Prevention of pelvic floor Dysfunctions in peri-partum women.
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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 7,5 %
4,5% 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%
1er trimestry 13%
2ème trimestry 18%
3ème 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 anRCT
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%
pRCT
Per Partum rehabilitation vs Placebo
REILLY,
Br J Obstet Gynecol 2002
Etude Anglaise
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% pRCT
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)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 2ème phase active (n = 67)
2ème 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 = 0,02Risk 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 2001SUI 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 pC-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 césarienneC - 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] NSPregnancy effect - 1 ?
WILSON, Br J Obstet Gynecol 1996
50
30
Taux IUE (%)
10
-10
1 2 3
Voie basse 24,5 34,3 37,7
Césarienne 5,2 23,3 38,9
Nombre d'accouchementPregnancy 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” (5ème, 7ème et 9ème mois)
Rééducation standard
Suivi à 1 ans et 6 ans (n = 516, 69%)
Efficacité à 1 an 69% vs 60% pImmediate 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, 1997Specific aims and ways of intervention
Field of reeducation Aims Ways
Pelvic floor 1) Prevention of UI and FI 1) Education, Booklet
2) Education 2) Perineal care
3) ↓ perineal pain 3) Ice, U/S, Pulsed electromagnetic
energy
4) Getting the knack 4) Education
5) Strengthening the PFM 5) Contractions of the PFM with and
without its synergists
Abdominal muscles 1) Stengthening the abdominal transverse 1) Contractions of abdominal transverse
2) Strengthening the abdominal muscles 2) Electrotherapy
3) ↓ abdominal pain (cesarean section) 3) TENS
Pelvis/Spine 1) Restore spine and pelvis static and Ergonomic advice, Pelvis posterior
dynamic tilt, Strengthening hip abd/adductors
General 1) ↑ blood flow 1) Massage, Active/Passive movements
2) Check constipation 2) Education, Fibers, Hydratation
3) Check abdominal respiration 3) Breathing, Abdominal transverse
ANAES, 2002; Chiarelli, 2003;Boissière,
1980; Aubard, 1988; Boissière, 1978;
Lecoutour, 1984; Gasquet, 1988; Grant,
1989; Davies, 1982; Smith, 1986;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 movement
ANAES, 2002; andLaFoy,
Boissière, 1980; 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 Ways
1) ↓ perineal pain 1) Cold therapy, PFM contractions
2) ↑ PFM strength 2) PFM trainig programme, BFB,
vaginal cones
3) Coordination of the knack 3) Education
4) ↓ UI and FI 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, 1997Long term reeducation
Abdominal muscles Aspect
Specific aims Ways
1) ↓ cicatricial abdominal pain 1) TENS, Massage
2) ↑ abdominal muscles 2) Abdominal muscles
strength training of the
transverse, internal and
external oblique and
rectus abdominis
3) Abdominal competence 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, 2002Long term reeducation
Pelvis/Spine aspect
Specific aims Ways
1) ↓ pelvis and spinal pain 1)↓ stress on ligaments and joints
Massage, Electrotherapy, Manual
therapy, Physical training programme,
Proprioception, Pelvic belt
2) Improve pelvis and 2) Strengthening abdominal, hip, trunk
spine static and extensors muscles, Proprioception,
dynamic Massage, Education, Ergonomic
advices
3) ↓ physical disability 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,2004Conclusion
- 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
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