3C OR NOT TO SEE? SHOULD CONSULTANTPRESENCE BE MANDATORY FOR ALL OBSTETRIC ANAL SPHINCTER INJURIESINVOLVING THE INTERNAL ANAL SPHINCTER?
K. WONG, V. ANDREWS;
Obstetricand Gynaecology, Univ. Hosp. Lewisham, London, United Kingdom.
Introduction: 3c obstetric analsphincter injuries (OASIs) occur when both the internal and externalanal sphincter (EAS) are torn. 3c tears can have an impact on qualityof life due to the associated defecatory symptoms. Symptoms are worsewhen compared to those where the damage involves the EAS only1.The extent of residual anal sphincter defects is associated with thedegree of anal incontinence 2. Research investigatingwhether the level of operator experience has an impact on outcomefollowing a primary repair of OASIs is conflicting 2,3.However, these studies did not differentiate between women sustaininginternal sphincter damage from those where only the EAS was torn. Wetherefore aimed to establish the impact of consultant presence at thetime of repair of 3c OASIs.
Objective: To evaluate theincidence of anal sphincter residual defects, and symptoms followinga primary repair of a 3c tear; and to compare the outcome dependingon whether a consultant obstetrician was present at the time ofrepair or not.
Methods: All women sustaining OASIs areoffered an appointment following delivery where they have astructured interview and a 3D endoanal ultrasound performed. All datawas collected prospectively.
Results: 133 women were seenover a two-year period. Fourteen (11%) women had a 3c tear. Five(36%)reported anal incontinence symptoms (Table 1). Women were more likelyto be asymptomatic when the repair was supervised by a consultant(75% vs 50%). Residual anal sphincter defects on endoanal ultrasoundwere found in six (43%) cases (Table 2). Residual defects were lesscommon when repair was supervised by a consultant (25% vs66.7%).
Conclusions: Three times more women had a defect onultrasound when a consultant was not present at the time of repair ofa 3c tear. There was a 25% reduction in anal incontinence symptomswhen a consultant was present. Individual obstetric units shouldaudit both consultant presence and the outcome for women sustainingOASIs when the internal anal sphincter is involved. This should formthe basis for unit guidelines.
References: 1. "Inconclusion, after primary repair of OASIS women who had sustained aGrade 3c/fourth-degree tear had a poorer outcome than did those whohad sustained a Grade 3a/3b tear." 2." Residual defects ofthe EAS and levator avulsion were independently associated withsignificant symptoms of anal incontinence as quantified using theSMIS.""There was a significantly higher incidence ofresidual EAS defects on ultrasound in women whose repair wasundertaken/supervised by consultants (54% vs 35%, P=0.04)" 3."five of nine women (56%) with an endosonographic sphincterdefectscore 8 or more had undergone primary sphincter repair by adoctor in training vs. nine of 39 women (23%) with an endosonographicsphincter score less than 8 (P = 0.05)".