{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T18:36:10Z","timestamp":1785522970471,"version":"3.56.0"},"reference-count":35,"publisher":"Wiley","issue":"2","license":[{"start":{"date-parts":[[2014,2,4]],"date-time":"2014-02-04T00:00:00Z","timestamp":1391472000000},"content-version":"vor","delay-in-days":3,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2014,2,1]],"date-time":"2014-02-01T00:00:00Z","timestamp":1391212800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["obgyn.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Ultrasound in Obstet &amp;amp; Gyne"],"published-print":{"date-parts":[[2014,2]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>\n                      <jats:italic>\n                        Childbirth causes overstretching of the levator ani muscle (\n                        <jats:styled-content style=\"fixed-case\">LAM<\/jats:styled-content>\n                        ), predisposing to avulsion.\n                        <jats:styled-content style=\"fixed-case\">LAM<\/jats:styled-content>\n                        avulsion has not been evaluated early postpartum using endovaginal ultrasound (\n                        <jats:styled-content style=\"fixed-case\">EVUS<\/jats:styled-content>\n                        ). The aim of this study was to evaluate the relationship between hematomas and\n                        <jats:styled-content style=\"fixed-case\">LAM<\/jats:styled-content>\n                        avulsion using\n                        <jats:styled-content style=\"fixed-case\">EVUS<\/jats:styled-content>\n                        and palpation early and late postpartum\n                      <\/jats:italic>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      <jats:italic>\n                        Nulliparous women were studied prospectively at 36\u2009weeks' gestation and within 4\u2009days and 3\u2009months postpartum. Palpation and high\u2010frequency three\u2010dimensional\n                        <jats:styled-content style=\"fixed-case\">EVUS<\/jats:styled-content>\n                        were performed. Two independent investigators reviewed the scans\n                      <\/jats:italic>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      <jats:italic>\n                        No antenatal\n                        <jats:styled-content style=\"fixed-case\">LAM<\/jats:styled-content>\n                        avulsions were found (\n                      <\/jats:italic>\n                      n\u2009=\u2009\n                      <jats:italic>\n                        269). 114\/199 (57.3%) women seen early postpartum agreed to examination. 27\/114 (23.7%) had well delineated, hypoechoic areas consistent with hematomas (100% agreement), 26 following vaginal delivery, one following emergency Cesarean section. In total, 38 hematomas were found (11 bilateral, 16 unilateral). Hematomas away from the attachment zone of the\n                        <jats:styled-content style=\"fixed-case\">LAM<\/jats:styled-content>\n                        to the pubic bone (\n                      <\/jats:italic>\n                      n\u2009=\u2009\n                      <jats:italic>22) resolved. Hematomas at the attachment zone (<\/jats:italic>\n                      n\u2009=\u2009\n                      <jats:italic>\n                        16) manifested as pubococcygeus avulsions 3\u2009months postpartum. In addition to these 16 avulsions, we found another 20 at 3\u2009months postpartum. 13\/20 were not scanned early postpartum and in seven no hematomas were seen, but avulsion was seen early postpartum. Overall,\n                        <jats:styled-content style=\"fixed-case\">LAM<\/jats:styled-content>\n                        avulsion was found in 23\/191 (12.0%) women (13 bilateral, 10 unilateral) 3\u2009months postpartum. Hematomas were significantly associated with episiotomy, instrumental delivery and increased hiatal measurements. Palpation was unreliable early postpartum as only seven avulsions were diagnosed\n                      <\/jats:italic>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>\n                      <jats:italic>\n                        Hematomas at the site of\n                        <jats:styled-content style=\"fixed-case\">LAM<\/jats:styled-content>\n                        attachment to the pubic bone always result in avulsion diagnosed 3\u2009months postpartum. However, one third of avulsions are not preceded by a hematoma at the site of LAM attachment to the pubic bone. Copyright \u00a9 2013 ISUOG. Published by John Wiley &amp; Sons Ltd\n                      <\/jats:italic>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1002\/uog.12571","type":"journal-article","created":{"date-parts":[[2013,7,25]],"date-time":"2013-07-25T14:48:30Z","timestamp":1374763710000},"page":"210-217","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":41,"title":["Levator hematoma at the attachment zone as an early marker for levator ani muscle avulsion"],"prefix":"10.1002","volume":"43","author":[{"given":"K.","family":"van Delft","sequence":"first","affiliation":[{"name":"Croydon University Hospital Department of Obstetrics and Gynaecology, Urogynaecology and Pelvic Floor Reconstruction Unit Croydon UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"R.","family":"Thakar","sequence":"additional","affiliation":[{"name":"Croydon University Hospital Department of Obstetrics and Gynaecology, Urogynaecology and Pelvic Floor Reconstruction Unit Croydon UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"S. Abbas","family":"Shobeiri","sequence":"additional","affiliation":[{"name":"The University of Oklahoma Health Sciences Center Department of Obstetrics and Gynecology, Section of Female Pelvic Medicine &amp; Reconstructive Surgery Oklahoma City OK USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"A. H.","family":"Sultan","sequence":"additional","affiliation":[{"name":"Croydon University Hospital Department of Obstetrics and Gynaecology, Urogynaecology and Pelvic Floor Reconstruction Unit Croydon UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2014,2,4]]},"reference":[{"key":"e_1_2_5_2_1","doi-asserted-by":"publisher","DOI":"10.1097\/01.AOG.0000109207.22354.65"},{"key":"e_1_2_5_3_1","doi-asserted-by":"publisher","DOI":"10.1097\/01.AOG.0000178779.62181.01"},{"key":"e_1_2_5_4_1","doi-asserted-by":"publisher","DOI":"10.1097\/01.AOG.0000194063.63206.1c"},{"key":"e_1_2_5_5_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1471-0528.2008.01751.x"},{"key":"e_1_2_5_6_1","doi-asserted-by":"publisher","DOI":"10.1097\/AOG.0b013e3181aa2c89"},{"key":"e_1_2_5_7_1","doi-asserted-by":"publisher","DOI":"10.1111\/1471-0528.12055"},{"key":"e_1_2_5_8_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0002-9378(43)90528-9"},{"key":"e_1_2_5_9_1","doi-asserted-by":"publisher","DOI":"10.1097\/00006250-200301000-00012"},{"key":"e_1_2_5_10_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2009.03.028"},{"key":"e_1_2_5_11_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2009.11.038"},{"key":"e_1_2_5_12_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1471-0528.2010.02704.x"},{"key":"e_1_2_5_13_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1471-0528.2011.03152.x"},{"key":"e_1_2_5_14_1","doi-asserted-by":"publisher","DOI":"10.1002\/uog.10132"},{"key":"e_1_2_5_15_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1479-828X.2007.00748.x"},{"key":"e_1_2_5_16_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00192-009-0928-4"},{"key":"e_1_2_5_17_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00192-010-1233-y"},{"key":"e_1_2_5_18_1","doi-asserted-by":"publisher","DOI":"10.1002\/uog.13193"},{"key":"e_1_2_5_19_1","doi-asserted-by":"publisher","DOI":"10.1002\/nau.20181"},{"key":"e_1_2_5_20_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00192-008-0575-1"},{"key":"e_1_2_5_21_1","doi-asserted-by":"publisher","DOI":"10.1002\/uog.12426"},{"key":"e_1_2_5_22_1","doi-asserted-by":"publisher","DOI":"10.1002\/uog.1899"},{"key":"e_1_2_5_23_1","doi-asserted-by":"publisher","DOI":"10.1097\/01.AOG.0000250901.57095.ba"},{"key":"e_1_2_5_24_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.juro.2008.01.098"},{"key":"e_1_2_5_25_1","doi-asserted-by":"publisher","DOI":"10.1097\/AOG.0b013e31828ce97d"},{"key":"e_1_2_5_26_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00192-010-1329-4"},{"key":"e_1_2_5_27_1","doi-asserted-by":"publisher","DOI":"10.1002\/uog.6268"},{"key":"e_1_2_5_28_1","doi-asserted-by":"publisher","DOI":"10.1259\/bjr\/19678081"},{"key":"e_1_2_5_29_1","doi-asserted-by":"publisher","DOI":"10.1002\/uog.8818"},{"key":"e_1_2_5_30_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00192-012-1912-y"},{"key":"e_1_2_5_31_1","doi-asserted-by":"publisher","DOI":"10.1002\/nau.21032"},{"key":"e_1_2_5_32_1","doi-asserted-by":"publisher","DOI":"10.2353\/ajpath.2007.060662"},{"key":"e_1_2_5_33_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00192-009-1068-6"},{"key":"e_1_2_5_34_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0029-7844(97)00682-0"},{"key":"e_1_2_5_35_1","doi-asserted-by":"publisher","DOI":"10.1002\/uog.7563"},{"key":"e_1_2_5_36_1","doi-asserted-by":"publisher","DOI":"10.3109\/01443615.2013.767787"}],"container-title":["Ultrasound in Obstetrics &amp; 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