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The Ultrasound Diagnostic Criteria for Diastasis Recti and Its Correlation with Pelvic Floor Dysfunction in Early Postpartum Women

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The Ultrasound Diagnostic Criteria for Diastasis Recti and Its Correlation with Pelvic Floor Dysfunction in Early Postpartum Women 713 Original Article The ultrasound diagnostic criteria for diastasis recti and its correlation with pelvic floor dysfunction in early postpartum women Enze Qu^, Jiawei Wu, Man Zhang, Lili Wu, Ting Zhang, Jing Xu, Xinling Zhang Department of Ultrasound, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China Correspondence to: Prof. Xinling Zhang, MD. Department of Ultrasound, Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Road, Guangzhou 510630, China. Email: [email protected]. Background: There has been a long-standing controversy about diastasis recti diagnostic criteria and its relation to pelvic floor dysfunction (PFD). This study aimed to establish ultrasound diagnostic criteria for diastasis recti and investigate the correlation between it and PFD in early postpartum females. Methods: The inter-rectus distance (IRD) was measured at 3 locations in 116 healthy nulliparous females and 108 postpartum females. At the same time, they remained relaxed and then maintained a head-lift posture. The measurement for the 90th percentile was used to define the normal IRD in the nulliparous group. Afterward, the 108 postpartum females underwent an ultrasonographic examination of pelvic floor function. The correlations of these values with the IRD were then examined. Results: We established the following ultrasonographic diagnostic criteria for diastasis recti: an IRD of >2 mm at 3 cm below the umbilicus, >20 mm at the umbilicus, and >14 mm at 3 cm above the umbilicus. The IRD was positively correlated with body mass index (BMI) in the nulliparous group (r=0.286, P<0.01) and with age in the postpartum group (r=0.230, P<0.05). The IRD was not relative to either the PFD ultrasound results or the clinical symptoms. Conclusions: We established a set of ultrasonographic diagnostic criteria for diastasis recti at 3 locations along the umbilicus. There is no clear correlation between diastasis recti and PFD in early postpartum females. Keywords: Diastasis recti; pelvic floor dysfunction (PFD); ultrasonography; diagnostic criteria Submitted Apr 22, 2020. Accepted for publication Oct 09, 2020. doi: 10.21037/qims-20-596 View this article at: http://dx.doi.org/10.21037/qims-20-596 Introduction The inter-rectus distance (IRD) can be measured via clinical palpation or calipers (4-6). These measurement Diastasis recti is are commonly defined as the separation between the 2 sides of the rectus abdominis muscle or methods are relatively convenient but may be inaccurate simply laxity of the linea alba (1). The condition is usually due to the thickness of subcutaneous fat and relaxation of caused by abdominal expansion and hormonal changes the abdominal wall (7,8). during pregnancy. The diastasis recti incidence is 27–100% Ultrasonography is regarded as the most accurate in women in late pregnancy and 30–68% in postpartum method for measuring the IRD (7), and its results are women (2,3). consistent with the data derived from palpation, calipers, ^ ORCID: 0000-0001-6628-6302. © Quantitative Imaging in Medicine and Surgery. All rights reserved. Quant Imaging Med Surg 2021;11(2):706-713 | http://dx.doi.org/10.21037/qims-20-596 Quantitative Imaging in Medicine and Surgery, Vol 11, No 2 February 2021 707 and intraoperative measurements (9-11). However, the participation in abdominal muscle training or rehabilitation differentiation between a normal IRD and pathological of the pelvic floor muscles after delivery; and (IV) avulsion separation remains controversial (12). Because there are few of the levator ani causing severe pelvic organ prolapse studies on diagnostic criteria for diastasis recti, it is difficult (POP). to define “normal” and “abnormal” conditions. Diastasis recti may develop at different locations above, at, and below Equipment and personnel the umbilicus, so the single-location diagnostic criteria used in most recent research and the lack of agreement on the The IRD was measured using the ProSound F75 system diagnostic criteria could lead to inaccurate incidence and (with a 5–12 MHz linear probe) from Hitachi-Aloka (Tokyo, high false-negative rates. Japan) and the Supersonic Imagine system (with a 4–15 MHz The abdominal muscle is essential for maintaining body linear probe) from Supersonic Imagine (Aix en Province, posture, torso and pelvic cavity stability, and abdominal France). Ultrasonographic examinations of pelvic floor organ support (13-15). Diastasis recti can cause several function were performed using the Voluson E8 system (with health complications, such as lower back pain and trunk an RAB 4–8 MHz volume probe) from GE Medical Systems muscle dysfunction (16,17). Current treatments require a (Tiefenbach, Austria). A senior clinician with >5 years much more individualized diastasis recti map, including of experience in musculoskeletal ultrasonography physiotherapy, prolotherapy, and surgical intervention. performed the IRD measurements. Three senior clinicians Additionally, diastasis recti may have an impact on pelvic with >5 years of experience in pelvic floor ultrasonography stabilization. In 2007, >60% of patients with diastasis recti performed pelvic floor function examinations. were found to exhibit concurrent pelvic floor dysfunction (PFD) (18). In contrast, a prospective study published Examination methods in 2017 revealed no association between diastasis recti and PFD (19). However, neither of these studies applied During the examination, each participant took a supine ultrasound to measure IRD, which may have led to a less position on the bed with the head resting on a thin pillow precise result. and the legs fully extended. The abdomen was fully exposed To define diastasis recti accurately, we first tried to set up from the xiphoid process to the pubic symphysis, and the ultrasound diagnostic criteria. The second goal was to efforts were made to ensure participant warm. The IRD investigate the correlation between diastasis recti and PFD was measured at the following 3 locations, with the subject in early postpartum females. in either a resting position or the head-lift posture: 3 cm below the umbilicus, at the umbilicus, and 3 cm above the umbilicus. We used a ruler to locate the probe. The Methods postpartum females were divided into different subgroups Study participants based on the results. For the head-lift posture, the subject’s head was elevated from the pillow by approximately 10 cm Between September 2017 and September 2018, 108 while the shoulders remained on the bed. We measured the females with weak pelvic floor muscles determined by IRD 3 times at each location and then used the mean value. vaginal palpation, who underwent a routine postpartum Additionally, we documented the deviation of the bilateral examination of pelvic floor function were recruited to rectus abdominis from the linea alba and other notable form the postpartum group, and 116 healthy nulliparous features. female volunteers from gynecological outpatient care were After urination, we asked the subject to perform pelvic recruited to form the nulliparous group. The postpartum muscle contractions with tomographic ultrasound imaging group periods were 3–12 months, which avoided the (TUI) to exclude levator avulsion. Afterward, the subject influence of natural recovery of diastasis recti (20). The was asked to perform the optimal Valsalva maneuver (with ethics approval number for this trial is KY2016-203. All a duration of ≥6 seconds), during which the area of the participants provided written informed consent. The levator hiatus and degree of organ prolapse in the anterior, exclusion criteria were as follows: (I) the inability to perform central, and posterior compartments of the pelvic cavity the head-lift posture or Valsalva maneuver; (II) poor healing were recorded (Figure 1). In the anterior compartment lies of the cesarean section incision or local skin infection; (III) the bladder and the urethra; in the central compartment lies © Quantitative Imaging in Medicine and Surgery. All rights reserved. Quant Imaging Med Surg 2021;11(2):706-713 | http://dx.doi.org/10.21037/qims-20-596 708 Qu et al. The relationship between diastasis recti and PFD A D E B C Figure 1 (A-C) Ultrasonographic images of the linea alba and the rectus muscles in a 20-year-old woman with a BMI of 20.5 kg/m2, G1P1. (A) Transverse scan showing an IRD of 10 mm at 3 cm I-U; (B) 43 mm at the umbilicus; (C) 36 mm at 3 cm S-U; (D) the bladder neck was 12 mm above the line of reference, and the lowest point of the cervix was 10 mm above the line of reference. No significant degree of posterior compartment prolapse was observed; (E) the area of levator hiatus (dotted line) was 16 cm2. Note the distorted linea alba in (B,C). G1P1, first pregnancy; S, symphysis pubis; B, bladder; U, uterine; R, rectal ampulla, IRD, inter-rectus distance; I-U, infraumbilical; S-U, supraumbilical. the uterus, cervix, and vagina; in the posterior compartment Third, we placed an adequate amount of gel on the lies the rectum ampulla and anal canal. For prolapse umbilicus to avoid gas interference. Fourth, if the IRD quantification, we measured the distance from the bladder was too wide to be displayed in a single image, the image neck, the lowest point of the cervix, and the rectal ampulla assembly or wide-view imaging mode was used. Moreover, to the reference line, which refers to the horizontal line the IRD was sensitive to changes due to breathing in some through the inferior margin of the symphysis pubis (21). females with severe diastasis recti. In these cases, we asked The hiatal area was measured in the rendered volume mode each female to hold her breath before the measurement. by tracing the levator muscles’ inner margin. All 3 senior clinicians calculated the data offline independently using 4D Statistical analysis View software (GE Healthcare, Tiefenbach, Austria). During the measurements, we paid close attention to The statistical software SPSS version 26.0 (SPSS Inc., the following issues.
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