVED S & BO K, Obstet Gynecol 2003 MORKVED S & BO K, Int Urogynecol J 2004 Etude Norvégienne - 12 séances entre 20 et 36 SA + travail à domicile Taux IUE 20 SA 36 SA 3 mois 145 Rééducations Prénatales 30% 33% 20% vs 144 Contrôles 31% 47% 31% -Pas de conséquence obstétricale de la rééducation - (réduction épisiotomies) p<0,05
RCT Per Partum rehabilitation vs Placebo REILLY, Etude Anglaise Br J Obstet Gynecol 2002 Patientes présentant une hypermobilité cervico-urétrale (groupe à risque) 1 séance / mois > 20 SA (5 à 6 séances) + travail à domicile Taux IUE à 3 mois 120 Rééducations Prénatales 19,2% vs 110 Education simple 32,7% p<0,05 Risque d IUE réduit de 40% (OR = 0,59 (0,37-0,92))
RCT Per Partum rehabilitation vs Placebo LEANZA V, IUGA 2008 Education + rééducation périnéale vs témoins n = 450 (primipares sans IUE avant la grossesse) Rééducation : 8 séances 14 et 36 SA + exercises quotidiens à domicile Rééducation Témoins p n (%) n = 218 n = 220 Fin de grossesse IUE 15 (6,9) 31 (14,1) 0,02 Périnéométrie > 2 174 (79,8) 57 (25,9) <0,001 IUE 9 sem PP 44 (20,2) 88 (40) <0,001 AVB spontané 155 (72,9) 130 (61,4) 0,01 Césarienne 63 (27,2) 90 (37,6) 0,01 Episiotomie 44/155 (28,4) 84/130 (64,8) <0,001 Déchirures 8/155 (5,2) 38/130 (29,2) <0,001 Durée expulsion (min) 20 ±12 32 ±17 <0,001
SUI Post-partum Risk Factors VIKTRUP, Am J Obstet Gynecol 2001 Terme avancé + Siège, jumeaux + Durée de la deuxième phase du travail + Durée des efforts expulsifs + Expression abdominale + Forceps +++ Ventouse NS Episiotomie NS Poids de naissance > 4000 gr +
Risk factors 1 SCHAFFER JI, Am J Obstet Gynecol 2005 n = 128 primipares à terme Comparaison 2 ème phase active (n = 67) 2 ème phase passive (n = 61) Bilan urodynamique à 3 mois du post-partum : - Taux IUE : 16% vs 12% NS - Taux hyperactivité vésicale : 8% vs 16% NS - Premier besoin : 160 vs 202 ml p = 0,02
Risk factors 2 Taux d IUE à 6 mois du post-partum VB Ventouse Forceps César en travail César programmée OR 1 0,75 1,96 0,59 0,38 HUGHES et ABRAMS, Congrès de la IUGA 2001 Taux d IUE persistante 1 ans après l accouchement VB Ventouse Forceps 15 j 7,2% 7% 15,3% 1 an 2,9% 2,8% 11% ARYA, Am J Obstet Gynecol 2001
SUI Risk factors 5 YEARS AFTER Delivrery VIKTRUP, Am J Obstet Gynecol 2001 Histoire de l IUE Risque d IUE à 5 ans - Pas d IUE ni avant, ni pendant, ni à 3 mois 19 % - IUE pendant la grossesse ou dans le post-partum immédiat mais disparition à 3 mois 42 % - IUE pendant la grossesse ou dans le post-partum immédiat et persistance à 3 mois 92 %
SUI Risk factors 10 YEARS AFTER Delivrery ALTMAN D, Obstet Gynecol 2006 Etude de cohorte prospective 304 primipares interrogées après accouchement voie basse Suivi longitudinal pendant 10 ans (81% revues) - Prévalence IUE modérée-sévère : 5/304 2% post-partum 27/229 12% 10 ans p<0,001 - Prévalence IU par urgenturies : 0/304 0% post-partum 31/229 13% 10 ans p<0,001 RR IU à 10 ans : 5,8 (IC 95% : 1,2-33,7) Facteurs de risque IUE à 10 ans : IUE à 9 mois (RR 13) et 5 ans (RR 14) Pas d effet nombre accouchement et autres variables obstétricales
C-section protect the risk of SUI - 1? HUGHES et ABRAMS, Congrès de la IUGA 2000 Etude prospective comparative (non randomisée) IUE à 3 mois 37 césariennes programmées 16 % vs 49 voies basses 31 % Rôle protecteur de la césarienne, mais taux d IUE après césarienne non négligeable...
C-section protect the risk of SUI - 2? Mac LENNAN, Br J Obstet Gynecol 2000 Enquête épidémiologique : 3000 questionnaires Nulliparité Césarienne VB spontanée Forceps RR IUE 1 2,5 3,4 4,3 (NS) (p < 0,05) Réduction du risque d IUE non significatif après césarienne
C - section protect the risk of SUI 3 Cochrane Database - 2003 Césarienne systématique vs VB 3 études (n=2396) A 3 mois Moins d IU si Césarienne RR 0.62 [95% CI 0.4-0.9] A 2 ans Incontinence urinaire RR 8.82 [95% CI 0.6-1.0] NS
Pregnancy effect - 1? WILSON, Br J Obstet Gynecol 1996 50 Taux IUE (%) 30 10-10 1 2 3 Voie basse 24,5 34,3 37,7 Césarienne 5,2 23,3 38,9 Nombre d'accouchement
Pregnancy effect - 2? Risque d IUE 4 ans après le premier accouchement indépendant du mode d accouchement (voie basse, expression, forceps ) Mais 9,5 % de césarienne (n = 29 / 277 voies basses ) FRITEL, Congrès de la SIFUD 2001 Le seul moyen de le prouver serait de réaliser un essai randomisé VB versus César!
Intérêt d une rééducation intensive? n = 747 patientes ayant une IUE à 3 mois du post-partum Randomisation Rééducation intensive (5 ème, 7 ème et 9 ème mois) Rééducation standard Suivi à 1 ans et 6 ans (n = 516, 69%) Efficacité à 1 an 69% vs 60% p<0,05 Efficacité à 6 ans 79% vs 76% NS GLAZENER CM, BMJ 2005
Immediate reeducation following delivery - Start the physiotherapy session 1 to 3 days following delivery - Group session are better than individual session Social contact with other women - Reduce breakdown - Stimulate inactive women and slow down the active one - Common aims of the immediate postpartum reeducation 1) Education on the postpartum care 2) Preventive action on postpartum potential complications ANAES, 2002; Boissière, 1980; Boissière, 1978; Gasquet, 1997
Specific aims and ways of intervention Field of reeducation Aims Ways Pelvic floor Abdominal muscles Pelvis/Spine General 1) Prevention of UI and FI 2) Education 3) perineal pain 4) Getting the knack 5) Strengthening the PFM 1) Stengthening the abdominal transverse 2) Strengthening the abdominal muscles 3) abdominal pain (cesarean section) 1) Restore spine and pelvis static and dynamic 1) blood flow 2) Check constipation 3) Check abdominal respiration ANAES, 2002; Chiarelli, 2003;Boissière, 1980; Aubard, 1988; Boissière, 1978; Lecoutour, 1984; Gasquet, 1988; Grant, 1989; Davies, 1982; Smith, 1986; 1) Education, Booklet 2) Perineal care 3) Ice, U/S, Pulsed electromagnetic energy 4) Education 5) Contractions of the PFM with and without its synergists 1) Contractions of abdominal transverse 2) Electrotherapy 3) TENS Ergonomic advice, Pelvis posterior tilt, Strengthening hip abd/adductors 1) Massage, Active/Passive movements 2) Education, Fibers, Hydratation 3) Breathing, Abdominal transverse
Immediate reeducation Points of agreement: Points of desagreement: - Global reeducation for every women - Abdominal transverse training - Pelvic floor has the priority - Number of contractions of the PFM - Good period for exchange - Keep lying position and low impact activites What does really work? 1) Ice for perineal pain 1) Vasoconstriction which blood flow and metabolic processes 2) Physiotherapist-delivered urinary continence promotion programme 1) UI and constipation 2) PFME and the knack adhesion 3) TENS for abdominal pain resulting from cesarean section 1) Pain associated with cutaneous ANAES, 2002; movement Boissière, 1980; and LaFoy, when general anaesthesia was provided 1989; Hill, 1989; Sengler, 1990; Valancogne, 1993; Lecoutour, 1984; Gasquet, 1997; Outrequin, 1980;
Long term reeducation following delivery (> 3 months) - Doctors manage physical reeducation according to 1) Pelvic floor disorders 1) Perineal pain and painful intercourse 2) Weakness of the PFM 3) UI or FI 4) Lack of coordination of the knack 2) Abdominal muscles disorders 1) Painful abdominal scar 2) Weakness of the abdominal muscles 3) Pelvis/spine disorders 1) Pelvic or spinal pain 2) Pelvic or spinal static problems - Individual and specific physiotherapist sessions - Common aims during the long term postpartum reeducation 1) Return to physical, social and professional activities 2) Curative care, NO esthetic objective ANAES, 2002; Boissière 1980; Aubard, 1988; Valancogne, 1993;
Long term reeducation Pelvic floor Aspect Specific aims 1) perineal pain 2) PFM strength 3) Coordination of the knack 4) UI and FI Ways 1) Cold therapy, PFM contractions 2) PFM trainig programme, BFB, vaginal cones 3) Education 4) PFM training programme What does really work? 1) 3 to 4 sets of 8-12 contractions, high resistance, close to maximum, three times/week 2) Verbal instructions are insufficient for PFME 3) With a PFM training programme: PFM strength, UI and FI 4) The success of PFME depends on: Frequency, Intensity, Home training 5) PFME are better than ES or vaginal cones 6) Combination of diverse ways ANAES, 2002; Boissière, 1980; Lecoutour, 1984; Cotelle-Bernède, 1989; Morkved, 2000; Morkved, 2003; Peeker, 2003; Sandler, 1999; Meyer, 2001; Morkved, 1996; Morkved, 1997
Long term reeducation Abdominal muscles Aspect Specific aims Ways 1) cicatricial abdominal pain 2) abdominal muscles strength 3) Abdominal competence 1) TENS, Massage 2) Abdominal muscles training of the transverse, internal and external oblique and rectus abdominis 3) The knack What does really work? 1) Few studies about abdominal muscles reeducation 2) Physiologic synergy between pelvic floor and abdominal muscles 3) No intra-abdominal increase pressure 4) Caufriez, 2002 designed an abdominal muscles training programme 1) perineal tone of 50% 2) waist size of 6% 3) Strength of abdominal muscles? ANAES, 2002; Boissière, 1980; Gasquet, 1997; Fatton, 1999; Sengler, 1990; Caufriez, 2002
Long term reeducation Pelvis/Spine aspect Specific aims 1) pelvis and spinal pain 2) Improve pelvis and spine static and dynamic 3) physical disability Ways 1) stress on ligaments and joints Massage, Electrotherapy, Manual therapy, Physical training programme, Proprioception, Pelvic belt 2) Strengthening abdominal, hip, trunk extensors muscles, Proprioception, Massage, Education, Ergonomic advices 3) pain and strengthening programme What does really work? 1) Few studies about this subjet 2) Pelvic belt restricted sacroiliac movement 3) Active modalities, Stabilisation program ANAES, 2002; Boissière, 1980; Lecoutour, 1984; Vleeming, 1992; Mens, 2000; Stuge,2004
Conclusion - Postpartum reeducation should begin as early as possible and... Is a Life time continuum - Prevention and treatment of various disorders - Interaction of PFM, abdominal muscles and Pelvis/Spine - Postpartum physical therapy has been used for many decades - Evidence based medecine research is a must - How to evaluate abdominal/pelvic floor muscles strength - Long term effects of postpartum reeducation on UI, FI, prolapse, pain, diastasis, posture - Effect of postpartum reeducation on the second delivery and postnatal physical disorders