Background
Little progress has been made in the prevention of pelvic floor disorders, despite
their significant health and economic impact. The identification of women who are
at risk remains a key element in targeting prevention and planning health resource
allocation strategies. Although events around the time of childbirth are recognized
clinically as important predictors, it is difficult to counsel women and to intervene
around the time of childbirth because of an inability to convey a patient’s risk accurately
in the presence of multiple risk factors and the long time lapse, which is often decades,
between obstetric events and the onset of pelvic floor disorders later in life. Prediction
models and scoring systems have been used in other areas of medicine to identify patients
who are at risk for chronic diseases. Models have been developed for use before delivery
that predict short-term risk of pelvic floor disorders after childbirth, but no models
that predict long-term risk exist.
Objective
The purpose of this study was to use variables that are known before and during childbirth
to develop and validate prognostic models that will estimate the risks of these disorders
12 and 20 years after delivery.
Study Design
Obstetric variables were collected from 2 cohorts: (1) women who gave birth in the
United Kingdom and New Zealand (n=3763) and (2) women from the Swedish Medical Birth
Register (n=4991). Pelvic floor disorders were self-reported 12 years after childbirth
in the United Kingdom/New Zealand cohort and 20 years after childbirth in the Swedish
Register. The cohorts were split so that data during the first half of the cohort’s
time period were used to fit prediction models, and validation was performed from
the second half (temporal validation). Because there is currently no consensus on
how to best define pelvic floor disorders from a patient’s perspective, we chose to
fit the data for each model using multiple outcome definitions for prolapse, urinary
incontinence, fecal incontinence, ≥1 pelvic floor disorder, and ≥2 pelvic floor disorders.
Model accuracy was measured in the following manner: (1) by ranking an individual’s
risk among all subjects in the cohort (discrimination) with the use of a concordance
index and (2) by observing whether the predicted probability was too high or low (calibration)
at a range of predicted probabilities with the use of visual plots.
Results
Models were able to discriminate between women who experienced bothersome symptoms
or received treatment at 12 and 20 years, respectively, for pelvic organ prolapse
(concordance indices, 0.570, 0.627), urinary incontinence (concordance indices, 0.653,
0.689), fecal incontinence (concordance indices, 0.618, 0.676), ≥1 pelvic floor disorders
(concordance indices, 0.639, 0.675), and ≥2 pelvic floor disorders (concordance indices,
0.635, 0.619). Route of delivery and family history of each pelvic floor disorder
were strong predictors in most models. Urinary incontinence before and during the
index pregnancy was a strong predictor for the development of all pelvic floor disorders
in most models 12 years after delivery. The 12- and 20-year bothersome symptoms or
treatment for prolapse models were accurate when predictions were provided for risk
from 0% to approximately 15%. The 12- and 20-year primiparous model began to over
predict when risk rates reached 20%. When we predicted bothersome symptoms or treatment
for urinary incontinence, the 12-year models were accurate when predictions ranged
from approximately 5–60%; the 20-year primiparous models were accurate from 5% and
80%. For bothersome symptoms or treatment for fecal incontinence, the 12- and 20-year
models were accurate from 1–15% risk and began to over predict at rates at >15% and
20%, respectively.
Conclusion
Models may provide an opportunity before birth to identify women who are at low risk
of the development of pelvic floor disorders and may provide institute prevention
strategies such as pelvic floor muscle training, weight control, or elective cesarean
section for women who are at higher risk. Models are provided at http://riskcalc.org/UR_CHOICE/.
Key words
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Article Info
Publication History
Published online: October 19, 2017
Accepted:
October 12,
2017
Received in revised form:
October 1,
2017
Received:
August 7,
2017
Footnotes
Supported in Sweden by a national grant (no. 11315) and grants from the Region of Västra Götaland, the Göteborg Medical Society and the Hjalmar Svenssons Fund, Sweden, and, in the UK/New Zealand, by the Wellbeing of Women/Royal College of Obstetricians and Gynaecologists and the Health Research Council of New Zealand.
The study sponsors did not participate in the study design, collection, analysis and interpretation of the data; the writing of the report or the decision to submit the paper for publication.
Dr Jelovsek receives royalties from UpToDate; Dr Barber receives royalties from UpToDate, Elsevier; Dr Gyhagen receives an honoraria from Astellas Pharma for speaker participation; Mr Elders receives statistical consulting fees and support consisting of travel for relevant meetings from University of Gothenburg; Dr Milsom received a grant (National LUA/ALF Grant no 11315) and an honorarium for lecture from SCA, Astellas Pharma, Allergan. Remaining authors report no conflict of interest.
Cite this article as: Jelovsek JE, Chagin K, Gyhagen M, et al. Predicting risk of pelvic floor disorders 12 and 20 years after delivery. Am J Obstet Gynecol 2018;218:222.e1-19.
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