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Indonesian Journal ofObstetrics and Gynecology

Majalah Obstetri dan Ginekologi Indonesia

Print ISSN: 2338-6401 — Online ISSN: 2338-7335

Official publication ofIndonesian Society of Obstetrics and Gynecology

www.indonesia.digitaljournals.org/index.php/IJOG

VOLUME 3, NO. 3, PAGE 121–182, July 2015

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Editorial

Daily Application of Evidence-Based Medicine

Research Articles

Husband's Support is a Main Factor Associated with Contraceptive Practices...

Female Sexual Function at Three Months Post-delivery in Spontaneous Labor and Cesarean Section...

Diagnostic Value of IGFBP-1 Rapid Test and Combined IGFBP-1-AFP in Vaginal Fluid from Premature Rupture of Amniotic Membranes...

CC-Human Menopausal Gonadotropin Combined with Growth Hormone in Mini-stimulation Protocol could Improve Clinical Outcome in Poor Ovarian Responders...

Endometrial Histology in Abnormal Uterine Bleeding with Risk Factors...

Pentoxifylline as a Therapy for Thin Endometrial Lining in Infertility...

IIIB-IV Degree Perineal Rupture Repair Using Overlapping and End-to-End Techniques with Pudendal Block Anesthesia...

Accuracy of Intraoperative Frozen Section in Diagnosing Malignancy of Ovarian Neoplasm...

p53 Gene Codon 72 Polymorphisms among Cervical Carcinoma Patients...

Effect of Smoking on Advanced Stage Cervical Cancer Patient Survival

Case Series

Pereira Suture: an Alternative Compression Suture to Treat Uterine Atony

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EDITORIAL BOARD

INDONESIAN JOURNAL OF OBSTETRICS AND GYNECOLOGYIndones  J Obstet Gynecol

Majalah Obstetri dan Ginekologi  Indonesia

Chief Editor Dr. dr. Junita Indarti, SpOG(K)Vice Chief Editor Dr. dr. Dwiana Ocviyanti, SpOG(K)Managing Editor Prof. dr. Med. Ali Baziad, SpOG(K)Prof. Dr. dr. Wachyu Hadisaputra, SpOG(K)Dr. dr. Noroyono Wibowo, SpOG(K)dr. Omo A Madjid, SpOG(K)Dr. dr. Eka R Gunardi, SpOG(K)dr. Andon Hestiantoro, SpOG(K)

Dr. dr. Ali Sungkar, SpOG(K)Dr. Med. Damar Prasmusinto, SpOG(K)dr. Kanadi Sumapraja, SpOG(K), MScdr. Herbert Situmorang, SpOG(K)Dr. dr. Yuditya Purwosunu, SpOG(K)Peer Reviewer this edition Prof. Dr. dr. Andrijono, SpOG(K) (Jakarta, Gynecologic Oncology)Prof. dr. Ariawan Soejoenoes, SpOG(K) (Semarang, Social Obstetrics and Gynecology)dr. Arietta Pusponegoro, SpOG(K) (Jakarta, Social Obstetrics and Gynecology)Dr. dr. Budi Wiweko, SpOG(K) (Jakarta, Reproductive Immunoendocrinology)Prof. Dr. Djamhoer Martaadisoebrata, SpOG(K) ( Bandung, Social Obstetrics and Gynecology)Dr. dr. Fidel G Siregar, SpOG(K) (Medan, Reproductive Immunoendocrinology)Dr. dr. Hariyono Winarto, SpOG(K) (Jakarta, Gynecology Oncology)Dr. dr. Hendy Hendarto, SpOG(K) (Surabaya, Reproductive Immunoendocrinology)dr. Heru Pradjatmo, SpOG(K) (Yogyakarta, Gynecology Oncology)dr. Nuswil Bernolian, SpOG(K) (Palembang, Fetomaternal)Dr. dr. Suskhan Djusad, SpOG(K) (Jakarta, Urogynecology)dr. Gita Pratama, SpOG (Jakarta, Reproductive Immunoendocrinology)Dr. dr. Sri Sulistyawati, SpOG(K) (Surakarta, Fetomaternal)Dr. dr. Tatit Nurseta, SpOG(K) (Malang, Gynecology Oncology)Dr. dr. Tono Djuwantono, SpOG(K), M.Kes (Bandung, Reproductive Immunoendocrinology)

International Peer Reviewer Prof. Togas Tulandi, MD, MHCM (Milton Leong Chair in Reproductive Medicine,McGill University, Montreal Canada)English Consultant dr. Ditha Adriana LohoAdministrative Staff Frachma Della Siregar, Eko Subaktiansyah

Publisher Indonesian Society of Obstetrics and GynecologyFirst Published July 1st 1974

Legal Information Ministers Decision Republic of Indonesia No. 016/KHS/DIT.P/II.1a/74Secretariat Address PKMI Building, Ground FloorKramat Sentiong Street 49A, Central Jakarta, 10450, IndonesiaTelephone: 021-3916670, Faximile: 021-3916671E-mail: inajog.indonesia@gmail.com; majalah_mogi@yahoo.comWebsite: www.indonesia.digitaljournals.org/index.php/IJOG

Printed by Tridasa Printer, Jakarta. Print ISSN 2338 – 6401  Online ISSN 2338 – 7335

Majalah Obstetri dan Ginekologi Indonesia (MOGI) is the official publication of the Association of Obstetrics andGynecology Indonesia since 1974. In 2010, the name is changed into Indonesian Journal Obstetrics and Gynecology(INAJOG). Due to this fact, we announced that the ISSN number will be changed from ISSN 0303-7924 into 2338-6401,and starting from July 2013 edition, the volume will be changed into Volume 1 No 3.

Accredited (2014-2019) by the Directorate General of Higher Education ofthe Ministry of Education and Culture of the Republic of Indonesia

(No.:212/P/2014, 3 Juli 2014)

Guideline for contributorsIndonesian Journal of Obstetrics and Gynecology will be pleasedto receive material contributed by anyone interested in obstetricsand gynecology, in the form of research report, literature review,or case report. With condition the material submitted to theIndonesian Journal of Obstetrics and Gynecology should neverhave been or will not be submitted to any other publication.Manuscript should be written in English. Author should followthe manuscript preparation guide:1. Title, should be brief, specific and informative. Include a short title(not exceeding 40 letters and spaces).2. Name of Author(s), should include full names of authors, addressto which proofs are to be sent, name and address of the Depart-ment(s) to which the works should be attributed.3. Abstract, concise description (not more than 250 words) of thebackground, purpose, methods, results and conclusions required.Keywords (3 - 5 words) should be provided below the abstract.4. Introduction, comprises the problem’s background, its formulationand purpose of the work and prospect for the future.5. Method, containing clarification on used materials and scheme ofexperiments. Method to be explained as possible in order to enableother examiners to undertake retrial if necessary. Reference shouldbe given to the unknown method.6. Result, should be presented in logical sequence with minimumnumber of tables and illustrations necessary for summarizing onlyimportant observations. The vertical and horizontal line in the tableshould be made at the least to simplify the view. Mathematical

equations, should be clearly stated. Decimal numbers should beseparated by point (.). Tables, illustration, and  photographsshould be cited in the text in consecutive order. Explain in footnotesall non-standard abbreviations that are used.7. Discussion, explaining the meaning of the examination’s results,in what way the reported result can solve the problems, differencesand equalities with previous study and development possibilities.This section should include the conclusion of the reported workand suggestion for further studies if necessary.8. Conclusion, answer(s) to the research question, should be writtenin brief and clear descriptive sentences.9. Reference, should be arranged according to the Vancouver system.References must be identified in the text by the super script Arabicnumerals and numbered in consecutive order as they are men-tioned in the text. The reference list should appear at the end ofthe articles in numeric sequence.I. Research reports preparation guidelinesThe text of research report should be devided into the followingsections: title,  name  of  author(s), abstract, objective, method,result that ended by conclusion, references.II. Reviews article preparation guidelinesThe text of literature reviews should be devided into the followingsections: title, name of author(s), abstract, introduction, over­view that ended by conclusion, references.III. Case reports preparation guidelinesThe text of case reports should be devided into the following sec-tions: title, name  of  author(s), abstract, introduction, case(s),and case management that completed with photograph/descrip-tive illustrations, discussion that ended by conclusion, refer­ences.Each article contains a maximum of three graphs. Colour or blackand white photographs must be submitted with clear illustrations andgraphs. Photographs should be prepared with the minimum size of125 x 195 mm2.The manuscript should be submitted in a compact disc and betyped using MS Word program, which are typed 1.5 lines space withwide margins on A4 paper. The length of article should not exceed 12pages. The left, right, top, and bottom margin should be 2.5 cm or 1inch length. The editor reserves the right to edit manuscript, fit articlesinto available, and ensure conciseness, clarity, and stylistic consistency.All accepted manuscript and their accompanying illustration becomethe permanent property of publisher, and may not be published else-where in full or in part, in print or electronically, without written per-mission from publisher. All data’s, opinion or statement appear on themanuscript are the sole responsibility of the contributor. Accordingly,the Publisher, the Editorial board, and their respective employees ofthe Indonesian Journal of Obstetrics and Gynecology accept no re-sponsibility or liability what so ever for the consequences of any suchinaccurate or misleading data, opinion, or statement. Ethical clearanceshould be attached on research report and case report article.

Pedoman untuk penulisIndonesian Journal of Obstetrics and Gynecology menerima sum-bangan tulisan dari para dokter di seluruh Indonesia yang tertarikdalam kebidanan dan kandungan, dalam bentuk laporan penelitian,tinjauan pustaka, atau laporan kasus. Naskah tersebut belum per-nah dan tidak akan diserahkan ke penerbit lain. Naskah harus di-tulis dalam bahasa Inggris. Penulis harus mengikuti panduan pe-nulisan naskah sebagai berikut:1. Judul, harus jelas, spesifik, informatif dan singkat (tidak melebihi 40huruf dan spasi).2. Nama Penulis, harus menyertakan nama lengkap penulis, alamatlengkap, nama dan alamat departemen.3. Abstrak, keterangan ringkas (tidak lebih dari 250 kata) dari latarbelakang, tujuan, metode, hasil dan kesimpulan yang diperlukan.Kata kunci (3 - 5 kata) harus disediakan di bawah abstrak.4. Pendahuluan, menunjukkan latar belakang masalah, tata cara pe-nelitian, tujuan diadakannya penelitian, serta prospeknya di masadepan.5. Metode, merupakan penjelasan tentang bahan yang digunakan danskema percobaan. Metode harus jelas untuk memungkinkan penelitilain untuk melakukan penelitian ulang. Untuk metode yang kurangjelas harus diberikan penjelasan.6. Hasil, disusun dalam urutan logis, jumlah tabel dan ilustrasi mini-mum dan hanya pada hasil penelitian yang sangat penting. Garisvertikal dan horisontal dalam tabel harus dihilangkan. Persamaan

Matematika, harus diuraikan dengan jelas. Nomor desimal, harusdipisahkan oleh koma (,). Tabel,  ilustrasi, dan  foto, harus dikutipberurutan. Jelaskan dalam catatan kaki semua singkatan tidak stan-dar yang digunakan.7. Diskusi, menjelaskan makna hasil pembahasan, dengan cara bagai-mana hasil dilaporkan dapat memecahkan masalah, perbedaan dankesamaan-kesamaan dengan studi sebelumnya dan kemungkinanpembangunan. Bagian ini harus mencakup kesimpulan pembahasantersebut dan saran untuk studi lebih lanjut jika diperlukan.8. Kesimpulan, merupakan jawaban atas pertanyaan penelitian. Di-tuliskan dalam kalimat-kalimat deskriptif yang singkat dan jelas.9. Referensi, harus disusun menurut sistem Vancouver. Referensi harusdiidentifikasi dalam teks dengan angka-angka Arab dan nomor su-perscript agar berturut-turut seperti yang disebutkan dalam teks.Daftar referensi harus terlihat diakhir artikel dalam urutan numerik.I. Pedoman penyusunan  laporan penelitianLaporan penelitian harus ditulis dalam format sebagai berikut:judul, nama penulis, abstrak, pendahuluan, tujuan, metode, ha­sil yang diakhiri dengan kesimpulan, referensi.II. Pedoman penyusunan tinjauan pustakaTinjauan pustaka harus dibagi menjadi bagian berikut: judul, na­ma penulis, abstrak, pendahuluan, tinjauan yang diakhiri dengankesimpulan, referensi.III. Pedoman penyusunan  laporan kasusLaporan kasus harus dibagi menjadi bagian berikut: judul, namapenulis, abstrak, pendahuluan, kasus, dan manajemen  kasusyang dilengkapi dengan foto/ilustrasi deskriptif, diskusi yang di-akhiri dengan kesimpulan, referensi.Setiap artikel berisi maksimal tiga grafik. Foto warna atau hitamputih yang diserahkan harus jelas baik ilustrasi atau grafiknya. Fotoharus disiapkan dengan ukuran minimum 125 x 195 mm2.Naskah diserahkan dalam compact disc, email, atau flash disc dandiketik menggunakan program MS Word. Ketentuan pengetikan sebagaiberikut: jarak baris 1,5 spasi dengan ukuran kertas A4. Panjang artikeltidak boleh lebih dari 12 halaman. Batas kiri, kanan, atas, dan bawahharus 2,5 cm atau 1 inci. Redaksi berhak mempunyai arsip, menyuntingartikel, memastikan keringkasan, kejelasan, dan konsistensi gaya sesuaistandar penerbitan IJOG. Semua naskah diterima dan ilustrasi yangmenyertainya menjadi milik penerbit permanen, dan penulis tidak diper-bolehkan mempublikasikan secara penuh atau sebagian, di media cetakatau elektronik selain IJOG, tanpa izin tertulis dari penerbit. Semua data,pendapat atau pernyataan muncul pada naskah merupakan tanggungjawab kontributornya. Oleh karena itu, Penerbit, Dewan redaksi, dankaryawan Indonesian  Journal of Obstetrics and Gynecology tidakbertanggung jawab atau berkewajiban apapun atas konsekuensi darisetiap data, pendapat, atau pernyataan yang tidak akurat atau menye-satkan.

INDONESIAN JOURNAL OF OBSTETRICS AND GYNECOLOGYIndones  J Obstet Gynecol

Majalah Obstetri dan Ginekologi  Indonesia

CONTENTVolume 3, Number 3, Page 121 – 182, July 2015Editorial

Junita  IndartiJakarta 122 Daily Application of Evidence­Based Medicine

Research ArticlesDarrell FernandoRachmat DediatJakarta 123 Husband’s Support is a Main Factor Associated with Contraceptive PracticesHusband’s support is a main factor associated with contraceptive practice. The choice of contracep-tive method should be adjusted according to the ability and desire of patients to prevent failuresin family planning.

SuntoroI Putu G KayikaJakarta 127 Female Sexual Function at Three Months Post­delivery in Spontaneous

Labor and Cesarean SectionSpontaneous labor is statistically significant for sexual dysfunction at three months post-delivery,especially for sexual encouragement and orgasm accession. Meanwhile, the variables with the ageof 30 years old or older of age were influential on sexual dysfunction, especially to the sexual sti-muli variable.Aryati

Lulut KusumawatiAgus SulistyonoSurabaya

133 Diagnostic  Value  of  IGFBP­1  Rapid  Test  and  Combined  IGFBP­1­AFP  inVaginal Fluid from Premature Rupture of Amniotic MembranesCombined IGFBP-1-AFP rapid test has a better diagnostic value than IGFBP-1 rapid test alone.

Arie A PolimIvan R Sini

Indra NC AnwarCaroline HutomoAryando Pradana

KurniawatiErliana FaniJakarta

140 CC­Human Menopausal Gonadotropin Combined with Growth Hormone inMini­stimulation Protocol could Improve Clinical Outcome in Poor OvarianRespondersCC-HMG regimen in mini-stimulation protocol is an effective option in poor responders.Additional GH in mini-stimulation program provided a higher number of top qualityembryos in women older than 40 years old, although there were no difference in clinical orongoing pregnancy rate.

Rudy HasanEddy Suparman

Rudy A LengkongManado146 Endometrial Histology in Abnormal Uterine Bleeding with Risk FactorsThere is a significant relationship between BMI and high fasting blood glucose with endometrialhyperplasia.

Muharam NatadisastraRiyan H Kurniawan

Devi M MalikJakarta151 Pentoxifylline as a Therapy for Thin Endometrial Lining in InfertilityThere was significant improvement of endometrial lining after pentoxifylline therapy.

Nuring PangastutiJunizaf

Ibnu PranotoBudi  I SantosoTyas PriyatiniYogyakarta, Jakarta

154 IIIB­IV Degree Perineal Rupture Repair Using Overlapping and End­to­EndTechniques with Pudendal Block AnesthesiaThere was no difference in the incidence of persistent sonographic anal sphincter defects, fecalurgency, anal incontinence, and fecal incontinence, after IIIb-IV degree perineal rupture repairusing overlapping technique in comparison with end-to-end technique.

Tofan W UtamiJasmine  Iskandar

Gregorius TanamasMona  JamtaniLaila Nuranna

Kartiwa H NuryantoJakarta161 Accuracy  of  Intraoperative  Frozen  Section  in  Diagnosing Malignancy  of

Ovarian NeoplasmWe found that the accuracy of intraoperative frozen section in our facility is adequate to diagnoseovarian neoplasm and can be used to assist in determining the extent of surgical management.Rustham BasyarAgustria Z Saleh

Irawan SastradinataYuwonoPalembang

165 p53 Gene Codon 72 Polymorphisms among Cervical Carcinoma PatientsProline mutation to Arginine in gene p53 P72R is one of the risk factor for cervical carcinoma.Bram Pradipta

AndrijonoAhmad FuadyJakarta

170 Effect of Smoking on Advanced Stage Cervical Cancer Patient SurvivalIn our study, smoking habits do not aggravate survival rate of advanced stage cervical cancerpatients but further research must be done with more sample. Stage, and tumor size both byphysical examination and ultrasound can be used as the prognostic factor.Case Series 

Agung B SetiyonoAlamsyah AzizAgus SulistyonoJohanes C MoseBandung, Surabaya

177 Pereira Suture: an Alternative Compression Suture to Treat Uterine AtonyPereira suture is an alternative surgical procedure for the treatment of uterine atony after failedconservative management.

Research Article

IIIB-IV Degree Perineal Rupture Repair Using Overlapping andEnd-to-End Techniques with Pudendal Block Anesthesia

Hasil Reparasi Robekan Perineum Derajat IIIB-IV Teknik Tumpang Tindihdan Ujung ke Ujung dengan Anestesi Blok Pudendal

Nuring Pangastuti1, Junizaf2, Ibnu Pranoto1, Budi I Santoso2, Tyas Priyatini2

Department of Obstetrics and Gynecology1Faculty of Medicine University of Gadjah Mada

Dr. Sardjito Central General HospitalYogyakarta

2Faculty of Medicine University of IndonesiaDr. Cipto Mangunkusumo General Hospital

Jakarta

INTRODUCTION

Vaginal deliveries remain regarded as the most se-cure and economical delivery procedures.1 In well-

conducted aid measures for vaginal delivery, morethan 85% of women experience perineal trauma, andabout 60-70% of them require repair. Some patients

Abstract

Objective: To compare the incidence of persistent sonographic analsphincter defect, fecal urgency, anal and fecal incontinence after IIIb-IV degree perineal rupture repair using overlapping and end-to-endtechnique.

Method: An open clinical trial with randomization was carried out inJuly 2010-April 2012. The population consisted of the patients whounderwent vaginal delivery in Dr. Sardjito Central General Hospital,Sleman District General Hospital, as well as Tegalrejo, Jetis and Mer-gangsan Community Health Centers who did no have complaints offecal urgency, anal incontinence, and/or fecal incontinence, and suf-fered IIIb-IV degree perineal rupture repaired within less than 24hours of rupture. The exclusion criteria included conditions in whichpatients could not undergo repair at the moment (shock, uncoopera-tive patient). Fourty-eight research samples were divided into 2groups, 24 samples for each of the treatment group (overlapping re-pair) and the control group (end-to-end repair). Local anesthesia wasperformed in a pudendal-block manner.

Result: Success of the repair was assessed based on the presence ofpersistent sonographic anal sphincter defects in the 6-week evaluationafter repair. Successful repair was higher in the overlapping groupthan that of the end-to-end group (94.74% vs 81.25%, p=0.31).Clinically and based on the Fecal Continence Scoring Scale (FCSS),evaluation at weeks II and VI indicated successful repair in bothgroups.

Conclusion: There was no difference in the incidence of persistentsonographic anal sphincter defects, fecal urgency, anal incontinence,and fecal incontinence, after IIIb-IV degree perineal rupture repairusing overlapping technique in comparison with end-to-end tech-nique.

[Indones J Obstet Gynecol 2015; 3: 154-160]

Keywords: end-to-end technique, III-IV degree perineal rupture,obstetric perineal rupture, overlapping technique

Abstrak

Tujuan: Untuk membandingkan kejadian persistent sonographic analsphincter defect, urgensi fekal, inkontinensia anal maupun fekal, pasca-reparasi robekan perineum derajat IIIb-IV dengan teknik tumpang tin-dih dan ujung ke ujung.

Metode: Dilakukan penelitian uji klinis terbuka dengan randomisasipada bulan Juli 2010-April 2012. Kriteria inklusi adalah pasien per-salinan pervaginam di RSUP Dr. Sardjito, RSUD Kabupaten Sle-man, Puskesmas Tegalrejo, Jetis dan Mergangsan, Yogyakarta, yangsebelumnya tidak memiliki keluhan urgensi fekal, inkontinensia anal,dan/atau inkontinensia fekal, yang mengalami robekan perineumderajat IIIb-IV dengan reparasi kurang dari 24 jam sejak kejadianruptur. Kriteria eksklusi adalah pasien yang tidak memungkinkan un-tuk dilakukan reparasi saat itu (syok, tidak dapat bekerja sama). Em-pat puluh delapan sampel penelitian dibagi dalam dua kelompok,masing-masing 24 sampel pada kelompok perlakuan (reparasi tum-pang tindih) dan kelompok kontrol (reparasi ujung ke ujung). Anestesilokal dilakukan secara blok pudendal.

Hasil: Keberhasilan reparasi dinilai dari gambaran persistent sonographicanal sphincter defect 6 minggu pascareparasi. Keberhasilan pada kelompoktumpang tindih lebih tinggi dibandingkan kelompok ujung ke ujung(94,74% vs 81,25%, p=0,31). Secara klinis maupun berdasarkan FCSS(Fecal Continence Scoring Scale), evaluasi minggu kedua dan keenammenunjukkan keberhasilan reparasi di kedua kelompok.

Kesimpulan: Tidak terdapat perbedaan kejadian persistent sonographicanal sphincter defect, urgensi fekal, inkontinensia anal maupun fekal pas-careparasi robekan perineum derajat IIIb-IV dengan teknik tumpangtindih dan teknik ujung ke ujung.

[Maj Obstet Ginekol Indones 2015; 3: 154-160]

Kata kunci: robekan perineum obstetri, robekan perineum derajat III-IV, teknik tumpang tindih, teknik ujung ke ujung

Correspondence: Nuring Pangastuti, Blunyah Gede 214 RT 12/34, Sinduadi Mlati, Sleman, Yogyakarta. Telephone: 0274-587333 (ext:291),0274-544003, 08122703752. Email: nuring_nw@yahoo.co.id

Indones J154 Pangastuti et al Obstet Gynecol

even experience III-to-IV degree perineal rupture.Research in Europe shows that as many as 0.5-3%of III-IV degree perineal rupture can be encoun-tered, while in the United States the incidence reach6-9%, with some sources reporting it to be 20%.2-5

The incidence varies due to differences in the systemused to measure the rupture degree, ignorance ofboth delivery helpers and delivery patients, as wellas the assumption that perineal trauma and its ac-companying problems are something normal as aconsequence of vaginal deliveries.6

The standard technique for III-IV degree perinealrupture repair is external anal sphincter suturing us-ing an end-to-end technique. In 1999, Sultan et alintroduced a new technique, namely an overlappingtechnique, and reported a decrease in the incidenceof anal incontinence from 41% to around 8% inpatients undergoing an overlapping repair technique.Research by Fernando et al noted the incidence offecal urgency to be 32% in end-to-end cases and3.7% in overlapping cases (p=0,02).7

Perineum is the outer door of the pelvis that isdivided into 2 triangles. The front triangle is calledthe urogenital triangle, and the triangle located be-hind the end of the anal canal is the anal triangle.The anal sphincter complex spans 3-4 cm in lengthand consists of external and internal anal sphincters.’Loop concepts’ (upper, middle, and basal loops)feature a single sphincter unit, which have differentstructures and functions.8-11 The perineal body is athree-dimensional central point between the uro-genital triangle and the anal triangle, consisting ofthe bulbospongiosus muscle fibers, superficialtransverse perineal muscle fibers and external analsphincter muscles.8,11-13

Several risk factors for perineal rupture includeprolonged second stage, precipitated parturition, ahistory of perineal rupture, large babies, malposi-tion, instrument-assisted delivery, short perineum,and episiotomy, as well as infiltration of local anes-thetics.1,3,12,14-17 There are two types perineal rup-ture due to obstetric anal sphincter injuries, overtand occult. The latter type usually occurs as a resultof the error determining the diagnosis, when theIII-IV degree perineal rupture is considered to beII degree.18

According to Sultan, there are classifications forperineal trauma, namely grade I, which compriseonly the vaginal epithelium or perineal skin lacera-tions; grade II, when only involving the perinealmuscles; grade III, which is rupture that reaches the

anal sphincter, which is further divided into IIIa(<50% of the external anal sphincter), IIIb (>50%of the thickness of the external anal sphincter), andIIIc (when the rupture reaches the internal analsphincter); and grade IV, which is the III-degreerupture accompanied with anal mucosa.3,7,16,19,20

Obstetricians have recognized the end-to-endtechnique since a long time ago as traditional/stand-ard techniques. The overlapping technique is morewidely used by colorectal surgeons and in gyneco-logy in cases of fecal incontinence. In general, theresults of the repair depend highly on the diagnosticaccuracy, the selected repair technique, the threadused, as well as post-repair treatment. Local anes-thesia (infiltration or pudendal block) can be usedon almost all measures of perineal repair, althoughgeneral or regional anesthesia produces bettersphincter relaxation.3,7,9,21-23 Evaluation on results ofrepair is performed at weeks 1, 2, 6, and 3 monthsafter repair. Complaints to be evaluated are com-plaints related to suturing, possibility of infectionup to dehiscence, impaired urination, defecation anddyspareunia.5 Evaluation in the third month can bedone using ultrasonography, anal manometry, elec-tromyography, measurement of pudendal nerve ter-minal latency time, and magnetic resonance imaging(MRI).21,24-27

Pudendal nerves are somatic nerves found in thepelvic region that innervate the external genitalia inboth men and women. These nerves originate fromthe sacral plexus, from the S2 to S4 ventral rami.The pudendal block anesthesia provides local anes-thesia to the perineal region and to approximatelythe lower third of the vagina. Complications includeallergic reactions, systemic toxic reactions, vaginalwall lacerations, hematoma, infections and subglu-teal abscess, until fatal complications (convulsionsto death).11,23,28-30 The anesthetic drug of lignocaine1-2% either with or without adrenaline is dilutedinto 0.5%. The maximum dose is 4 mg/kg bodyweight for lignocaine without adrenaline, and 7mg/kg weight for lignocaine with adrenaline(1:200.000).31 The pudendal-block anesthetic tech-nique is a relatively inexpensive anesthetic tech-nique, is quite easy to perform and can be done inall delivery-assisting places.

In this study, we aim to compare the incidenceof persistent sonographic anal sphincter defect, fecalurgency, anal and fecal incontinence after IIIb-IVdegree perineal rupture repair using overlapping andend-to-end technique.

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METHODS

This study was an open clinical trial with computerrandomization. Patients were divided into twogroups, the treatment group receiving overlappingperineal rupture repair, and the control groupreceiving end-to-end repair.

The population consisted of patients who under-went vaginal delivery with perineal rupture degreesIIIb, IIIc or IV, hospitalized in Dr. Sardjito CentralGeneral Hospital, Sleman District General Hospitals,as well as Tegalrejo, Jetis and Mergangsan Commu-nity Health Centers in Yogyakarta. The inclusion cri-teria included patients without previous complaintsof fecal urgency, fecal or anal incontinence, with therepair being performed within less than 24 hours ofthe rupture, and the patients were willing to partici-pate in the study. The exclusion criteria included con-ditions where the patients could not undergo repairat the moment (shock or uncooperative patient). Thestudy was conducted from July 2010 until April 2012.

The independent variable consisted of perinealrupture degrees IIIb, IIIc or IV repair using over-lapping and end-to-end techniques. The dependentvariable was repair success defined as the absence ofpersistent sonographic anal sphincter defects, fecalurgency, anal incontinence, and fecal incontinence.

Repair was initiated with pudendal-block anes-thesia using lidocaine 1%.23,30 The rectal mucosawas sutured using interrupted sutures with poly-glactin 910 thread number 3-0, intraluminal knots,followed by continued suturing of internal analsphincter. Repair of the external anal sphincter wasperformed using techniques determined based oncomputer randomization, including the overlappingtechnique and end-to-end technique, with poly-glactin 910 thread number 2-0. The end-to-end re-pair technique is a suturing technique performed bybringing the ends of the external anal sphincter onboth sides to be united and to perform sutures atthe ends of the muscles with sufficient thickness(3-4 sutures). The overlapping repair technique is asuturing technique that brings together the ends ofthe external anal sphincter with mattress sutures re-sulting in a greater surface of inter-contacting tis-sues between the two ends of the muscles.9 Perinealmuscles were sutured interruptedly using the samethread. Repair of the vaginal mucosa began at 1 cmabove the top of the rupture wounds, with unlockedrunning sutures, and then the perineal skin was su-tured using continuous subcuticular suturing, usingpolyglactin 910 number 3-0.

Persistent sonographic anal sphincter defects re-fer to fixed pictures of ultrasonography in the formsof anal sphincter muscle defects after perineal rup-ture repair, either with or without clinical com-plaints.25,26 Fecal urgency refers to the conditionwhere patients feel like they would like to have abowel movement and cannot hold it until they arriveat the toilet (less than 5 minutes).3,32 In this study,anal incontinence is used in cases of flatus inconti-nence in order to distinguish it from fecal inconti-nence, which is defined as the inability to controlthe discharge of liquid and solid feces.16,17,32

Antibiotics were given prior to the repair action,that was 1 gram of Ampicillin intravenously, withallergy testing performed beforehand. Patients withallergies can take 1 gram of Cefotaxime. Oral anti-biotic Ampicillin caplets 500 mg/6 hours and Me-tronidazole tablets 500 mg/8 hours were given for5 days. Analgesics were given orally, specifically me-fenamic acid caplets 500 mg every 8 hours, oribuprofen tablets 100 mg every 12 hours for 5 days.A spoon of laxantia syrup was given every 12 hoursfor 7 days along with a high-fiber diet. Suppositorydrug administration was not allowed.

The Dauer catheter number 14F was installed for24 hours. Residual urine examination was performedno later than 6 hours after the catheter had beenremoved and the patient could urinate spontane-ously. Perineal treatment was done by always main-taining cleanliness. The patient could be dischargedfrom the hospital after they could urinate sponta-neously without any complaint.

Evaluation at weeks 1 and 2 after the repair wasmade to assess any complaints, the condition of therepaired tissue, the ability of flatus and bowel move-ment. Assessment was also carried out to fill theFecal Continence Scoring Scale.3 At week 6, evalua-tion was performed using digital rectal examinationand ultrasonography. Pelvic floor muscle exercisesin a Kegel manner was introduced to patients atweek 1 after repair.

Ultrasonography examination using a Voluson730 pro 3D USG tool in a transperineal manner wasperformed to assess the presence of persistentsonographic anal sphincter defects. Abdominalprobe that had been lubricated and covered with aspecial type of plastic was placed on the fourchette.Assessment was made to determine the presence orabsence of defects in the internal and external analsphincter.

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Repair was considered successful if there were nopersistent sonographic anal sphincter defect picturesobtained in the evaluation at week 6 after repair.Repair was considered as failed if there were picturesof persistent sonographic anal sphincter defects,and/or fecal urgency complaints, and/or anal incon-tinence, and/or fecal incontinence obtained at week6 after repair, when dehiscence until the externalanal sphincter occurred, or when failure or compli-cations of anesthesia occurred.

RESULTS

Forty-eight research samples with IIIb-IV degreeperineal rupture were recruited, 24 patients random-

ized to the repair group using an overlapping tech-nique and 24 patients randomized to the repairgroup using an end-to-end technique.

During the week 1 and 2 evaluation, all the pa-tients were considered to have successful repair ofthe perineal rupture. After 6 week evaluation, therewere 5 patients who cannot be contacted in theoverlapping group, while in the end-to-end groupthere were 8 patients who cannot be contacted forfollow-up. Therefore, we have 19 samples in theoverlapping group and 16 samples in the end-to-endgroup at 6 weeks post-repair. There was one samplewho had failed repair in the overlapping group,while three patients in the end-to-end group hadfailed repair.

Vaginal parturient patients with IIIb-IV degree perineal rupture (Dr Sardjito Central General Hospital/ Sleman District General Hospital/ Tegalrejo/Jetis/Mergangsan Community Health Centers- Yogyakarta)

48 samples

Perineal rupture repair

(randomization)

overlapping end-to-end 24 samples 24 samples

Evaluation Weeks 1 & 2

overlapping end-to-end 24 samples 24 samples

Succeed: Failed: Succeed: Failed:

24 samples 0 sample 24 samples 0 sample

Evaluation Week 6 overlapping end-to-end 19 samples 16 samples

Clinical appearance: Clinical appearance:

Succeed: Failed: Succeed: Failed: 19 samples 0 sample 16 samples 0 sample

Ultrasonography: Ultrasonography: Succeed: Failed: Succeed: Failed: 18 samples 1 sample 13 samples 3 samples

Defect: 1 sample Defect: 3 samples (SAE+SAI) (SAE+SAI:1, only SAE:2)

Vol 3, No 3July 2015 IIIB-IV degree perineal rupture 157

We can see from Table 1 that in the group whounderwent overlapping repair, the sample who hadpersistent sonographic anal sphincter defect had in-ternal and external anal sphincter defect. Out of thethree samples who had failed repair, one sample had

internal and external anal sphincter defect, and theother two patients only suffered external analsphincter defect. However, this difference was notfound to be significant statistically.

Figure 1. Ultrasonography Pictures for Sample Number 29

Figure 2. Ultrasonography Pictures for Sample Number 44

Table 1. The Occurrence of Persistent Sonographic Anal Sphincter Defects at Evaluation Week 6

Repair TechniqueInternal anal sphincter defects

% RR (95%CI) pYes No

Overlapping 1 18 5.26 0.83 (0.05-14.48) 1.00

End-to-End 1 15 6.25

Repair TechniqueExternal anal sphincter defects

% RR (95%CI) pYes No

Overlapping 1 18 5.26 0.24 (0.02-2.58) 0.24

End-to-End 3 13 18.75

Table 2. Success of Perineal Repair (Ultrasonography) at Evaluation Week 6

Repair TechniqueRepair Success

% RR (95%CI) pYes No

Overlapping 18 1 94.74 4.15 (0.39-44.57) 0.31

End-to-End 13 3 81.25

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From Table 2 we can see that the success ratesof both repair techniques were high, with the over-lapping technique having 94.74% success rate, andthe end-to-end technique had 81.25% success rate.Statistically, no significant difference was found be-tween both groups (p=0.31). However, from Table3 we can see that no clinical indication of failed re-pair was found in either groups at both the 2-weekand 6-week evaluation.

DISCUSSION

The research findings show that the samples in bothgroups are homogeneous. The success of repair wasassessed based on the presence or absence of imagesrelated to persistent sonographic anal sphincter de-fect in the 6th week evaluation after repair. In thisassessment, successful repair in the overlappinggroup reached 94.74%, higher than the end-to-endgroup (81.25%). However, it was not found to besignificantly different (p=0.31). Some risk factorswere jointly present in 3 out of the 4 samples whohad failed repairs. However, no variable was foundto be more influential than the others in the inci-dence of persistent sonographic anal sphincter de-fects.

Clinically and based on the FCSS, evaluation afterrepair at weeks 2 and 6 indicated successful repairof both groups. There were 3 out of 4 samples withanal sphincter defects, which experienced dehis-cence up to the subcutaneous area (one of themeven presented with pus), in the evaluation at week1 after repair. This dehiscence did not reach the ex-ternal anal sphincter. The treatment given resultedin tissue repair at the 2nd week evaluation.

At the 6th week evaluation after repair, the samplesize had been reduced by 13 subjects. This was dueto the inability to contact the samples for follow-upuntil week 12 after the repair. The reason most com-monly found for this situation was the return of thesamples to their hometown after the completion oftheir puerperium and the eruption of Mount Merapi

in Yogyakarta, especially in the area of Sleman Re-gency.

Based on the data presented, it remains necessaryto conduct further research in Indonesia with moresamples in order to generate maximum researchfindings. The selection of either overlapping or end-to-end repair technique should be adapted to theperineal conditions and situations at the time therepair is performed since the success rates of bothtechniques did not show a significant difference.

CONCLUSION

In this study, there were no differences in the inci-dence of persistent sonographic anal sphincter de-fects after IIIb-IV degree perineal rupture repairusing an overlapping technique in comparison withan end-to-end technique. Similarly, there were nodifferences in terms of repair results in relation tothe presence of fecal urgency, anal incontinence, andfecal incontinence.

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