Franziska Siafarikas

• Siafarikas, Franziska; Benth, Jurate Saltyte; Stær-Jensen, Jette; Reimers, C.; Bø, Kari & Engh, Anna Marie Ellström (2026). Levator hiatus area from 21 weeks' gestation to 8 years after first delivery according to vaginal parity: prospective cohort study with an 8‐year recall extension. Ultrasound in Obstetrics and Gynecology. ISSN 0960-7692. 68(2), s. 273–283. doi: 10.1002/uog.70278. Fulltekst i vitenarkiv Vis sammendrag

  Objectives The first aim was to describe longitudinal changes in levator hiatus area from 21 weeks' gestation in the first pregnancy to 1 and 8 years after first delivery, according to subsequent vaginal parity in women with vaginal delivery or Cesarean section (CS) at first delivery. The second aim was to assess the effect of subsequent vaginal delivery on levator hiatus area after first vaginal delivery. Methods In this prospective cohort study with an 8‐year recall extension, 183 initially nulliparous women underwent three‐ and four‐dimensional transperineal ultrasound examination at 21 weeks' gestation and 1 and 8 years after first delivery. The levator hiatus area at rest, during maximum pelvic floor muscle contraction and during maximum Valsalva maneuver was assessed at each timepoint. Participants with multiple vaginal deliveries (vaginal multiparae), only one vaginal delivery (vaginal primiparae), CS for all deliveries and vaginal birth after CS were compared. The differences between study groups in levator hiatus area over time were assessed using a linear mixed model. Results Overall, vaginal multiparae showed a statistically significant non‐linear increase in levator hiatus area from 21 weeks' gestation to 8 years after first delivery ( P  < 0.001). In contrast, participants who delivered exclusively by CS showed a decrease in levator hiatus area from 21 weeks' gestation to the 8‐year follow‐up. Subsequent vaginal delivery after an initial vaginal delivery did not affect the levator hiatus area during Valsalva maneuver. At the 1‐year and 8‐year follow‐up after the first vaginal delivery, levator hiatus area at rest remained unchanged in vaginal multiparae but decreased in vaginal primiparae. At the 8‐year follow‐up, vaginal multiparae had a larger hiatus area during pelvic floor muscle contraction than did vaginal primiparae. Conclusions In this study, the levator hiatus area was influenced by the mode of the first delivery and by subsequent vaginal deliveries. Overall, the levator hiatus area increased from 21 weeks' gestation to 8 years in participants with at least one vaginal delivery and decreased in those who delivered exclusively by CS. Subsequent vaginal delivery after a first did not seem to affect the levator hiatus area measured during Valsalva maneuver. © 2026 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

• Risløkken, Jeanette; Macedo, Marthe Dalevoll; Bø, Kari; Engh, Anna Marie Ellström & Siafarikas, Franziska (2026). Occurrence of wound infections after perineal tears and perineal assessment in postpartum care: A prospective cohort study. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. doi: 10.1111/aogs.70262. Fulltekst i vitenarkiv Vis sammendrag

  Abstract Introduction There is considerable variation in reported perineal wound infection occurrences and limited knowledge of postpartum follow‐up for perineal injuries. The primary aim of this study was to assess the occurrence of symptoms of perineal wound infections and infections requiring medical intervention within the first 30 days postpartum. The secondary aim was to investigate perineal assessment by healthcare providers in postpartum care. Material and Methods This single‐center cohort study was conducted between October 2020 and October 2022. In this analysis, participants with perineal tears and episiotomies following vaginal deliveries were included. Women were contacted via telephone seven to 10 days postpartum and asked about symptoms for infection recommended by the “Surgical Site Infection Surveillance Service.” At 3 months postpartum, participants reported via questionnaire on receiving medical interventions for wound infection and whether a healthcare provider inspected their perineal tear. Results The study sample comprises a total of 748 primi‐ and multiparous women (58.3% primipara, 41.7% multipara). Sixteen participants (2.2%) reported wound infection symptoms. Wound infections requiring medical interventions were identified in seven women (1.1%), all of whom were primipara. This included five cases with an episiotomy and two cases with a second‐degree tear. Half of the participants had their perineal tear inspected during the 6‐week follow‐up visit. Depending on tear category, between 25% and 72% of women who did not undergo an inspection would have preferred one. Conclusions In our population, symptoms of perineal wound infection were 2.2% and infections requiring medical intervention were 1.1%. Half of the participants received a perineal tear inspection at the 6‐week follow‐up visit.

• Grindheim, Sindre; Siafarikas, Franziska; Volløyhaug, Ingrid; Kessler, Jørg & Baghestan, Elham (2026). Pelvic floor symptoms one year postpartum following forceps and vacuum deliveries: Impact of levator ani muscle avulsion. American Journal of Obstetrics and Gynecology. ISSN 0002-9378. 234(6), s. 1629–1638. doi: 10.1016/j.ajog.2026.02.018. Fulltekst i vitenarkiv Vis sammendrag

  Background: Pelvic floor symptoms, such as vaginal bulge and stress urinary incontinence, are closely linked to vaginal delivery, especially assisted vaginal delivery. Also, levator avulsion, which might occur during vaginal delivery, increases the risk for pelvic floor dysfunction. However, the isolated impact of forceps or vacuum in women with and without avulsion is still not well understood. Objective: We aimed to determine if the presence of vaginal bulge symptoms and urinary incontinence one year postpartum differed between different vaginal delivery modes accounting for levator ani muscle avulsion. Additionally, we aimed to assess the overall presence and bother of pelvic floor dysfunction across different delivery modes. Study design: This is a cross-sectional analysis of Bergen Birth study, a prospective observational cohort study comparing maternal and neonatal outcomes after forceps, vacuum and spontaneous vaginal delivery. Primiparous women with a singleton vaginal delivery at term between June 2021 and April 2023 were eligible. Exposure was defined as delivery mode (spontaneous vaginal-, vacuum-, or forceps delivery). They later underwent a transperineal ultrasound examination for assessment of levator avulsion and answered the Pelvic floor distress inventory-20 (PFDI-20) for grading of pelvic floor symptoms 9-12 months post- partum. Primary outcomes were defined as the presence of vaginal bulge symptoms, stress urinary incontinence, and urge urinary incontinence on the PFDI-20 questionnaire with the degree of bother graded as “somewhat” or higher. Multiple logistic regression analysis was performed to compare the odds of vaginal bulge symptoms, stress urinary incontinence and urgency urinary incontinence between different modes of delivery. Age, BMI and self-reported pre-pregnancy urinary dysfunction were adjusted for as potential confounders. Non-parametric tests were used to compare the PFDI -20 sum score between different delivery modes. Results: For this study, 699 women were available for analysis, 238 had forceps, 238 had vacuum and 223 had a spontaneous vaginal delivery. A total of 142/699 (20.3%) had levator avulsion. Vaginal bulge symptoms were present among 10 (4.5%), 19 (8.0%), and 37 (15.6%) of women after spontaneous, vacuum assisted, and forceps assisted delivery respectively. Women who underwent forceps delivery had an adjusted odds- ratio (aOR) of 3.21 (95%CI: 1.56-7.14) of reporting bulge symptoms one year postpartum compared to women with spontaneous deliveries and aOR: 1.87 (95%CI: 1.02-3.49) compared to women with vacuum delivery. In contrast, vacuum delivery was not associated with bulge symptoms compared to spontaneous delivery (aOR:1.74, 95%CI: 0.80-4.02). In the subgroup analysis of women with intact levator ani, the difference between forceps and vacuum was not significant (aOR: 1.59, 95%CI: 0.74-3.47). No association was found between mode of delivery and stress- or urgency urinary incontinence. Levator avulsion was associated with more bulge symptoms (aOR:3.58, 95% CI: 2.06-6.18) and urgency urinary incontinence (aOR: 2.00, 95% CI: 1.11-3.51). Median PFDI-20 score was statistically higher in the forceps group compared to the vacuum and spontaneous vaginal delivery groups (25.0 vs 18.2, p= 0.03 and 25.0 vs 16.7, p= 0.02 respectively). Conclusion: Forceps delivery increased the odds of vaginal bulge symptoms one year after delivery compared to both vacuum and spontaneous birth. In women with no levator ani muscle avulsion, we found no difference between the instruments. A higher PFDI-20 score indicates greater symptom burden after forceps delivery, which seems to be mediated through the presence of levator ani avulsion.

• Macedo, Marthe Dalevoll; Lilleberg, Hanne Sether; Risløkken, Jeanette; Benth, Jurate Saltyte; Engh, Anna Marie Ellström & Siafarikas, Franziska (2025). Prevalence and Risk Factors for Vaginal Flatus From Mid-Pregnancy to 12 Months Postpartum: A Longitudinal Cohort Study. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 133(3), s. 487–494. doi: 10.1111/1471-0528.70063. Fulltekst i vitenarkiv Vis sammendrag

  Objective To assess the prevalence of and trend in bothersome vaginal flatus from mid-pregnancy to 12 months postpartum, according to vaginal parity. The secondary objective was to assess differences in pelvic floor anatomy as risk factors for bothersome flatus at 12 months postpartum. Design Longitudinal cohort study. Setting Akershus University Hospital, Norway. Sample 880 women with vaginal births. Methods Participants completed questionnaires in mid-pregnancy, at 3 and 12 months postpartum, and attended a gynaecological examination including ultrasound at 12 months postpartum. Parity was classified as primipara, secundipara, or multipara (no, one, or ≥ 2 previous vaginal births, respectively). A generalised linear mixed model and logistic regression models were used for analysis. Main Outcome Measures Bothersome vaginal flatus, defined as responding “often” or “always” to the question “Are you bothered by sounds caused by air escaping from the vagina?” Results The prevalence of bothersome flatus in mid-pregnancy, at 3 and 12 months postpartum was: primiparas: 0.7%, 4.0%, and 2.5%; secundiparas: 2.3%, 4.4%, and 7.3%; multiparas: 5.4%, 3.0%, and 7.1%, respectively. Compared to primiparas, multiparas had higher odds in pregnancy (OR 14.0, 95% CI 1.8–108.1), and both secundi- and multiparas had higher odds at 12 months postpartum (OR 4.8, 95% CI 1.3–17.6, and OR 6.4, 95% CI 1.1–38.6, respectively). Independent risk factors for bothersome flatus included levator avulsion (aOR 3.6, 95% CI 1.5–8.7), a larger genital hiatus (aOR 2.0, 95% CI 1.2–3.3), and a shorter perineal body (aOR 0.8, 95% CI 0.6–1.0). Conclusion Parity and differences in pelvic floor anatomy affect the odds for bothersome vaginal flatus during the first postpartum year.

• Grindheim, Sindre; Volløyhaug, Ingrid; Siafarikas, Franziska; Kessler, Jørg & Baghestan, Elham (2025). Impact of delivery indication on levator ani muscle avulsion in forceps- and vacuum-assisted deliveries: prospective cohort study. Ultrasound in Obstetrics and Gynecology. ISSN 0960-7692. 66(6), s. 795–804. doi: 10.1002/uog.70094. Fulltekst i vitenarkiv
• Lilleberg, Hanne Sether; Siafarikas, Franziska; Starck, Marianne; Rotstein, Emilia; Bø, Kari & Engh, Anna Marie Ellström (2025). Perineal Body Anatomy in Primiparas Assessed by Three-Dimensional Endovaginal and Endoanal Ultrasound: A Reliability Study. International Urogynecology Journal. ISSN 0937-3462. doi: 10.1007/s00192-025-06379-5. Fulltekst i vitenarkiv Vis sammendrag

  Abstract Introduction and Hypothesis The integrity of the perineal body (PB) is essential for pelvic floor function. Anatomical deviations in the PB anatomy after childbirth can lead to pelvic floor symptoms, but the reliability of ultrasound assessments for these deviations is unclear. This study evaluates the intra- and inter-rater reliability of detecting deviations in the muscles fusing into the PB and measuring its size using three-dimensional endovaginal (3D EVUS) and endoanal ultrasound (3D EAUS) 1 year postpartum. Methods Forty primiparous women underwent 3D EVUS and 3D EAUS 1 year after birth. The transverse perineal, puboperinealis, and puboanalis muscles were identified where they fuse into the PB. Deviations were defined as discontinuities in or absence of muscle fibers on the right, left, or center. Measurements of PB height, length, and area were taken in the mid-sagittal plane. Intra- and inter-rater reliability for muscle deviations were assessed using percentage agreement and Cohen’s kappa, while PB size measurements were evaluated using the intra-class correlation coefficient. Results Kappa values indicated excellent intra- and inter-rater reliability for the transverse perineal muscle ( κ = 0.881, κ = 0.871) and puboperinealis muscle ( κ = 0.849, κ = 0.810) in 3D EVUS. For the puboanalis muscle, intra-rater reliability was excellent ( κ = 1.00) and inter-rater reliability was good ( κ = 0.658). Similar kappa values were found using 3D EAUS. Percentage agreement for deviations ranged from 90% to 100% for both ultrasound methods. PB measurement also showed good to excellent reliability: 0.76-0.97 for 3D EVUS and 0.90–0.99 for 3D EAUS. Conclusion 3D EVUS and 3D EAUS are reliable methods for assessing PB muscle deviations and its size 1 year postpartum.

• Lilleberg, Hanne Sether; Siafarikas, Franziska; Bø, Kari & Engh, Anna Marie Ellström (2025). Severity of perineal tears and deviations in perineal body anatomy: A three‐dimensional ultrasound study. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. doi: 10.1111/aogs.70114. Fulltekst i vitenarkiv Vis sammendrag

  Abstract Introduction Perineal tears are classified into four degrees based on severity. Second‐degree tears, which involve the muscles fusing into the perineal body, but not the anal sphincter, vary in extent and have recently been subcategorized. However, knowledge about their long‐term anatomical impact on the perineal body remains limited, as postpartum evaluation has largely relied on inspection and palpation. This study aimed to examine the association between the severity of perineal tears not affecting the anal sphincter, diagnosed at delivery, and deviations in the muscles fusing into the perineal body, assessed by three‐dimensional ultrasound 1 year after vaginal delivery. Material and Methods This prospective cohort study included 384 primiparous women with vaginal deliveries at Akershus University Hospital, Norway, from January 2021 to July 2022. Perineal tears were classified and sutured according to international standards at delivery. In addition, second‐degree tears were subclassified according to the percentage of the perineal body damage (<50% = 2A, ≥50% = 2B, entire perineal body without anal sphincter = 2C). Women with third‐ or fourth‐degree tears were excluded. One year after delivery, participants underwent three‐dimensional endovaginal and endoanal ultrasound examinations. The transverse perineal, puboperinealis, and puboanalis muscles were examined at their fusion into the perineal body. A deviation was defined as a muscle discontinuity or absence in at least one of the muscles. Results The proportion of women with sonographically detected muscle deviations increased with tear severity: 22% for first‐degree ( n  = 24), 52.7% for 2A ( n  = 29), 60% for 2B ( n  = 21) and 86.2% for 2C ( n  = 25). Among women with episiotomies ( n  = 126), 60.6% had one or more muscle deviations. A higher number of muscles were affected in the 2C tear group compared to 2B and 2A. Conclusion Sonographic deviations in the muscles fusing into the perineal body increase with the severity of perineal tears.

• Risløkken, Jeanette; Macedo, Marthe Dalevoll; Bø, Kari; Engh, Anna Marie Ellström & Siafarikas, Franziska (2025). The severity of second-degree perineal tears and dyspareunia during one year postpartum: A prospective cohort study. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. 104(5), s. 968–975. doi: 10.1111/aogs.15084. Fulltekst i vitenarkiv
• Haug, Ala Jabri; Støer, Nathalie Charlotte; Langseth, Hilde; Siafarikas, Franziska; Botteri, Edoardo & Fortner, Shannon Renee Turzanski [Vis alle 7 forfattere av denne artikkelen] (2025). Non-steroidal anti-inflammatory medication use and endometrial cancer survival: A population-based Norwegian cohort study. International Journal of Cancer. ISSN 0020-7136. 157(2), s. 277–287. doi: 10.1002/ijc.35363. Fulltekst i vitenarkiv Vis sammendrag

  While nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to improve survival in certain cancers, data in patients with endometrial cancer (EC) is conflicting. This study investigated use of aspirin and nonaspirin NSAIDs (NA-NSAIDs) and EC-specific—and all-cause death. This nationwide cohort study linked data from the Cancer Registry of Norway with The Norwegian Prescription database. Patients diagnosed with EC from 2004 to 2018 were included. Post-diagnosis exposure to aspirin and NA-NSAIDs was defined as ≥3 consecutive prescriptions ≥30 days after EC diagnosis, with pre-diagnosis use as ≥2 filled prescriptions <6 months prior to diagnosis. Follow-up started 10 months after diagnosis. Hazard ratios for the risk of death were calculated with multivariable Cox-regression models. Our study population included 7751 individuals with EC, 685 (9%) were aspirin users and 620 (8%) were NA-NSAIDs users. The median follow-up time was 5.0 years, with 1518 (20%) deaths observed (n = 728 (9%) EC-specific). In multivariable analysis, aspirin use was significantly associated with a 19% higher risk of all-cause death compared to non-users (HR = 1.19, 95% CI [1.01–1.41]). The association was stronger among combined pre- and postdiagnosis use (HR = 1.35 [1.12–1.64]). NA-NSAIDs use increased risk of cancer-related death (HR = 1.25 [0.99–1.58]) and there was a dose–response association with significantly higher risk of cancer-specific death with higher cumulative doses (HR = 1.33 [1.02–1.75]). We found a higher risk of cancer-specific—and all-cause death among patients that used aspirin and NA-NSAIDs after a diagnosis of EC. Further studies on the biological mechanisms underlying these associations are needed.

• Lilleberg, Hanne Sether; Siafarikas, Franziska; Starck, Marianne; Bø, Kari; Rotstein, Emilia & Engh, Anna Marie Ellström (2025). Association Between Sonographic Deviations in the Perineum and Symptoms of a Deficient Perineum in Primiparous Women One Year After Birth: A Prospective Cohort Study. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 132(8), s. 1114–1121. doi: 10.1111/1471-0528.18135. Fulltekst i vitenarkiv Vis sammendrag

  Objectives This study aimed to investigate whether primiparous women with sonographic deviations in the muscles fusing into the perineal body reported more symptoms of deficient perineum than women without deviations 1 year after birth. Design Non-consecutive prospective cohort study. Setting Akershus University Hospital, Norway. Population Three hundred and eighty-eight primiparas. Methods Women were examined 1 year after birth using three-dimensional endovaginal and endoanal ultrasound with a high-resolution probe. In the blinded analysis, the transverse perineal, the puboperinealis and the puboanalis muscles were identified where they fuse into the perineal body and assessed for deviations. Symptoms of deficient perineum were evaluated using the ‘Karolinska Symptoms After Perineal Teras Inventory’ (KAPTAIN). Main Outcome Measures Symptoms of a deficient perineum, assessed using two outcomes: the median total score of KAPTAIN and a KAPTAIN score ≥ 8 1 year postpartum. Results Sonographic deviations in one or more of the muscles fusing into the perineal body 1 year after birth were observed in 168 participants (43.3%). Of these, 54 (32.1%) reported a KAPTAIN score ≥ 8. The median KAPTAIN score was 6.0 (IQR 3.0–9.0) in the group with sonographic deviations and 4.0 (IQR 2.0–6.0) in women with a sonographically intact perineum (p > 0.001). The unadjusted and adjusted odds ratio (OR) for reporting a KAPTAIN score ≥ 8 was 2.9 (95% CI 1.7–4.7) and 2.3 (95% CI 1.2–4.2), respectively, when comparing women with sonographic deviations to those with no sonographic deviations. Conclusion Our results indicate that sonographic deviations of the perineal body are associated with symptoms of a deficient perineum in primiparous women 1 year after birth.

• Risløkken, Jeanette; Macedo, Marthe Dalevoll; Bø, Kari; Engh, Anna Marie Ellström & Siafarikas, Franziska (2024). The severity of second-degree perineal tears and perineal pain during three months postpartum: A prospective cohort study. Midwifery. ISSN 0266-6138. 131. doi: 10.1016/j.midw.2024.103930. Fulltekst i vitenarkiv Vis sammendrag

  Background: Second-degree perineal tears are common and can vary widely in the extent of tissue trauma. Therefore, a better understanding of perineal pain based on tissue trauma severity in second-degree tears is needed. Aim: The primary aim of this study was to assess differences in perineal pain according to the severity of perineal tears, with a focus on subcategories of second-degree tears, during the first three months postpartum. The secondary aim was to assess the use of pain medication and breastfeeding patterns according to the severity of the second-degree tears. Methods: In this observational cohort study, nulli- and multiparous women with singleton pregnancies were included during pregnancy. After birth, perineal tears were classified using the latest international classification system. In addition, second-degree tears were subcategorised according to percentage of damage to the perineum (<50 %=2A,>50 % but less than entire perineum=2B, affecting entire perineum, anal sphincter not involved=2C). Perineal pain, use of pain medication and breastfeeding patterns were assessed during a phone interview seven to ten days postpartum and through an electronic questionnaire three months postpartum. Findings: Out of 880 vaginal births, 852 participants completed the phone interview and 715 answered the electronic questionnaire. During the first three months postpartum, women with 2C-tears reported statistically significantly higher pain scores and more frequent use of pain medication compared to women with 2A-tears. There was no statistically significant difference between the number of participants not breastfeeding between second-degree tear subcategories. Conclusion: Women with 2C-tears reported higher perineal pain scores and more use of pain medication compared to those with less severe tears during three months postpartum.

• Siafarikas, Franziska; Stær-Jensen, Jette; Reimers, Cathrine; Bø, Kari & Engh, Anna Marie Ellström (2024). Levator ani muscle avulsion and subsequent vaginal delivery: 8-year longitudinal follow-up. Ultrasound in Obstetrics and Gynecology. ISSN 0960-7692. 64(1), s. 112–119. doi: 10.1002/uog.27599. Fulltekst i vitenarkiv Vis sammendrag

  Objectives: The aim of this study is to assess the evolution of levator avulsion from 1 year to 8 years after first delivery in women with subsequent vaginal deliveries compared to women without subsequent vaginal deliveries. Further, we aim to assess whether women with full and partial avulsion 8 years after first delivery have larger levator hiatus area and more symptoms of pelvic organ prolapse compared to women with normal levator insertion. Methods: In this single center longitudinal study 195 initially primiparous women were included and underwent transperineal ultrasound 1 year and 8 years after first delivery. Muscle insertion was assessed by tomographic ultrasound imaging in the axial plane. Full levator avulsion was defined as abnormal muscle insertion in all three central slices. Partial levator avulsion was defined as abnormal muscle insertion in one but less than three central slices. Eight years after first delivery levator hiatus area was assessed at rest, during maximum pelvic floor muscle contraction, and maximum Valsalva maneuver. To assess symptoms of pelvic organ prolapse the vaginal symptoms module from the International Consultation on Incontinence Questionnaire was used. Results: At 1 year follow-up, 25 women (12.8%) showed signs of avulsion, 20 women fulfilled sonographic criteria for full avulsion and 5 women fulfilled sonographic criteria for partial avulsion. Eight years after first delivery, 35 (17.9%) women were diagnosed with avulsion, of them 25 women were diagnosed with full avulsion and 10 women were diagnosed with partial avulsion. No women with partial and full avulsion at 1 year improved on their avulsion status at 8-year follow-up. In the subsequent vaginal delivery group, 21 women (14%) were diagnosed with partial and full levator avulsion 1 year after first delivery, and 31 women (20.7%) were diagnosed with partial and full avulsion 8 years after first delivery. Of the 45 women without subsequent vaginal delivery, one woman with partial avulsion 1 year after first delivery was diagnosed as full avulsion at 8-year follow-up. All women with full avulsion at 1-year follow-up were diagnosed as full avulsion at 8 years regardless of subsequent vaginal delivery. At 8-year follow-up women with full avulsion had statistically significant larger levator hiatus area compared to women with normal muscle insertion. Vaginal symptoms scores ranged between 5.5 (SD 5.7) and 6.0 (SD 4.0) and vaginal symptom quality of life scores ranged between 0.9 (SD 1.4) and 1.5 (SD 2.2) and did not differ statistically significantly between women with normal muscle insertion and women with partial and full avulsion at 8-year follow-up. Conclusion: More avulsions 8 years after first delivery compared to one year after first delivery were found in women with subsequent vaginal delivery. Except one primipara, none of the women without subsequent vaginal delivery changed on their levator status from 1 to 8 years after first delivery. Larger levator hiatus area was found in women with full avulsion compared to women with normal muscle insertion at 8-year follow-up. Vaginal symptoms scores were low and did not differ between women with normal muscle insertion, partial and full avulsion at 8-year follow-up.

• Macedo, Marthe Dalevoll; Risløkken, Jeanette; Rotstein, Emilia; Benth, Jurate Saltyte; Engh, Anna Marie Ellström & Siafarikas, Franziska (2024). Pelvic floor symptoms according to the severity of second-degree perineal tears within 12 months post-partum: A longitudinal prospective cohort study. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. 103(7), s. 1366–1376. doi: 10.1111/aogs.14854. Fulltekst i vitenarkiv Vis sammendrag

  Introduction Second-degree perineal tears following vaginal birth are common and presumed to be of little clinical importance. However, the extent of damage to the perineal body varies widely, and there is reason to believe that larger second-degree tears may be associated with more pelvic floor symptoms, compared to lesser form. Therefore, the aim of this study was to assess differences in pelvic floor symptoms according to the severity of second-degree perineal tears up to 12 months post-partum, stratified by parity. Material and Methods This was a prospective cohort study conducted at Akershus University Hospital, a tertiary referral hospital in Norway. The study sample consisted of 409 primiparas and 394 multiparas with vaginal births. Perineal tears were classified using the classification system recommended by the Royal College of Obstetricians and Gynecologists. Further, second-degree tears were subclassified as 2A, 2B, or 2C, depending on the percentage of damage to the perineal body. Episiotomies were analyzed as a separate group. Pelvic floor symptoms were assessed using the Karolinska Symptoms After Perineal Tear Inventory (KAPTAIN). A linear mixed model was estimated to assess the trend in pelvic floor symptom scores according to perineal tear category and stratified by parity. The primary and secondary outcome measures were the mean sum scores of the KAPTAIN-Inventory, measured in pregnancy (at 18 weeks of gestation), at 3- and 12 months post-partum, and the reported impact of genital discomfort on quality of life measured in pregnancy and at 12 months post-partum. Results There were no significant differences in pelvic floor symptom scores over time, or at any timepoint, between no tear, first-degree tear, or second-degree tear subcategories, for primi-, and multiparas. Pelvic floor symptoms increased from pregnancy to 3 months post-partum and remained higher at 12 months post-partum compared to pregnancy in all perineal tear categories. Compared to primiparas, multiparas reported a significantly higher impact of genital discomfort on quality of life in pregnancy and at 12 months post-partum. Conclusions There were no statistically significant differences in pelvic floor symptoms according to the severity of second-degree perineal tears.

• Macedo, Marthe Dalevoll; Risløkken, Jeanette; Halle, Tuva Kristine Toresdatter; Engh, Anna Marie Ellström & Siafarikas, Franziska (2024). Occurrence and risk factors for second-degree perineal tears: A prospective cohort study using a detailed classification system. Birth. ISSN 0730-7659. 51(3), s. 602–611. doi: 10.1111/birt.12817. Fulltekst i vitenarkiv Vis sammendrag

  Background The amount of tissue trauma within second-degree perineal tears varies widely. Therefore, subcategorization of second-degree tears and a better understanding of their occurrence and risk factors are needed. The aim of this study was to assess the occurrence of perineal tears when second-degree tears were subcategorized. Furthermore, we aimed to assess the association between variables related to perineal anatomy and other potential risk factors, with second-degree tear subcategories. Methods This prospective cohort study included 880 primiparous and multiparous women giving birth to one child vaginally. Perineal tears were categorized using the classification system recommended by the Royal College of Obstetricians and Gynaecologists. In addition, second-degree tears were subcategorized as 2A, 2B, or 2C according to the percentage of damage to the perineal body. Selected variables related to perineal anatomy were as follows: length of genital hiatus; perineal body length; and previous perineal trauma. Risk factors for second-degree tear subcategories were analyzed using a multinominal regression model. Results Perineal tears occurred as follows: first-degree: 35.6% (n = 313), 2A: 16.3% (n = 143), 2B: 9.1% (n = 80), 2C: 6.6% (n = 58), and third- or fourth-degree: 1.6% (n = 14). In total, 169/880 participants underwent an episiotomy. When episiotomies were excluded, the risk for 2B, or 2C tears increased with smaller genital hiatus, larger perineal body, previous perineal trauma, primiparity, higher gestational age, instrumental vaginal delivery and fetal presentation other than occiput anterior. Conclusion The occurrence of second-degree tear subcategories was 16.3% for 2A tears, 9.1% for 2B tears, and 6.6% for 2C tears. Factors related to perineal anatomy increased the odds for experiencing a second-degree tear in a more severe subcategory.

• Hilde, Gunvor; Stær-Jensen, Jette; Siafarikas, Franziska; Engh, Anna Marie Ellström & Bø, Kari (2022). Postpartum pelvic floor muscle training, levator ani avulsion and levator hiatus area: a randomized trial. International Urogynecology Journal. ISSN 0937-3462. 34(2), s. 1–11. doi: 10.1007/s00192-022-05406-z. Fulltekst i vitenarkiv Vis sammendrag

  Introduction and hypothesis Vaginal delivery may lead to tearing of the levator ani (LA) muscle from its bony insertions (complete LA avulsion) and increased levator hiatus (LH) area, both risk factors for pelvic foor dysfunctions. Early active rehabilitation is standard treatment after musculo-skeletal injury. We hypothesized that pelvic foor muscle training (PFMT) early postpartum would reduce the presence of LA avulsions and reduce LH area. Methods We carried out a planned secondary analysis from a randomized controlled study. Primiparous women (n=175) giving birth vaginally were included 6 weeks postpartum, stratifed on complete LA avulsion, and thereafter randomized to PFMT or control. The training participants (n=87) attended a supervised PFMT class once a week and performed home-based PFMT daily for 16 weeks. The control participants (n=88) received no intervention. Presence of complete LA avulsion, LH area at rest, maximal contraction, and maximal Valsalva maneuver were assessed by transperineal ultrasound. Betweengroup comparisons were analyzed by analysis of covariance for continuous data, and relative risk (RR) for categorical data. Results Six months postpartum, the number of women who had complete LA avulsion was reduced from 27 to 14 within the PFMT group (44% reduction) and from 28 to 17 within the control group (39% reduction). The between-group diference was not signifcant, RR 0.85 (95% CI 0.53 to 1.37). Further, no signifcant between-group diferences were found for LH area at rest, during contraction, or Valsalva. Conclusions Supervised PFMT class combined with home exercise early postpartum did not reduce the presence of complete LA avulsion or LH area more than natural remission.

• Siafarikas, Franziska; Halle, Tuva Kristine Toresdatter; Benth, Jurate Saltyte; Stær-Jensen, Jette; Reimers, Cathrine & Bø, Kari [Vis alle 7 forfattere av denne artikkelen] (2022). Pelvic floor symptoms from first pregnancy up to 8 years after the first delivery: a longitudinal study. American Journal of Obstetrics and Gynecology. ISSN 0002-9378. 227(4), s. 613.e1–613.e15. doi: 10.1016/j.ajog.2022.06.020. Fulltekst i vitenarkiv Vis sammendrag

  Background: Despite the strong association between vaginal childbirth and pelvic floor dysfunction, genetic factors, pregnancy, advancing age, and lifestyle also play a role. The pelvic floor undergoes substantial changes during pregnancy which may contribute to pelvic floor dysfunction. On the other hand, these changes may be favorable to allow for vaginal delivery. However, there is a lack of studies assessing pelvic floor symptoms over time according to delivery mode, which includes women prior to delivery. Objective: The aim of this study was to describe urinary incontinence, vaginal symptoms, and bowel control symptoms from 21 weeks of gestation in the first pregnancy and up to 8 years after the first delivery, stratified by delivery mode. Study design: This is a longitudinal observational cohort study. 300 nulliparous women were recruited during their first pregnancy. Pelvic floor symptoms were assessed at 21 and 37 weeks of gestation, and 6 weeks, 6 months, 12 months and 8 years after first delivery using the International Consultation on Incontinence Questionnaire (ICIQ) modules: the urinary incontinence sum score; the weighted vaginal symptom sum score; the vaginal-associated quality of life score; the bowel control sum score; and the bowel-associated quality of life sum score. Delivery mode at first delivery defined delivery groups as: normal vaginal, operative vaginal and cesarean delivery. A linear mixed model analysis was used to assess symptom scores over time and to assess the differences in symptom scores between the delivery groups. Results: Of the 300 women included in the study, of which 193 attended the 8-year follow-up. Pelvic floor symptoms differed in women with vaginal and cesarean delivery. The symptom scores showed a non-linear statistically significant trend. In women, who delivered vaginally, there was an increase of urinary incontinence and vaginal symptom scores already during pregnancy. In women, who later delivered by cesarean, there was a decrease of symptoms scores during pregnancy, and overall lower symptom scores compared to women with vaginal delivery until 12 months after first delivery. Pelvic floor symptoms scores increased from 12 months to 8 years after the first delivery and exceeded pregnancy levels in all delivery groups, however overall symptom scores were low. Differences between delivery groups were not statistically significant. Conclusion: Pelvic floor symptoms differed in women with vaginal and cesarean delivery from the first pregnancy up to 8 years after the first delivery. These differences were recognizable already prior to first delivery.

• Bø, Kari; Næss, Karoline; Stær-Jensen, Jette; Siafarikas, Franziska; Engh, Anna Marie Ellström & Hilde, Gunvor (2022). Recovery of pelvic floor muscle strength and endurance 6 and 12 months postpartum in primiparous women—a prospective cohort study. International Urogynecology Journal. ISSN 0937-3462. 33(12), s. 3455–3464. doi: 10.1007/s00192-022-05334-y. Fulltekst i vitenarkiv Vis sammendrag

  Introduction and hypothesis: To date there has been scant knowledge on the natural recovery of the pelvic floor muscles (PFMs) after childbirth. The aims of the present study were to investigate whether PFM variables at 6 and 12 months postpartum had returned to mid-pregnancy levels and assess risk factors for reduced recovery at 12 months postpartum. Methods: This was a prospective cohort study following 235 nulliparous pregnant women from mid-pregnancy to 12 months postpartum. Vaginal resting pressure (VRP), PFM strength and endurance were assessed by manometry at 22 weeks, 6 and 12 months postpartum. Multiple linear regression was used to address factors influencing PFM variables beyond birth mode. Results: Cesarean section was protective for change in PFM variables. From mid-pregnancy to 12 months postpartum there was a 20% reduction in VRP (p<0.001) and a 7.5 % reduction in PFM strength (p=0.007), and an increase of 9% in PFM endurance (p=0.002) in the normal vaginal birth. The instrumental vaginal group had a decline in VRP of 21% (p<0.001) and PFM strength of 15% (p=0.011), but no significant change in PFM endurance. Higher BMI at 12 months postpartum, longer second stage of labor, and major tears of the levator ani muscle had a negative influence on the PFM recovery beyond delivery mode. Conclusions: At 12 months postpartum following vaginal delivery, the PFMs are not fully recovered compared with mid-pregnancy values. More follow-up physical therapy may be warranted in the postpartum period, especially for women with complicated vaginal births and higher BMI.

• Macedo, Marthe Dalevoll; Engh, Anna Marie Ellström & Siafarikas, Franziska (2022). Detailed classification of second-degree perineal tears in the delivery ward: an inter-rater agreement study. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. 101(8), s. 880–888. doi: 10.1111/aogs.14369. Fulltekst i vitenarkiv Vis sammendrag

  Introduction Second-degree perineal tears can vary widely as to the extent of trauma, which may be relevant for women's pelvic floor health postpartum. However, the short- and long-term consequences of second-degree perineal tears are poorly understood, likely due to the lack of a detailed classification system. Such a classification system for second-degree tears has been suggested but the inter-rater agreement has not yet been assessed. The aim of this study was to assess the inter-rater agreement of the already established classification system for perineal tears recommended by the Royal College of Obstetricians and Gynaecologists (RCOG classification) among midwives. Further, we aimed to assess the inter-rater agreement of a classification system that provides three sub-categories for second-degree perineal tears. Material and methods This was an inter-rater agreement study, conducted at Akershus University Hospital in Norway from 31 August to 29 November 2020. All midwives working in the delivery ward participated in the study. Midwives classified the integrity of the perineum of all women delivering vaginally within the study period. During the first month of the study, tears were classified by two midwives who were blinded to each other's findings, and the agreement of the RCOG classification was assessed. The following month, the detailed classification system was introduced to the midwifery staff. The last month, perineal tears were classified by two midwives using the detailed classification system, and the agreement was assessed. Inter-rater agreement was measured using Fleiss multirater kappa (k) and Kendall's coefficient of concordance (KCCw). Results The inter-rater agreement for the RCOG classification was good to very good, with k = 0.705 (95% confidence interval [CI] 0.62–0.79, P < 0.001), KCCw = 0.928 (P < 0.001). The inter-rater agreement for the detailed classification system was good to very good, with k = 0.748 (95% CI 0.67–0.83, P < 0.001), KCCw = 0.956 (P < 0.001). Conclusions The inter-rater agreement among midwives using both the RCOG classification and the detailed classification system among midwives was good to very good. The detailed classification system provides additional information about the extent of tissue trauma in second-degree tears, warranted for future research on women's pelvic floor health postpartum.

• Halle, Tuva Kristine Toresdatter; Stær-Jensen, Jette; Hilde, Gunvor; Bø, Kari; Engh, Marie Ellström & Siafarikas, Franziska (2020). Change in prevalence of major levator ani muscle defects from 6 weeks to 1 year postpartum, and maternal and obstetric risk factors: A longitudinal ultrasound study. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. 99(10), s. 1403–1410. doi: 10.1111/aogs.13878. Fulltekst i vitenarkiv Vis sammendrag

  Introduction: The present study aimed first to investigate the change in prevalence of major levator ani muscle (LAM) defects, also called avulsions, from 6 weeks to 1 year postpartum, and second to assess maternal and obstetric risk factors for having persistent major LAM defects/avulsions at 1 year postpartum. Material and methods: This is a secondary analysis of data from a prospective cohort study including 300 nulliparous women at 17-19 weeks of gestation. Major LAM defects were diagnosed at 6 weeks and 1 year postpartum using transperineal ultrasonography. We defined persistent major LAM defects as a defect diagnosed both at 6 weeks and 1 year postpartum. Maternal and obstetric data were obtained from the hospital's electronic birth records. Pelvic floor muscle function was measured vaginally by manometer at 21 weeks of gestation. The main outcome measurement was change in prevalence of major LAM defects. Maternal and obstetric risk factors for having persistent major LAM defect were also assessed. Results: Prevalence of major LAM defects was 19.4% at 6 weeks and 10.4% at 1 year postpartum. No new major LAM defects were diagnosed at 1 year postpartum. Persisting major LAM defects were associated with longer second stage of labor (median 74.5 minutes vs median 48.0 minutes, P = .012) and higher neonatal birthweight (mean difference of 232.3 g, 95% confidence interval [CI] 21.5-443.1). Vacuum delivery was independently associated with persistent major LAM defects, adjusted OR 3.0 (95% CI 1.0-9.0). Conclusions: There was a 50% reduction of sonographically diagnosed major LAM defects from 6 weeks to 1 year postpartum. This finding suggests that assessment of the major LAM 6 weeks postpartum may be too early to diagnose defects/avulsions. Long second stage of labor, high neonatal birthweight and vacuum delivery were associated with persistent major LAM defects/avulsions.

• Reimers, Cathrine; Siafarikas, Franziska; Stær-Jensen, Jette; Småstuen, Milada Cvancarova; Bø, Kari & Engh, Marie Ellström (2018). Risk factors for anatomic pelvic organ prolapse at 6 weeks postpartum: a prospective observational study. International Urogynecology Journal. ISSN 0937-3462. doi: 10.1007/s00192-018-3650-2. Fulltekst i vitenarkiv Vis sammendrag

  Introduction and hypothesis: The objective was to identify risk factors for postpartum anatomic pelvic organ prolapse (aPOP) by comparing women with and without aPOP at 6 weeks postpartum with regard to pelvic floor measurements antepartum and obstetrical characteristics. Methods: We carried out a prospective observational cohort study including nulliparous pregnant women in a Norwegian university hospital. Participants underwent clinical examinations, including pelvic organ prolapse quantification system (POP-Q) and transperineal ultrasound at gestational week 21 and at 6 weeks postpartum. Background and obstetrical information was obtained from an electronic questionnaire and from the patient’s electronic medical file respectively. Associations were estimated using logistic regression analyses. The dependent variable was aPOP, defined as POP-Q stage ≥2 at 6 weeks postpartum. Independent variables were mid-pregnancy measurements of selected POP-Q variables and levator hiatus area (LHarea), delivery route, and the presence of major levator ani muscle (LAM) injuries at 6 weeks postpartum. Results: A larger LHarea, a more distensible LAM, a longer distance from the meatus urethra to the anus (Gh + Pb) and a more caudal position of the anterior vaginal wall (Ba) at mid-pregnancy were risk factors for aPOP at 6 weeks postpartum, whereas delivery route and the presence of major LAM injuries were not. Conclusion: Prelabor differences in the pelvic floor rather than obstetrical events were risk factors for aPOP at 6 weeks postpartum.

• Reimers, Cathrine; Stær-Jensen, Jette Elisabeth; Siafarikas, Franziska; Bø, Kari & Engh, Marie Ellström (2017). Association between vaginal bulge and anatomical pelvic organ prolapse during pregnancy and postpartum: an observational study. International Urogynecology Journal. ISSN 0937-3462. 29(3), s. 441–448. doi: 10.1007/s00192-017-3407-3. Fulltekst i vitenarkiv Vis sammendrag

  Introduction and hypothesis: Pelvic organ prolapse (POP) is defined as the coexistence of anatomical POP and relevant symptoms. Vaginal bulge is the symptom most closely associated with the anatomical condition in nonpregnant women. Even if childbearing is a major risk factor for the development of POP, there is scant knowledge on the prevalence of specific POP symptoms, and how these symptoms relate to anatomical POP during pregnancy and postpartum. The aim of this study was to explore whether vaginal bulge symptoms were associated with anatomical POP in pregnancy and postpartum, and to present the prevalence of vaginal bulge symptoms throughout this period. Methods: A prospective observational study was carried out following 300 nulliparous pregnant women with repeat assessments from mid-pregnancy until 1 year postpartum. Symptoms of vaginal bulge defined as the sensation of a vaginal bulge inside and/or outside the vagina were assessed by electronic questionnaires. Anatomical POP defined as pelvic organ prolapse quantification system (POP-Q) stage ≥2 has been presented in a previous publication and showed a range of 1–9%. The association between the symptom vaginal bulge and anatomical POP at the various visits was analyzed using Fisher’s exact test. Results: Prevalence of vaginal bulge ranged between 16 and 23%. At 6 weeks postpartum the symptom was associated with anatomical POP; otherwise, these two features were unrelated. Conclusions: The symptom vaginal bulge was barely associated with anatomical POP, and cannot identify anatomical POP in pregnancy or postpartum.

• Tennfjord, Merete Kolberg; Hilde, Gunvor; Stær-Jensen, Jette Elisabeth; Siafarikas, Franziska; Engh, Marie Ellström & Bø, Kari (2016). Effect of postpartum pelvic floor muscle training on vaginal symptoms and sexual dysfunction—secondary analysis of a randomised trial. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 123(4), s. 634–642. doi: 10.1111/1471-0528.13823. Fulltekst i vitenarkiv Vis sammendrag

  Objective: Evaluate effect of pelvic floor muscle training (PFMT) on vaginal symptoms and sexual matters, dyspareunia and coital incontinence in primiparous women stratified by major or no defects of the levator ani muscle. Design: Randomised controlled trial (RCT). Setting: Akershus University Hospital, Norway. Sample: About 175 primiparous women with a singleton vaginal delivery. Methods: Two-armed assessor blinded parallel group RCT from 6 weeks to 6 months postpartum comparing effect of PFMT versus control. Main outcome measures: International Consultation on Incontinence Modular Questionnaire—vaginal symptoms questionnaire (ICIQ-VS) and ICIQ sexual matters module (ICIQ-FLUTSsex). Results: Overall, analysis (n = 175) showed no difference between training and control groups in women having vaginal symptoms or symptoms related to sexual dysfunction 6 months postpartum. The majority of women (88%) had intercourse and there was no difference between groups. Unadjusted subgroup analysis of women with a major defect of the levator ani muscle (n = 55) showed that women in the training group had 45% less risk of having the symptom ‘vagina feels loose or lax’ compared with the control group (relative risk 0.55, 95% confidence interval 0.31, 0.95; P = 0.03). Conclusions: Unadjusted analysis showed that in women with major defect of the levator ani muscle, significantly fewer in the training group had the symptom ‘vagina feels loose or lax’ compared with the control group. No difference was found between groups for symptoms related to sexual dysfunction. More studies are needed to explore effect of PFMT on vaginal symptoms and sexual dysfunction.

• Reimers, Cathrine; Stær-Jensen, Jette Elisabeth; Siafarikas, Franziska; Benth, Jurate Saltyte; Bø, Kari & Engh, Marie Ellström (2016). Change in pelvic organ support during pregnancy and the first year postpartum: a longitudinal study. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 123(5), s. 821–829. doi: 10.1111/1471-0528.13432. Fulltekst i vitenarkiv Vis sammendrag

  Objective: To describe changes in pelvic organ support from mid pregnancy until 1 year postpartum among nulliparous pregnant women, and to examine whether delivery route affects changes in pelvic organ support. Design: Prospective cohort study. Setting: Akershus University Hospital in Norway. Population: A cohort of 300 nulliparous pregnant women included at mid-pregnancy. Methods: Pelvic organ support assessed at 21 and 37 weeks of gestation, and again at 6 weeks, 6 months, and 12 months postpartum, by the use of the Pelvic Organ Prolapse Quantification (POP-Q) system. Linear mixed model was used to assess longitudinal change in pelvic organ support. Main outcome measures: Prevalence of anatomic POP. Change in POP-Q variables over time and between delivery groups. Results: The prevalence of anatomic POP ranged from 0 to 10%. Vaginal POP-Q points made a cranial shift from mid to late pregnancy, a caudal shift following delivery, and again a cranial shift after 6 weeks postpartum. Postpartum change was present following both vaginal and caesarean deliveries, but was more pronounced following vaginal delivery. The perineal body and genital hiatus became longer from mid to late pregnancy, and shortened after 6 weeks postpartum. At 12 months postpartum all POP-Q points, except cervix, had recovered to baseline in the vaginal delivery group. Conclusions: The prevalence of anatomic POP was low in this cohort. There was change in pelvic organ support both during pregnancy and following vaginal as well as caesarean delivery. The short-term ability to recover was good after the first pregnancy and delivery.

• Siafarikas, Franziska; Stær-Jensen, Jette Elisabeth; Hilde, Gunvor; Bø, Kari & Engh, Marie Ellström (2015). The levator ani muscle during pregnancy and major levator ani muscle defects diagnosed postpartum: a three- and four-dimensional transperineal ultrasound study. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 122(8), s. 1083–1091. doi: 10.1111/1471-0528.13332. Fulltekst i vitenarkiv Vis sammendrag

  Objective: To investigate associations between levator hiatus area and levator ani muscle function during pregnancy and major levator ani muscle defects postpartum. Design: Observational prospective cohort study. Setting: University hospital, Norway. Sample: A cohort of 234 nulliparous women at 21 and 37 weeks of gestation, and at 6 weeks postpartum. Methods: Ultrasound measurements of the levator hiatus at rest, during pelvic floor muscle contraction, and during the Valsalva manoeuvre were taken at 21 and 37 weeks of gestation. Levator ani muscle function was estimated as the percentage changes in levator ani muscle length from rest to contraction, and the level of muscle stretch during the Valsalva manoeuvre. Major levator ani muscle defects were diagnosed at 6 weeks postpartum using tomographic ultrasound imaging. Main outcome measures: Associations between ultrasound measurements antepartum and major levator ani muscle defects postpartum. Results: Women with major levator ani muscle defects postpartum had significantly smaller levator hiatus area at rest and during the Valsalva manoeuvre at mid-pregnancy (mean difference 1.03 cm2, 95% CI 0.31–1.76; 2.92 cm2, 95% CI 1.77–4.07), and at 37 weeks of gestation (mean difference 1.47 cm2, 95% CI 0.62–2.32; 2.84 cm2, 95% CI 0.88–4.80), than women without such defects. They also had significantly less shortening of the levator ani muscle during contraction at 37 weeks of gestation. Conclusions: Smaller levator hiatus area at rest and during the Valsalva manoeuvre at mid and late pregnancy, and less shortening of the levator ani muscle during contraction at 37 weeks of gestation, are associated with major levator ani muscle defects postpartum.

• Stær-Jensen, Jette Elisabeth; Siafarikas, Franziska; Hilde, Gunvor; Benth, Jurate Saltyte; Bø, Kari & Engh, Marie Ellström (2015). Postpartum Recovery of Levator Hiatus and Bladder Neck Mobility in Relation to Pregnancy. Obstetrics and Gynecology. ISSN 0029-7844. 125(3), s. 531–539. doi: 10.1097/AOG.0000000000000645. Fulltekst i vitenarkiv
• Bø, Kari; Hilde, Gunvor; Stær-Jensen, Jette Elisabeth; Siafarikas, Franziska; Tennfjord, Merete Kolberg & Engh, Marie Ellström (2015). Does general exercise training before and during pregnancy influence the pelvic floor “opening” and delivery outcome? A 3D/4D ultrasound study following nulliparous pregnant women from mid-pregnancy to childbirth. British Journal of Sports Medicine. ISSN 0306-3674. 49(3), s. 196–199. doi: 10.1136/bjsports-2014-093548. Fulltekst i vitenarkiv Vis sammendrag

  Background: It has been suggested that women who are regular exercisers have a tighter pelvic floor and thereby have more difficulty during childbirth than non-exercising women. We investigated whether women exercising before and during pregnancy have a narrower levator hiatus (LH) area than their sedentary counterparts. We also studied whether regular exercise at gestational week 37 influences delivery outcome. Methods: Cohort study of 274 nulliparous pregnant women assessed at mid-pregnancy and gestational week 37 by three-dimensional/four-dimensional transperineal ultrasonography of the LH area. Exercisers were defined as those exercising ≥30 min three times per week and non-exercisers as not exercising. Exercise data were collected via electronic questionnaire at mean gestational weeks 21 and 37. Labour and delivery outcomes were collected from the women's electronic medical birth records. Differences between exercisers and non-exercisers were analysed using independent sample t test or χ2 test. p Value was set to ≤0.05. Results: At gestational week 37, exercisers had a significantly larger LH area than non-exercisers at rest and during PFM contraction (mean difference −1.6 cm2 (95% CI −3.0 to −0.3), p=0.02 and −1.1 cm2 (95% CI −2.0 to −0.1), p=0.04, respectively). No significant differences were found between exercisers and non-exercisers at week 37 in any labour or delivery outcomes. Conclusions: The results of the present study do not support the hypothesis that women exercising regularly before or during pregnancy have a narrower LH area or more complicated childbirths than non-exercising women.

• Tennfjord, Merete Kolberg; Hilde, Gunvor; Stær-Jensen, Jette Elisabeth; Siafarikas, Franziska; Engh, Marie Ellström & Bø, Kari (2015). Coital incontinence and vaginal symptoms and the relationship to pelvic floor muscle function in primiparous women at 12 months postpartum: A cross-sectional study. Journal of Sexual Medicine. ISSN 1743-6095. 12(4), s. 994–1003. doi: 10.1111/jsm.12836. Fulltekst i vitenarkiv
• Bø, Kari; Hilde, Gunvor; Stær-Jensen, Jette Elisabeth; Siafarikas, Franziska; Tennfjord, Merete Kolberg & Engh, Marie Ellström (2015). Postpartum pelvic floor muscle training and pelvic organ prolapse - A randomized trial of primiparous women. American Journal of Obstetrics and Gynecology. ISSN 0002-9378. 212(1), s. 38e1–38e7. doi: 10.1016/j.ajog.2014.06.049. Fulltekst i vitenarkiv Vis sammendrag

  Objective: Pelvic organ prolapse (POP) is a common and distressing condition. The aim of the present study was to evaluate the effect of pelvic floor muscle training (PFMT) on prevention and treatment of symptoms and signs of POP in primiparous postpartum women. Study design: This was a parallel group assessor blind randomized controlled trial. One hundred and seventy-five primiparous postpartum women, mean age 29.8 years (SD 4.1), stratified on major levator ani defects or no defect diagnosed by 3/4D ultrasound, participated in a four month PFMT program starting at 6-8 weeks postpartum or control. All participants had thorough individual instruction and assessment of ability to perform correct pelvic floor muscle contractions. The PFMT group followed a supervised, weekly group training program and performed 3 sets of 8-12 daily maximal contractions at home. Main outcome was POP stage II or greater assessed by POP quantification (POP-Q) and bladder neck position assessed by 3/4 D transperineal ultrasonography. Secondary outcome was symptoms of vaginal bulge using International Consultation on Incontinence vaginal symptoms questionnaire (ICIQ-vag). Results: Ninety-six percent of the intervention group adhered to ≥ 80% of both group and home training sessions. At post-intervention there was no significant risk difference in POP (RR: 1.62 (95% CI: 0.55, 4.75), bladder neck position or symptoms of vaginal bulging. Conclusion: No effect was found of postpartum PFMT on POP in primiparous women. More RCTs are needed before strong conclusions can be drawn on the effect of PFMT on POP in the this particular population.

• Bø, Kari; Hilde, Gunvor; Tennfjord, Merete Kolberg; Stær-Jensen, Jette Elisabeth; Siafarikas, Franziska & Engh, Marie Ellstrøm (2014). Pelvic floor muscle variables and levator hiatus dimensions: a 3/4D transperineal ultrasound cross-sectional study on 300 nulliparous pregnant women. International Urogynecology Journal. ISSN 0937-3462. 25(10), s. 1357–1361. doi: 10.1007/s00192-014-2408-8. Fulltekst i vitenarkiv Vis sammendrag

  Introduction and hypothesis: The aims of the present study were to investigate the correlation among vaginal resting pressure and pelvic floor muscle (PFM) strength and endurance, and the correlation between the same variables and levator hiatus (LH) dimensions in nulliparous pregnant women. Methods: This was a cross-sectional study of 300 nulliparous pregnant women, mean age 28.7 years (SD 4.3) and prepregnancy BMI 23.9 kg/m2 (SD 3.9), assessed at mean gestational week 20.8 (±1.4). Vaginal resting pressure and PFM strength and endurance were measured using a high precision pressure transducer connected to a vaginal balloon. LH dimensions (transverse and anterior–posterior diameters_ and LH area were assessed using 3/4D transperineal ultrasound in the axial plane of minimal hiatal dimensions using render mode. The Pearson correlation was used to analyze correlations among vaginal resting pressure and PFM strength and endurance, and between PFM variables and LH dimensions. Level of significance was set at 0.05. Results: Pelvic floormuscle strength and vaginal resting pressure were significantly, but weakly correlated (r=0.198, p<0.001). PFM strength and endurance showed a strong correlation (r=0.929, p<0.001). High vaginal resting pressure was moderately correlated with a small LH area at rest (r=−0.451, p<0.001), but there was no significant correlation neither between PFM strength and LH area at rest (r=−0.012, p=0.84) nor between muscle endurance and LH area at rest (r=−0.014, p=0.81). A strong PFM contraction correlated moderately with reduction of the LH area (r=−0.367, p<0.001). Conclusions: Pelvic floor muscle strength and endurance are strongly correlated, butdo not correlate with a smaller LH area at rest.

• Siafarikas, Franziska; Stær-Jensen, Jette; Hilde, Gunvor; Bø, Kari & Engh, Marie Ellstrøm (2014). Levator hiatus dimensions in late pregnancy and the process of labor : a 3- and 4-dimensional transperineal ultrasound study. American Journal of Obstetrics and Gynecology. ISSN 0002-9378. 210(5), s. 484.e1–484.e7. doi: 10.1016/j.ajog.2014.02.021. Fulltekst i vitenarkiv Vis sammendrag

  Objective: The objectives of the investigation were to study the association between levator hiatus dimensions in late pregnancy and both the length of second stage of labor and also the delivery mode in women delivering their first child. Study Design: In this cohort study, 231 nulliparous women were examined with 3- and 4-dimensional transperineal ultrasonography at 37 weeks of gestation. The anteroposterior, transverse diameter, and the area of levator hiatus were measured at rest, during levator ani muscle contraction, and during Valsalva maneuver. The second stage of labor was divided into passive and active second stage and delivery modes into normal vaginal or instrumental deliveries. Spearman correlation coefficient, independent-sample t test, and standard logistic regression were used for analysis. Results: Larger levator hiatus dimensions at rest and during contraction at 37 weeks of gestation correlated with a shorter duration of the active second stage in women with normal vaginal delivery (Spearman correlation coefficient, –0.13 to –0.35, P ≤ .08). Women having normal vaginal deliveries had significantly larger transverse diameter at rest, during contraction, and during Valsalva maneuver compared with women having instrumental deliveries (mean difference, 0.29; 95% confidence interval (CI), 0.16–0.41; mean difference, 0.33; 95% CI, 0.21–0.44 and mean difference, 0.24; 95% CI, 0.06–0.42; P < .05). The same was true for the levator hiatus area at rest and during contraction (mean difference, 1.22; 95% CI, 0.37–2.07 and mean difference, 0.84; 95% CI, 0.22–1.46; P < .01). These estimates were unchanged by adjustments in the logistic regression analysis. Conclusion: Larger levator hiatus dimensions in late pregnancy had a significant association with a shorter active second stage of labor and normal vaginal delivery.

• Stær-Jensen, Jette; Richter, Franziska; Hilde, Gunvor; Brækken, Ingeborg Hoff; Bø, Kari & Engh, Marie Ellstrøm (2013). Pelvic Floor Muscle Injuries 6 Weeks Post Partum-An Intra- and Inter-Rater Study. Neurourology and Urodynamics. ISSN 0733-2467. 32(7), s. 993–997. doi: 10.1002/nau.22337. Fulltekst i vitenarkiv
• Bø, Kari; Hilde, Gunvor; Stær-Jensen, Jette; Siafarikas, Franziska & Engh, Marie Ellstrøm (2013). Too tight to give birth? Assessment of pelvic floor muscle function in 277 nulliparous pregnant women. International Urogynecology Journal. ISSN 0937-3462. 24(12), s. 2065–2070. doi: 10.1007/s00192-013-2133-8. Fulltekst i vitenarkiv Vis sammendrag

  Introduction and hypothesis Theoretically, tight or strong pelvic floor muscles may impair the progress of labor and lead to instrumental deliveries. We aimed to investigate whether vaginal resting pressure, pelvic floor muscle strength, or endurance at midpregnancy affect delivery outcome. Methods This was a prospective cohort study of women giving birth at a university hospital. Vaginal resting pressure, pelvic floor muscle strength, and endurance in 300 nulliparous pregnant women were assessed at mean gestational week 20.8 (±1.4) using a high precision pressure transducer connected to a vaginal balloon. Delivery outcome measures [acute cesarean section, prolonged second stage of labor (> 2 h), instrumental vaginal delivery (vacuum and forceps), episiotomy, and thirdand fourth-degree perineal tear) were retrieved from the hospital’s electronic birth records. Results Twenty-three women were lost to follow-up, mostly because they gave birth at another hospital. Women with prolonged second stage had significantly higher resting pressure than women with second stage less than 2 h; the mean difference was 4.4 cmH2O [95 % confidence interval (CI) 1.2–7.6], p<0.01, adjusted odds ratio 1.049 (95 % CI 1.011– 1.089, p=0.012). Vaginal resting pressure did not affect other delivery outcomes. Pelvic floor muscle strength and endurance similarly were not associated with any delivery outcomes. Conclusions While midpregnancy vaginal resting pressure is associated with prolonged second stage of labor, neither vaginal resting pressure nor pelvic floor muscle strength or endurance are associated with operative delivery or perineal tears. Strong pelvic floor muscles are not disadvantageous for vaginal delivery.

• Hilde, Gunvor; Stær-Jensen, Jette; Richter, Franziska; Engh, Marie Ellstrøm; Brækken, Ingeborg Hoff & Bø, Kari (2013). Impact of childbirth and mode of delivery on vaginal resting pressure and on pelvic floor muscle strength and endurance. American Journal of Obstetrics and Gynecology. ISSN 0002-9378. 208(1), s. e1–e7. doi: 10.1016/j.ajog.2012.10.878. Fulltekst i vitenarkiv Vis sammendrag

  Objective: We sought to study impact of delivery mode on vaginal resting pressure (VRP) and on pelvic floor muscle (PFM) strength and endurance, and whether these measurements differed in women with and without urinary incontinence. Study Design: We conducted a cohort study following 277 nulliparous women from midpregnancy to 6 weeks postpartum. Manometer was used for PFM measurements; differences were analyzed by t test (within groups) and analysis of variance (between groups). Results: Only VRP changed significantly (10% reduction, P = .001) after emergency cesarean section. After normal and instrumental vaginal delivery, VRP was reduced by 29% and 30%; PFM strength by 54% and 66%; and endurance by 53% and 65%, respectively. Significant differences for all PFM measures (P < .001) were found when comparing cesarean vs normal and instrumental vaginal delivery, respectively. Urinary continent women at both time points had significantly higher PFM strength and endurance than incontinent counterparts (P < .05). Conclusion: Pronounced reductions in VRP and in PFM strength and endurance were found after vaginal delivery. Continent women were stronger than incontinent counterparts.

• Stær-Jensen, Jette; Siafarikas, Franziska; Hilde, Gunvor; Bø, Kari & Engh, Marie Ellstrøm (2013). Ultrasonographic Evaluation of Pelvic Organ Support During Pregnancy. Obstetrics and Gynecology. ISSN 0029-7844. 122(2-2), s. 329–336. doi: 10.1097/AOG.0b013e318299f62c. Fulltekst i vitenarkiv Vis sammendrag

  OBJECTIVE: To investigate whether pregnancy affects levator hiatus dimensions and the position and mobility of the bladder neck and the levator ani muscle in nulliparous pregnant women. METHODS: In the present study, 274 nulliparous pregnant women were examined at 21 weeks and 37 weeks of gestation using three-dimensional and four-dimensional transperineal ultrasonography at rest, during contraction, and during Valsalva maneuver. Levator hiatus dimensions were the anteroposterior diameter, the transverse diameter, and the area measured in rendered images. Positions of the bladder neck and levator plate were analyzed in the midsagittal plane, and mobility was calculated as displacement of the bladder neck or levator plate from rest to contraction or from rest to Valsalva. RESULTS: A significant increase for all levator hiatus dimension measurements was found from 21 weeks to 37 weeks of gestation. The most marked change was found for levator hiatus area at rest and during Valsalva maneuver, in which the mean area was increased by 17.1% (11.7–13.7 cm2) and 21.4% (15.4–18.7 cm2), respectively. Bladder neck mobility changed significantly during pregnancy. The most marked change was seen from rest to contraction (mean –14 mm, standard deviation 0.4). CONCLUSIONS: An increase of all hiatal dimensions as well as bladder neck mobility was found from 21 weeks to 37 weeks of gestation in nulliparous pregnant women. The findings indicate that the changes in pelvic organ support are not solely caused by delivery, but also by physiologic changes during pregnancy.

• Hilde, Gunvor; Stær-Jensen, Jette; Siafarikas, Franziska; Gjestland, Kristin; Engh, Marie Ellstrøm & Bø, Kari (2013). How well can pelvic floor muscles with major defects contract? A cross-sectional comparative study 6 weeks after delivery using transperineal 3D/4D ultrasound and manometer. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 120(11), s. 1423–1429. doi: 10.1111/1471-0528.12321. Fulltekst i vitenarkiv
• Siafarikas, Franziska; Stær-Jensen, Jette; Brækken, Ingeborg Hoff; Bø, Kari & Engh, Marie Ellstrøm (2013). Learning process for performing and analyzing 3D/4D transperineal ultrasound imaging and interobserver reliability study. Ultrasound in Obstetrics and Gynecology. ISSN 0960-7692. 41(3), s. 312–317. doi: 10.1002/uog.11192. Fulltekst i vitenarkiv Vis sammendrag

  Objectives: To evaluate the learning process for acquiring three- and four-dimensional (3D/4D) transperineal ultrasound volumes of the levator hiatus (LH) dimensions at rest, during pelvic floor muscle (PFM) contraction and on Valsalva maneuver, and for analyzing the ultrasound volumes, as well as to perform an interobserver reliability study between two independent ultrasound examiners. Methods: This was a prospective study including 22 women. We monitored the learning process of an inexperienced examiner (IE) performing 3D/4D transperineal ultrasonography and analyzing the volumes. The examination included acquiring volumes during three PFM contractions and three Valsalva maneuvers. LH dimensions were determined in the axial plane. The learning process was documented by estimating agreement between the IE and an experienced examiner (E) using the intraclass correlation coefficient. Agreement was calculated in blocks of 10 ultrasound examinations and analyzed volumes. After the learning process was complete the interobserver reliability for the technique was calculated between these two independent examiners. Results: For offline analysis of the first 10 ultrasound volumes obtained by E, good to very good agreement between E and IE was achieved for all LH measurements except for the left and right levator–urethra gap and pubic arc. For the next 10 analyzed volumes, agreement improved for all LH measurements. Volumes that had been obtained by IE and E were then re-evaluated by IE, and good to very good agreement was found for all LH measurements indicating consistency in volume acquisition. The interobserver reliability study showed excellent ICC values (ICC, 0.81–0.97) for all LH measurements except the pubic arc (ICC = 0.67). Conclusion: 3D/4D transperineal ultrasound is a reliable technique that can be learned in a short period of time

• Hilde, Gunvor; Stær-Jensen, Jette; Siafarikas, Franziska; Engh, Marie Ellstrøm & Bø, Kari (2013). Postpartum Pelvic Floor Muscle Training and Urinary Incontinence: A Randomized Controlled Trial. Obstetrics and Gynecology. ISSN 0029-7844. 122(6), s. 1231–1238. doi: 10.1097/AOG.0000000000000012. Fulltekst i vitenarkiv Vis sammendrag

  OBJECTIVE: To evaluate whether postpartum pelvic floor muscle training decrease prevalence of any urinary incontinence (UI) in primiparous women with and without UI at inclusion (mixed population) and further to perform stratified analyses on women with and without major levator ani muscle defects. METHODS: A two-armed assessor-blinded randomized controlled trial including primiparous women 6 weeks after vaginal delivery was conducted. Participants were stratified on major levator ani muscle defects, verified by transperineal ultrasonography, and thereafter randomly allocated to training or control. All participants were taught to contract the pelvic floor muscles. The control participants received no further intervention, whereas training participants attended a weekly supervised pelvic floor muscle training class and performed daily home exercise for 16 weeks. Primary outcome was self-reported UI analyzed by relative risk. RESULTS: We included 175 women, 55 with major levator ani muscle defects and 120 without. Prevalence of UI at baseline was 39.1% in the training group (n=87) and 50% among those in the control group (n=88). Fifteen women (8.6%) were lost to follow-up. At 6 months after delivery (postintervention), 34.5% and 38.6% reported UI in the training and control groups, respectively. Relative risk analysis of UI gave a nonsignificant effect size of 0.89 (95% confidence interval [CI] 0.60–1.32). Results were similar for the stratum with and without major levator ani muscle defects, 0.89 (95% CI 0.51–1.56) and 0.90 (95% CI 0.53–1.52), respectively. CONCLUSIONS: Postpartum pelvic floor training did not decrease UI prevalence 6 months after delivery in primiparous women. Stratified analysis on women with and without major levator ani muscle defects showed similar nonsignificant results.

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• Reimers, Cathrine; Stær-Jensen, Jette; Siafarikas, Franziska; Bø, Kari & Engh, Marie Ellström (2018). Correction to: Association between vaginal bulge and anatomical pelvic organ prolapse during pregnancy and postpartum: an observational study. International Urogynecology Journal. ISSN 0937-3462. 29(3), s. 449–449. doi: 10.1007/s00192-018-3564-z. Fulltekst i vitenarkiv
• Tennfjord, Merete Kolberg; Bø, Kari; Engh, Marie Ellström; Hilde, Gunvor; Stær-Jensen, Jette & Siafarikas, Franziska (2015). EFFEKT AV BEKKENBUNNSTRENING ETTER FØDSEL FOR VAGINALE SYMPTOMER OG SEKSUELL DYSFUNKSJON- EN RANDOMISERT KONTROLLERT STUDIE. Fulltekst i vitenarkiv Vis sammendrag

  Innledning Bekkenbunnstrening er førsteledds behandling for stress inkontinens og underlivs prolaps. Det er ingen konsensus for behandling av andre vaginale symptomer eller seksuelle forhold hos førstegangsfødende kvinner etter fødsel. Målsetting var å undersøke om bekkenbunnstrening kan redusere vaginale symptomer og forbedre seksuelle forhold hos førstegangsfødende kvinner etter fødsel. Metode Et hundre sytti-fem kvinner, gjennomsnitt alder 29.8 år (SD 4.1) ble inkludert i en 2 armet blindet randomisert kontrollert studie som startet 6 uker etter fødsel. Kvinnene ble stratifisert på skade av levator ani muskelen eller ikke skade verifisert av ultralyd. Alle deltakere ble instruert i riktig bekkenbunnssammentrekning. Treningsgruppen mottok veiledet, ukentlig gruppe trening og gjorde hjemme øvelser i 16 uker, mens kontroll gruppen fikk ingen videre oppfølging. Utfallet var selv-rapporterte vaginale symptomer og seksuelle forhold undersøkt med International Consultation on Incontinence Modular Questionnaire (ICIQ) vaginal symptoms questionnaire. Resultater ble analysert som intention to treat og rapportert som relativ risk. Resultat Det var ingen forskjell mellom gruppene i forhold til de som ikke hadde samleie ved 6 måneder etter fødsel. I den totale gruppen var det ingen forskjell mellom gruppene for vaginale symptomer eller seksuelle forhold. I stratum med skade på levator ani muskelen var det i treningsgruppen signifikant færre som følte at skjeden var for “slapp” sammenlignet med kontrollgruppen 10/27 (37%) versus 19/28 (67.9%), (RR 0.55, 95%KI 0.31, 0.95, p=0.03). Diskusjon og konklusjon I tillegg til at bekkenbunnstrening er anbefalt som førsteledds behandling for stress inkontinens og underlivsprolaps, kan disse resultatene brukes som motivasjon for bekkenbunnstrening for andre typer symptomer som følelsen av å ha for “slapp skjede” hos kvinner med skade på levator ani muskelen.

• Hilde, Gunvor; Stær-Jensen, Jette Elisabeth; Siafarikas, Franziska; Gjestland, Kristin; Engh, Marie Ellström & Bø, Kari (2014). Authors' reply: How well can pelvic floor muscles with major defects contract? A cross- sectional comparative study six weeks post partum using transperineal 3D/4D ultrasound and manometer. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 121(9), s. 1174–1175. doi: 10.1111/1471-0528.12596. Fulltekst i vitenarkiv
• Tennfjord, Merete Kolberg; Bø, Kari; Engh, Marie Ellström; Hilde, Gunvor; Stær-Jensen, Jette & Siafarikas, Franziska (2013). COITAL INCONTINENCE DURING PREGNANCY AND POSTPARTUM AND ASSOCIATIONS WITH PELVIC FLOOR MUSCLES. Fulltekst i vitenarkiv Vis sammendrag

  Objective: The aim of this study was to investigate the presence of coital incontinence (CI) before pregnancy, at gestational week 21 and 37, 6 -and 12 months postpartum and associations with other symptoms of urinary incontinence (UI). Further, to compare women with CI to women with no UI in relation to vaginal resting pressure (VRP), pelvic floor muscle (PFM) strength and endurance. Background: CI is urinary leakage with sexual intercourse (1). It has been suggested that CI is linked with stress urinary incontinence (SUI) and that a weak PFM may be one cause of the condition (2). There is scant knowledge on VRP, PFM strength and endurance in relation to CI in pregnancy and the postpartum period. Methods: Three hundred nulliparous pregnant women were included in this prospective cohort study. Mean age at inclusion was 28.7 years (SD 4.3) and mean pre-pregnancy body mass index 23.9 kg/m2 (SD 3.9). At 6 weeks postpartum 71 women were recruited to a parallel ongoing randomized controlled trial and excluded from the cohort. International Consultation on Incontinence Modular Questionnaire, sexual matters module (ICIQ Flutsex) was used for data collection on the presence of CI and the perceived impact of CI on sexual life. Participants were assessed as having CI if they responded having one or more episodes of leakage during intercourse the last 3 months prior to pregnancy and the last 4 weeks at gestational week 21 and 37, 6 -and 12 months postpartum. Questions regarding pre-gestational CI were asked retrospectively at week 21. Presence of UI and type of UI was assessed by answers given for “when does urine leak?” in ICIQ-Urinary Incontinence Short Form (ICIQ UI SF). VRP, PFM strength and endurance were measured at gestational week 21, 6 –and 12 months postpartum with a vaginal balloon catheter connected to a high precision pressure transducer in combination with visual observation (3). Background variables are reported as means and SD and descriptive variables as frequencies. Between groups comparisons were analysed with Mann-Whitney U Test. P-values <0.05 were considered significant. Results: Three(1%) of the 299 women having sexual intercourse reported CI prior to pregnancy, 2(0.7% ) of 284 at gestational week 21, 2(0.9%) of 227 at gestational week 37, 6(3.4%) of 179 at 6 months and 3(1.7%) of 179 at 12 months postpartum. UI was present in 46 of 300(15%) at pre-pregnancy, 104 of 300(35%) at gestational week 21, 139 of 277(50%) at gestational week 37, 68 of 196(35%) at 6 months postpartum and in 71 of 178(40%) at 12 months postpartum. Among the 13 women reporting CI once or more; 5 women complained of SUI, 2 of urgency urinary incontinence and 2 of mixed urinary incontinence. Four reported CI only, with no symptoms of other types of UI. Mean level of bother was 5.6(SD 5.1) pre-pregnancy, 1.5(SD 2.1) at gestational week 21, 4.5(SD 2.1) at gestational week 37, 3.8(SD 2.0) at 6 months postpartum and 4.5(SD 0.7) at 12 months postpartum. VRP was statistically significantly lower in women with CI at gestational week 21 compared to continent women. PFM strength and endurance showed no statistically significant difference between the groups Conclusions: In women delivering their first child CI was a rare but moderately bothersome condition. CI often co-exists with other symptoms of UI. There was no difference in PFM strength and endurance

• Staer-Jensen, J.; Siafarikas, Franziska; Hilde, Gunvor; Bø, Kari & Engh, Marie Ellstrøm (2013). DO MAJOR DEFECTS OF THE LEVATOR ANI MUSCLE HEAL WITHIN THE FIRST 6 MONTHS POSTPARTUM? Neurourology and Urodynamics. ISSN 0733-2467. 32(6), s. 650–651. Fulltekst i vitenarkiv
• Reimers, Cathrine; Stær-Jensen, Jette; Siafarikas, Franziska; Benth, Jurate Saltyte; Bø, Kari & Engh, Marie Ellstrøm (2013). Pelvic organ support assessed during pregnancy and post partum; a cohort study following 229 nulliparous pregnant women from mid-pregnsncy until one year post portum using pop q. Neurourology and Urodynamics. ISSN 0733-2467. 32(6), s. 809–811. Fulltekst i vitenarkiv
• Stær-Jensen, Jette; Siafarikas, Franziska; Hilde, Gunvor; Bø, Kari & Engh, Marie Ellström (2013). Ultrasonographic Evaluation of Pelvic Organ Support During Pregnancy EDITORIAL COMMENT. Obstetrical and Gynecological Survey. ISSN 0029-7828. 68(11), s. 735–736. Fulltekst i vitenarkiv
• Bø, Kari; Hilde, Gunvor; Tennfjord, M.K.; Jensen, Johan Skog; Siafarikas, Franziska & Engh, Marie Ellstrøm (2013). RANDOMIZED CONTROLLED TRIAL OF PELVIC FLOOR MUSCLE TRAINING TO PREVENT AND TREAT PELVIC ORGAN PROLAPSE IN POSTPARTUM PRIMIPAROUS WOMEN. Neurourology and Urodynamics. ISSN 0733-2467. 32(6), s. 806–807. Fulltekst i vitenarkiv
• Tennfjord, Merete Kolberg; Bø, Kari; Engh, Marie Ellström; Hilde, Gunvor; Siafarikas, Franziska & Stær-Jensen, Jette (2012). DYSPAREUNIA IN RELATION TO PELVIC FLOOR MUSCLE FUNCTION - A LONGITUDINAL STUDY FROM PREGESTATION TO SIX MONTHS POSTPARTUM. Fulltekst i vitenarkiv Vis sammendrag

  Objective: The aim of the present study was to investigate the presence of dyspareunia from pregestation to six months postpartum. Further, to study dyspareunia in relation to pelvic floor muscle (PFM) function. Background: To date there is scant knowledge on female sexual dysfunction (FSD) in relation to PFM function. Dyspareunia is pain or discomfort related to sexual intercourse (1), and is an area of controversy with respect to prevalence, underlying causes and treatment (2). Methods: Three hundred nulliparous pregnant women, mean age at inclusion 28.7 (range 19-40, SD 4.3) and prepregnancy BMI 23.9 (SD 3.9) were included in this prospective cohort study. Inclusion criteria: ability to speak and understand the native speaking language. Exclusion criteria: multiple pregnancies or premature birth <32w. Ongoing exclusion criteria: previous miscarriage after week 16, still birth and serious illness of mother or child. International Consultation on Incontinence Modular Questionnaire, sexual matters module (ICIQ-FLUTSex) were used to collect data regarding the presence of dypareunia and the perceived impact of dyspareunia on sexual life, on a scale ranging from 0-10. Zero being no impact and 10 major impact. Dyspareunia was defined as one or more episodes of pain during intercourse the last 3 months before the pregnancy and the last 4 weeks at gestational week 22 and 37, 6 weeks- and 6 months postpartum. Questions regarding pregestational dyspareunia were asked retrospectively. Vaginal resting pressure (VRP), maximum voluntary contraction (MVC) and PFM endurance were measured at gestational week 22, 6 weeks- and 6 months postpartum with fiberoptic pressure transducer connected to a vaginal balloon catheter (camtech AS) in combination with visual observation. The method is assessed to be reliable and valid (3). Background variables are reported as means with range and SD and descriptive variables as frequencies. VRP, MVC and PFM endurance are reported as means and SD. Between groups comparisons were analysed with Independent Samples T-Test. P-values < 0.05 were considered significant. Results: Women not having sexual intercourse were 15 (5 %) at gestational week 22, 50 (18 %) at gestational week 37, 182 (65 %) at 6 weeks- and 20 (10 %) at 6 months postpartum. 83 (27.7 %) of the 299 women having sexual intercourse reported dyspareunia during the last 3 months before pregnancy, 87 (30.5% ) of 285 at gestational week 22, 94 (41 %) of 227 at gestational week 37, 52 (52.5 %) of 99 at 6 weeks- and 81 (44.7 %) of 181 at 6 months postpartum. Mean perceived impact of dyspareunia was 3.4 (SD 2.5) prepregnancy, 3.5 (SD 2.3) at gestational week 22, 4.0 (SD 2.5) at gestational week 37, 4.7 (SD 2.9) at 6 weeks- and 4.5 (SD 2.9) at 6 months postpartum. There were no statistically significant differences in VRP, MVC and PFM endurance in women with and without dyspareunia at gestational week 22, 6 weeks- and 6 months postpartum. Conclusions: To our knowledge this is the first longitudinal study on dyspareunia following first time pregnant mothers from gestational week 22 to 6 months postpartum, including clinical assessment of PFM function. The prevalence of dyspareunia was high even before pregnancy, rose during pregnancy and was 45 % at 6 months postpartum. There was no difference in VRP, MVC or PFM endurance in women with and without dyspareunia

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