OBSTETRICAL ANAL SPHINCTER INJURY - RISK FACTORS AND OUTCOME OF SURGICAL REPAIR BY END-TO-END RE-APPROXIMATION TECHNIQUE

摘要

reapproximation technique for its repair. STUDY DESIGN: A prospective observational study. PLACE AND DURATION: Obstetrics and Gynaecology Unit-A, Khyber Teaching Hospital, Peshawar, from 1st January 2011 to 31st December 2013. METHODOLOGY: All patients with obstetrical anal sphincter injury (OASI) i.e. third and fourth degree perineal tears, after vaginal delivery were included. Data including age, parity, labour characteristics, types of delivery, fetal weight, degree of tear, any previous repair, follow up and outcome were recorded. Primary or secondary repair according to the case was done by end-to-end reapproximation technique. Post operative care was standardized, antibiotics, laxative and pelvic floor exercises were advised. Follow up was done at 6 and then 12 weeks. RESULTS: Thirty two patient had OASI, n = 23 (71.87%) had third degree and n= 9(29.13%) had fourth degree perineal tear. Mean age was 26.07 + 1 S.D (range 19-40 years) including 16(50%) primipara, 12(37.50%) P2-P3 and 4(12.50%) P4 or more. Spontaneous vaginal delivery (SVD) in 21(65.63%), SVD with episiotomy in 5(15.62%) while Breech 1 and instrumental delivery in 5(15.62%). The risk factors identified were nulliparity, heavier fetal weight (?3.8kg), instrumental delivery, fetal malposition, extension of episiotomy, induction of labour (IOL), oxytocin use and unattended labour. No risk factor could be identified in 6(18.75% patients, more than one factor was identified in 8 women. Seventeen (53.12%) patients with third degree and n= 9(28.13%) with fourth degree tear had primary repair and 9(28.13%) had secondary repair. At 12 weeks follow up over all n=28(87.75%) women were asymptomatic and continent, 1(3.12%) had faecal urgency, 1(3.12%) continence to flatus on physical exersion, in 2(6.25%) repair was unsuccessful with incontinence to stool & flatus. Minor complication were wound infection 2(6.25%) and dyspariuria in 4(12.50%). CONCLUSION: Obstetrical risk factors commonly associated with anal sphincter tear were nulliparity, instrumental deliveries, heavier fetal weight, malpositions, prolong labour and delivery by unskilled birth attendants. Our practice of end-to-end approximation technique for repair anal sphincter tears was associated with good outcome in terms of anal continence at 6-12 weeks.