Risk of Surgically Managed Pelvic Floor Dysfunction in Relation to Age at First Delivery

Advancing maternal age at childbirth has been associated with increased risk of unfavorable perinatal outcomes, including levator muscle injury, anal sphincter laceration, and stress urinary incontinence (SUI). There is no clear evidence for an association between advanced maternal age and subsequent surgically managed SUI and pelvic organ prolapse (POP). It is possible that any maternal ageYrelated increase in risk of SUI and POP later in life could be influenced by the mode of delivery. This nationwide register cohort study was designed to investigate the possible association of age at first childbirth and mode of delivery with surgically managed SUI and POP. Data obtained from the Swedish Medical Birth Register on women with only cesarean delivery (n = 30,880) or only vaginal delivery (n = 59,585) were compared with those from the Swedish Patient Register to estimate incidence rates of SUI and POP in relation to maternal age at delivery and mode of delivery. Analyses stratified by age showed that vaginal delivery consistently increased the risks of SUI and POP surgery later in life. Among women 30 years or older with a vaginal delivery, incidence rates of POP surgery were twice that of women younger than 30 years (13.8 [95% confidence interval, 12.7Y15.1] vs 6.4 [95% confidence interval, 6.0Y6.8] per 10,000 person-years). Exclusion of instrumental vaginal delivery had no effect on outcome. These findings show that advanced maternal age at first delivery increases the risk of SUI and POP surgery later in life whether delivery is vaginal or cesarean. EDITORIAL COMMENTARY (This study of registry data shows the research value of a national health service with longitudinal data on the entire population. Researchers were able to cross reference data from a birth registry with the Swedish National Patient Register, which contained data about all major surgical procedures, using a unique individual registration number. In this way, they identified reconstructive surgeries in all women who had had only vaginal deliveries or only cesarean deliveries, as well as the age at first delivery. Their analysis group of 90,465 subjects is powerfully large. They found that, in women who delivered for the first time after the age of 30 years, vaginal delivery increased the risk of stress incontinence surgery 2.4 times more and increased the risk of prolapse surgery 11 times more than having only cesarean delivery. Looking at the data in 5-year age strata revealed that increasing maternal age at first delivery increased the likelihood of both stress incontinence and prolapse surgery, regardless of the mode of delivery. Furthermore, women having vaginal delivery who later had stress incontinence surgery had surgery on average 3 years earlier than did women who had only cesarean delivery, suggesting that their symptoms were not only more common but also more severe. These data emphasize the currently accepted concept that vaginal parity increases the likelihood of pelvic floor dysfunction, but also show a substantial risk of worse function if first delivery 28 Obstetrical and Gynecological Survey Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. is postponed into a woman’s fourth decade of life. The latter finding is what is really new in this report. Trends in recent decades in the developed world to delay childbearing may well be adding even further to the increasing demands for urogynecologic care we have already recognized occurring via demographic shifts toward an older population. We need to anticipate this need and encourage young clinicians to pursue subspecialty training in the newly board-certified field of Female Pelvic Medicine and Reconstructive SurgeryVACW). Determinants of Lymph Node Count in Endometrial Cancer Surgical Staging Beatrice Cormier, Philippe Sauthier, Christian Lussier, Geng Zang, and Marie-Helene Mayrand Gynecologic Oncology Service (B.C., P.S., M.-H.M.), Department of Obstetrics and Gynecology, Université de Montréal; Department of Pathology (C.L.), Hôpital Sacré-Coeur; Research Center (G.Z.), Centre Hospitalier de l’Université de Montréal; and §Department of Social and Preventive (M.-H.M.), Medicine, Université de Montréal, Montréal, Québec, Canada Int J Gynecol Cancer 2012;22:1361Y1366