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Obstetrics and Gynegology2019№8
Diagnosis of the pelvic floor...

Diagnosis of the pelvic floor microcirculation with laser Doppler flowmetry in reproductive-aged women

DOI
https://dx.doi.org/10.18565/aig.2019.8.160-164

Yashchuk A.G., Musin I.I., Rakhmatullina I.R., Kamalova K.A., Fatkullina I.B.

1) Clinical Site, Bashkir State Medical University, Ufa, Russia; 2) Women health clinic, Ufa, Russia; 3) GBUZ RB “Maternity hospital №3”, Ufa, Russia
Objective. To evaluate the pelvic floor microvascular bed using laser Doppler flowmetry (LDF) in reproductive-aged women.
Subjects and methods. All examinees were divided into 5 groups: 1) women after vaginal delivery (VD); 2) those who had undergone cesarean section (CS); 3) those who had a history of one spontaneous miscarriage at less than 12 weeks’ gestation; 4) those who had a history of two pregnancy losses before 12 weeks’ gestation. LDF readings were once recorded for 30 seconds from 2 points, from the anterior and posterior vaginal walls. To determine normal LDF values, Group 5 (a control group) of apparently healthy women having no history of pregnancies was made up.
Results. The LDF values for anterior vaginal wall blood flow were lower. A substantial decrease in blood flow was recorded in the women after VD and CS. There were no microcirculatory disorders in Group 3. The women with recurrent miscarriage had significantly lower blood flow values.
Conclusion. LDF is a non-invasive technique that can be used to diagnose pelvic floor microcirculatory disorders. A significant blood flow decrease was recorded in women who had undergone BP and CS, which necessitates more detailed monitoring of these patient groups and inclusion of medical methods for pelvic floor restoration into a postpartum rehabilitation program. Women with recurrent miscarriage have significantly lower blood flow values and require that rehabilitation programs that include pharmacological agents and physiotherapeutic procedures aimed at improving pelvic floor microcirculation should be drawn up.

Keywords

laser Doppler flowmetry
pelvic floor microcirculation
diagnosis of pelvic floor microcirculatory disorders

Basic risk factors, which provoke pelvic floor muscles dysfunction development include pregnancy, vaginal delivery, birth trauma, connective tissue dysplasia [1-4]. Due to somatic pathology, metabolic disturbances in pelvic floor tissues lead to pelvic floor muscles dysfunction. The frequency of the disease in women of reproductive age varies from 26% to 63.1% [5]. Nowadays lots of clinical and instrumental methods of evaluation of pelvic floor status exist. In modern clinical practice non-invasive diagnostics of blood microcirculation are of critical importance. The main difficulties in examination of the blood microcirculation are connected with the small size of capillaries and high intraorgan vascular branching. One of the methods is laser Doppler flowmetry (LDF) [6-10]. LDF is successfully used for patient’s blood microcirculation status evaluation in endocrinology, oncology, urology, ophthalmology, gastroenterology, dermatology, dentistry, pediatrics, obstetrics and gynecology and in the group of patients with different cardiovascular and respiratory diseases [11-24].

The purpose of the study is to evaluate pelvic floor blood microcirculation status in women of reproductive age using LDF method.

Materials and Methods

One of the main tasks of the study was to evaluate normal indices of pelvic floor blood flow from anterior and posterior vaginal walls in nulligravidas of reproductive age and indices of pelvic floor blood flow in women after vaginal delivery, cesarean section, one miscarriage and recurrent pregnancy loss.

Women of reproductive age with 1st or 2nd degree of vaginal purity were eligible for inclusion. Women with more than two miscarriages, 3rd or 4th degree of vaginal purity, acute infectious diseases of pelvic organs and acute stage of chronic infectious diseases of pelvic organs, pelvic organ prolapse of stages III-IV according to POP-Q classification, emergency cesarean section, connective tissue dysplasia markers, namely a positive “thumb” test, a positive wrist test, hypermobility of joints.

Informed consent to participate in our research was obtained from all patients. The women of the same were divided into four groups. Group 1 included 33 patients after vaginal delivery at the age of 28.85±4.8 years. Group 2 included 23 patients after cesarean section at the age of 27.38±4.75 years. Group 3 included 24 women with one miscarriage up to 12 weeks of gestation. Mean age in this group was 26.52±4.89 years. Group 4 included 22 women with two miscarriages up to 12 weeks of gestation. Mean age was 29.78±3.37 years. LDF data registration was made once for 30 seconds from two points from anterior and posterior vaginal walls. In order to define normal LDF indices, there was control group 5 which included 21 healthy nulligravidas. Single LDF indices registration from two vaginal points for 30 seconds was made in that group.

All women underwent gynecological examination for pelvic organ prolapse detection, according to POP-Q classification, gynecologic specimens were obtained. All women were tested on connective tissue dysplasia markers.

Postpartum measurements were performed during lactation amenorrhea, two months after vaginal delivery (cesarean section). In women of groups 3, 4 and 5 all measurements were performed in luteal phase of the menstrual cycle.

In order to evaluate pelvic floor blood microcirculation, we used analyzer of blood microcirculation LAKK-01 (Scientific Productive Enterprise “LASMA”, Russia). Method is based on detection of tissue perfusion with blood using Doppler frequency shift measurement, which occurs during tissue sensing with laser ray. Furthermore, rays reflected from tissue compounds are registered. Acquired signal characterizes blood flow in 1.5 mm3 of the tissue. Data registration was made with the help of probe from two points. The 1st point was located in the middle of conditional line, which connected external urethral meatus and cervical canal. The 2nd point was located in the middle of the conditional line, which connected anus and cervical canal. Probe fixation was made with the help of Bunsen’s holder. Obtained data were analyzed using LAKK2_20 software. The following parameters were assessed:

М is the arithmetic mean of the microcirculatory blood perfusion, measured in perfusion units (p.u.). М changes (increase or decrease) characterize perfusion growth or perfusion reduction.

σ is the standard deviation of the blood flow oscillations amplitude from the arithmetic mean of М index. It characterizes perfusion temporal variability and reflects blood flow variability in all frequency ranges. This parameter is measured in p.u.

Kv is variation coefficient, which represents correlation between tissue perfusion value and its variability. Кv=σ/М×100%. The higher is Кv index, the higher is vasomotor activity of microvessels [8, 10].

A total of 246 registrations of LDF indices were conducted.

Statistical processing of results was carried out using Windows 7 operating system, the IBM SPSS Statistics 20 software package. For description of numeric values of sample data with a normal distribution we used sample mean deviation and sample standard deviation. The nature of distribution of quantitative values was calculated with the use of Kolmogorov-Smirnov test. For indices with normal distribution we used methods of parametric statistics (the arithmetic mean and standard error – Student’s criterion, Pirson’s coefficient of linear correlation). For indices without normal distribution, we calculated median. The significance of differences of quantitative indices was evaluated by Mann-Witney criterion, the significance of differences of relative indices was evaluated by χ2 Pirson’s criterion.

Results

Results are based on LDF data analysis in the control group (n=21), which included women with normal pelvic floor anatomy according to POP-Q classification, stages 0-2. The following mean indices were calculated: М of anterior vaginal wall (Мavw) was 19.52±0.53 p.u., М of posterior vaginal wall (Мpvw) was 20.7±1.1 p.u. The standard deviation σ of anterior vaginal wall (σavw) was 3.28±0.36 p.u. The standard deviation σ of posterior vaginal wall (σpvw) was 3.71±0.34 p.u. Variation coeffitient Kv of anterior vaginal wall (Kvavw) was 16.84±0.02%, Kv of posterior vaginal wall (Kvpvw) was 17.93±0.02%.

Due to the absence of data on normal LDF indices from vaginal walls in women of reproductive age in the scientific literature, we accepted LDF indices in women of group 5 as normal (Table).

Discussion

LDF indices obtained from posterior vaginal wall are higher then indices from the anterior vaginal wall.

In the group of women after vaginal delivery, LDF indices are statistically lower than ones in the group of nulligravidas.

In the group of women after cesarean section there was blood flow decrease in comparison with control group. However, these indices are higher than LDF indices in women after vaginal delivery. Obviously, in group 2 there are other mechanisms of blood microcirculation disturbance, they are not connected with the delivery, but they might be connected with the pregnancy course. This fact might be connected with chronic ischemia of muscular, fascial and nervous pelvic structures and increased intraabdominal pressure during pregnancy.

In the group of women with one miscarriage there were no differences in LDF data in comparison with control group.

In the group of women with recurrent pregnancy loss, LDF indices were statistically lower than ones in the control group.

Conclusion

Method of laser Doppler flowmetry is non-invasive, it may be used for pelvic floor blood microcirculation disturbances. LDF indices from posterior vaginal wall are higher than indices from the anterior vaginal wall. Blood flow decrease is registered statistically by LDF data in women after vaginal delivery and cesarean section. These women might need detailed monitoring, postpartum rehabilitation using Kegel’s exercises, pharmacology and physiotherapy aimed at the improvement of pelvic floor blood microcirculation.

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Received 17.05.2018

Accepted 22.06.2018

About the Authors

Yashuk Alfiya G., head of the department of obstetrics and gynecology №2, doctor of medicine, professor of Bashkir State medical university.
Tel.: +7 (917)343-17-15 e-mail: alfiya_galimovna@mail.ru
450008 450008Ufa, city, Lenina 3 street.
Rahmatullina Irina R., professor of the chair of Oncology with the course of oncology and pathologoanatomy of post diploma institution education. Government educational institution of higher professional education, Bashkir State medical university. Tel.: +7(3472)72-41-73 e-mail: rectorat@anrb.ru
450008 Ufa, city, Lenina 3 street.
Musin Ilnur I., pHd, ass. Of Obstetrics and gynaecology chair of Bashkir State medical university №2. Tel.: +7(917)67-10-64 e-mail: ilnur-musin@yandex.ru
450008 Ufa city, Lenina 3 street.
Kamalova Kseniya A., obstetrician-gynecologist, reproductologist «Women health» clinic. Tel.: +7(917)347-75-97 e-mail: kosya1987@yandex.ru
450000 Ufa, city 450000, Kirova 52 street.
Fatkullina Irina B., doctor of medicine, professor of Obstetrics and gynecology chair with IPDO course №2, deputy chief physician on medical part GBIH RB Maternity hospital №3, Tel.: 8-3472-64-96-50, e-mail.: ag2@bashgmu.ru
450065 Ufa, city, Koltsevaya 131 street.

For citation: Yashchuk A.G., Rakhmatullina I.R., Musin I.I., Kamalova K.A., Fatkullina I. B. Diagnosis of the pelvic floor microcirculation with laser Doppler flowmetry in reproductive-aged women.
Akusherstvo i Ginekologiya/Obstetrics and Gynecology. 2019; (8): 160-64 (in Russian)/
http://dx.doi.org/10.18565/aig.2019.8.160-164

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