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Prevalence of high-grade perineal tear during labor in Mexican adolescents/ Prevalencia de desgarro de alto grado en parto de adolescentes mexicanas.

Introduction

It is estimated that the birth rate in adolescents (range from 15 to 19 years) is 49 per 1,000 inhabitants, which corresponds to 11% of the worldwide births (1), of which 90% occur in low-and middle-income countries (2). Mexico is the country with the highest prevalence rate of teenage pregnancies among the Organization for Economic Cooperation and Development (OECD) members (3) and is considered one of the countries with the highest rate of pregnancies in this age group (1). In 2015, there were 405,876 pregnancies in adolescents aged 15 to 18 in Mexico, representing 18.2% of all births in the country (4). The importance of adolescent pregnancy lies in the fact that it represents a risk factor for complications for the mother-product binomial (2). The risk for the newborn is premature age (<37 weeks), low birth weight, and APGAR score <7 (5-7). Furthermore, for adolescent women there is an increased risk of obstetric complications, among which are preeclampsia-eclampsia, postpartum hemorrhage, puerperal endometritis, systemic infections, increased use of episiotomy and perineal tears during delivery, the latter being the most frequent obstetric injury (7-9).

Primiparity is recognized as a risk factor for perineal tears (10), since up to 73% of primiparous women develop moderate perineal tears, and 1% to 19% of vaginal births occur with sphincter laceration, thus involving third or fourth degree tears. Another factor is a high BMI, as this increases the risk of macrosomia and instrumented delivery (110, that has a greater risk, whether forceps or vacuum extraction are used (12). Regarding the episiotomy, its performance during delivery increases the number of severe perineal tears, being mediolateral technique the least damaging (13). Specifically, in adolescent delivery, risk factors for perineal tears have been documented: primiparity, fetal position, gestational diabetes (which requires insulin for glucose control), and duration of the second stage of labor (14).

It is estimated that third- and fourth-degree tears occur in 0.8% of all vaginal deliveries in Mexico (15). Likewise, obstetric anal sphincter injuries are associated with short and long-term sequelae, mainly anal incontinence, rectovaginal fistulas, wound dehiscence, and abscess formation, which affect physically and psychologically patients (11,16-18). In addition, fistulas and fecal incontinence (19,20) are mostly due to inadequate reconstruction of the anal sphincter, which is associated with medico-legal problems and increased health care costs (21).

The objective of this study is to determine the prevalence of third-and fourth-degree tears in teenage deliveries and in the general population of a public tertiary level hospital in Monterrey, Mexico. In addition, to determine if it is a risk for the development of high-grade perineal tears. Furthermore, to assess whether adolescence is related to risk factors for delivery-related perineal tears compared to deliveries in adult women, who developed high-grade perineal tears,

Materials and Methods

This is an observational and analytic study.

Sample

We reviewed the records of women with vaginal obstetric care (January 1st-December 31st, 2014) in the High Specialty Maternal-Child Hospital (Hospital Materno-Infantil at Monterrey, Mexico), which is a reference center that provides general and specialty obstetric care in the Northeast of Mexico. All cases were reviewed, but only cases with third- and fourth-degree tears were considered because of the anal sphincter involvement. Cases with presentations other than cephalic, multiple pregnancies, cesarean birth or premature delivery (<36 weeks of gestation) were excluded. From these cases, the following data was documented: delivery, episiotomy, weight of the product, mother's body mass index at the time of delivery and parity of the patient.

Statistical analysis

Age cut-off value was set at 19 years old, considering adolescents those patients under 19 years old. The adult women (<19 old) population in the sample was used for comparison (SygmaPlot; Systat v. 12). Prevalence was calculated relative to the total number of vaginal deliveries for the study period. Data is presented as number and percentage or median and range where appropriate. To determine risk association, the unmatched odds ratio was calculated. The Fisher exact test and Mann-Whitney U test were used to compare qualitative variables and quantitative variables. Statistical significance was considered for p [less than or equal to] 0.05.

Ethical aspects

This study was approved by the Investigation and Ethics Committee (IRB) of both the Hospital and the Medical School. All data was collected anonymously. The information gathered for the study was for exclusive research purposes and only the researchers involved had access.

Results

During 2014, 13,882 births were cared for at the hospital during 2014. Of these, 8,847 were vaginal deliveries, 27% in adolescents (2,404 deliveries). A total of 179 cases of patients with third- and fourth-degree tears were identified, for a general prevalence of 2.0% during the study year. Adolescents accounted for 60 cases (33.5%), for a prevalence of 2.5% of tears in this age group (Fig. 1), higher than the prevalence of adult women (1.84%). The risk of high-grade tears was higher in adolescent deliveries in contrast to the births in adult women (OR= 1.36, 95% CI= 0.99-1.86, p= 0.05).

Table 1 shows the results of the comparison of risk factors in deliveries with high-grade tear in adolescents versus adults. No significant difference was found when comparing the collected variables.

Discussion

In this study, a higher prevalence of high-grade perineal tears during delivery in the general population was found compared to that previously reported of 0.8% (15). This last work converged the experience of 21 centers in Mexico, representing a greater and more diverse sample. However, in five of these centers, third- and fourth-degree obstetric lacerations were not reported, which could imply a report bias (under reporting). As a possible explanation for the higher prevalence in our sample, is important to emphasize that the information is based on a single center. In addition, it may represent a selection bias since it is a reference unit for obstetric care of high complex cases for the population with public health services in the northeast of the country. We propose studies to allow for a better characterization of the differences between the prevalence and risk factors of obstetric perineal lacerations within the several regions of our country.

There are few studies where adolescent age is considered a risk factor for the development of high-grade tears. In the literature review carried out for the preparation of this manuscript, no studies were found that determined adolescent delivery as a risk factor for the Mexican population for this kind of pathology. Experiences in other populations supports adolescence as a risk factor for this complication (22), although some evidence suggest otherwise (15,23,24).

As a limitation of this work, it was not possible to perform an analysis where adolescence was determined as an independent risk factor for the development of high-grade tears during labor. In addition, although the result is statistically significant, the confidence interval of the crude odds ratio is very wide and is below unity. Even so, the data suggest that it is a group prone to this pathology and we encourage clinicians to be alert during the obstetric vaginal care of this age group to try to prevent this complication.

Conclusions

In adolescent population, there is a higher prevalence of tears during vaginal delivery compared to adult women, and that reported in other studies in the Mexican population. The differences in the prevalence found compared to previous publications could be related to underreporting or selection bias. Likewise, the data suggest that adolescence could be a risk factor for high-grade tears. It is important to highlight the limited literature on perineal tears focused on the adolescent and Mexican population. The practical implications of these findings are to recognize adolescents as a vulnerable group for the development of high-grade perineal tears during delivery. Hence justifying the development of programs focused on decreasing the prevalence of high-grade perineal tears during vaginal obstetric care in our population, with special emphasis on adolescents.

Article history:

Received: 09 August 2017

Revised: 19 November 2018

Accepted: 10 December 2018

DOI: 10.25100/cm.49i4.3515

References

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Maria Teresa Sanchez-Avila, Marisol Galvan-Caudillo, Jaime Javier Cantu-Pompa, Natalia Vazquez-Romero, Jhanea Patricia MartinezLopez, Victor Manuel Matias-Barrios, Abryl Mariana Avitia-Herrera, Luis Alonso Morales-Garza, Claudia Eugenia Hernandez- Escobar, Gonzalo Soto-Fuenzalida, Maria Teresa Gonzalez-Garza

Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Departamento de Ciencias Clinicas. Monterrey, Nuevo Leon, Mexico

Corresponding Author

Maria Teresa Sanchez-Avila. Av. Eugenio Garza Sada 2501 sur Col. Tecnologico C.P. 64849. Monterrey, Nuevo Leon, Mexico. Phone. +52 (81) 8358-2000 E-mail: mariat_sanchez@tec.mx

Caption: Figure 1. Flow chart of case selection
Table 1. Comparison of patients with high-grade tears with variables
of interest

                                      Patients groups

Variables           Adolescent        Adult ([greater       General
                    (<19 years old)         than or      population
                                       equal to] 19       with high-
                                          years old)     grade tears

Cases               60 (33.5%)           119 (66.5%)      179 (100%)
Age                 17 (14-18)            22 (19-40)      20 (14-40)
Primiparity         56 (93.3%)            83 (69.7%)     139 (77.7%)
Instrumental        48 (80.0%)            88 (74.0%)     136 (76.0%)
delivery
Episiotomy
realization
BMI                 25.13                       25.89           25.61
                    (17.80-39.43)      (18.90-48.39)    (17.80-48.39)
Product weigh (g)   3,390                       3,270           3,300
                    (2,230-4,060)      (2,250-4,390)    (2,230-4,390)
3rd degree tears    54 (90.0%)           108 (90.8%)      162(90.5%)
4th degree tears    6 (10.0%)              11 (9.2%)       17 (9.5%)
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Title Annotation:Original article
Author:Sanchez-Avila, Maria Teresa; Galvan-Caudillo, Marisol; Cantu-Pompa, Jaime Javier; Vazquez-Romero, Na
Publication:Colombia Medica
Date:Oct 1, 2018
Words:2389
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