Time to standardise terminology in the ultrasound study of the pelvic floor in pregnant women

Youssef, Aly

doi:10.1111/1471-0528.17765

BJOG

2024

DOI: 10.1111/1471-0528.17765

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Time to standardise terminology in the ultrasound study of the pelvic floor in pregnant women

Aly Youssef

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Murdoch‐Ward,

Nahon,

De‐Vitry Smith

et al. 2024

BJOG

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Dear Dr. Papageorghiou, Many thanks to Dr Aly Youssef for raising the need for standardising terminology in the ultrasound study of the pelvic floor in pregnant women. 1 We agree that standardisation is urgently required as the interest in investigating pelvic floor relaxation and distensibility in pregnant women and its association with birth outcomes grows. Using conflicting terminology to describe a pelvic floor contraction that is inappropriate for the task of bearing down is, as Dr Youssef suggests, confusing for the audience. We appreciate the description made by Youssef et al., 2 and the study referenced; however, we think that there are multiple issues with using the terminology levator co-activation. Levator ani muscle (LAM) co-activation is a positive term used to describe the normal levator ani co-activation with other postural muscles such as transversus abdominis and the diaphragm in response to normal movement and breathing. 3 Using LAM co-activation in the context of an abnormal response is itself confusing, particularly when the levator ani muscles are not co-activating with any other muscle.Second, a LAM contraction is an appropriate response to increasing intra-abdominal pressure, as occurs in the Valsalva manoeuvre. 4 We understand the use of Valsalva in many studies is in fact the bearing down manoeuvre (BDM), which is where, the fundamental problem lies. In our study, Murdoch-Ward et al., 5 we chose to use the language paradoxical LAM contraction, because it describes an inappropriate motor pattern of the LAM during the BDM. We would be interested in further conversation to come to an agreement on the best terminology to use here.We appreciate the concern with introducing the 2-mm cutoff for defining inappropriate LAM activation during the BDM using transperineal real-time ultrasound (TPUS). In our study, as we did not use absolute values of the anteriorposterior diameter (APD), we felt capturing an absolute zero to define no movement would be possibly erroneous and thus possibly confound our results. We therefore decided to define no movement with some range for error. Clinicians are using TPUS to measure APD in pregnant women to analyse the response of the LAM to the BDM thanks to the work of many researchers including Dr Youssef and his team. 2 According to the inter-rater reliably study by Bernard et al. 6 there is a standard error measurement between raters of 1.5 mm, suggesting that we should consider standardising an error measurement for use for the APD clinically in pregnant women. Once again, we would be happy to participate in a discussion on standardising the use of TPUS, in particular the APD measure in pregnant women, to ensure that discussion between researchers and clinicians is transferrable and accurate.Many thanks is once again extended to Dr Youssef for the feedback, we very much look forward to reading future research by Dr Youssef and his team and collaborating on standardising terminology.

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Murdoch‐Ward,

Nahon,

De‐Vitry Smith

et al. 2024

BJOG

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Time to standardise terminology in the ultrasound study of the pelvic floor in pregnant women

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