OBJECTIVE: Assess postpartum changes in the levator ani muscle using magnetic resonance imaging and relate these changes to obstetric events and risk factors associated with pelvic floor dysfunction.STUDY DESIGN: A board-certified radiologist specializing in abdominal imaging evaluated 146 pelvic magnetic resonance studies from 57 primiparous women 6 weeks and 6 months after first obstetric delivery and 32 nulliparous women. A yes/no determination of muscle body and insertion integrity, muscle thinning, and measurement of muscle thickness in millimeters was made for each of 4 muscle sites: right and left puborectalis and right and left ileococcygeous. Incidence of muscle abnormality and mean muscle thickness was tested in pairs between (1) nulliparous women and 6-week primiparous women; (2) 6 week and 6 month primiparous pairs; and (3) 3 age/race groups using test of 2 proportions and 1-way analysis of variance.RESULTS: Initial review indicated only 3 subjects not of African American or white race, and only 1 African American primiparous woman of age 30 years or older; therefore, statistical analysis was limited to 45 primiparous women and 25 nulliparous women. Incidence of any abnormality at any of the 4 sites was considered abnormal. In those subjects recovering to normal magnetic resonance by 6 months, an average of nearly 60% increase in right puborectalis muscle thickness compared with that seen at 6 weeks indicated the extent of the injury. Subjects with injury to both the puborectalis and ileococcygeous at 6 weeks did not recover to normal at 6 months, whereas those with injury only to the puborectalis tended to have normal magnetic resonance images at 6 months.CONCLUSION: Nulliparity did not guarantee a normal assessment of levator ani anatomy by our blinded reader, and frequency of injury in this series is somewhat greater than that previously reported for primiparous women. Younger white primiparous women had a better recovery at 6 months than older white women. Subjects experiencing more global injury, in particular to the ileococcygeous, tended not to recover muscle bulk.

Purpose: The overexpression of vascular endothelial growth factor (VEGF) is associated with poor outcomes in colorectal cancer patients. Bevacizumab, a VEGF inhibitor, enhances the effects of chemotherapy and radiation therapy on tumor cytotoxicity in preclinical models, including colorectal cancer. A Phase I trial was undertaken to evaluate the combination of bevacizumab, capecitabine, oxaliplatin, and radiation therapy in patients with rectal cancer.Methods and Materials: Patients with pathologically confirmed adenocarcinoma of the rectum were eligible. Pretreatment staging included computerized tomography, endoscopic ultrasound, and surgical evaluation. Patients received 50.4 Gy of external beam radiation therapy (EBRT) to the tumor in 28 fractions. Capecitabine, oxaliplatin, and bevacizumab were administered concurrently with radiation therapy. After EBRT completion, patients were restaged and evaluated for surgery. Primary endpoints included the determination of dose-limiting toxicity and a recommended Phase II dose, non dose-limiting toxicity, and preliminary radiographic and pathologic response rates.Results: Eleven patients were enrolled. All were evalluable for toxicity and efficacy. Dose level 2 was associated with unacceptable toxicity (primarily diarrhea). Dose level 1 had an acceptable toxicity profile. The recommended Phase II dose in our study was bevacizumab 15 mg/kg Day 1 + 10 mg/kg Days 8 and 22, oxaliplatin 50 mg/m(2) weekly, and capecitabine 625 mg/m(2) bid during radiation days. Six patients had clinical responses. Two patients had a pathologic complete response, and 3 had microscopic disease only. One patient experienced a postoperative abscess, one a syncopal episode during adjuvant chemotherapy, and one a subclinical myocardial infarction during adjuvant chemotherapy.Conclusions: The combination of bevacizumab, capecitabine, oxaliplatin, and radiation therapy in rectal cancer was tolerable, with encouraging response rates. Further investigation with this regimen is being pursued in a. Phase II setting. (C) 2007 Elsevier Inc.

Apseudoaneurysm is a pulsatile hematoma that communicates with the lumen of a damaged parent artery via a small neck. Pseudoaneurysms of the uterine artery are rare causes of delayed postpartum hemorrhage. In this setting, accurate diagnosis using pelvic sonography with Doppler imaging is critical to allow for proper treatment with either surgical arterial ligation or transcatheter embolization because curettage may cause life-threatening uterine bleeding. 1 Reports in the literature regarding uterine artery pseudoaneurysms as etiologic factors in postpartum hemorrhage mainly involve patients with a history of uterine trauma and include cases after both vaginal 2-4 and cesarean 4-8 deliveries. We report a case of a uterine artery pseudoaneurysm after an uncomplicated spontaneous vaginal delivery in a patient with no surgical history.

Loyola University Medical Center, Maywood, IL Disclosure – Speakers Bureau: L. Hoyte, Odyssey/Indevus Pharm; Advisory Board: L. Hoyte, Volugraphics Inc.

Objective: Compare pelvic morphology between asymptomatic African-American and white nulliparous women.Study design: Resting Supine T2-weighted magnetic resonance (MR) images were obtained in 12 African-American (AA) and 10 white American (WA) women Without pelvic floor dysfunction. Three-dimensional models were reconstructed from the MR images by a masked investigator, and predefined bony and Soft tissue pelvic floor parameters were measured and compared. Nonparametric statistics were used, with significance considered at P < .05.Results: Subjects were similar in age and body mass index. Levator ani volume was significantly greater in the AA versus the WA group (mean = 26.8 vs 19.8 cm(3), P = .002). The levator-symphysis gap was smaller in the AA (left-18.2, right-18.8 mm) versus the WA group (22.4, 22.6 mm, P = .003, .048) on the left and right. Significant differences were seen in bladder neck position, urethral angle, and the pubic arch angle.Conclusion: The increased muscle bulk and closer puborectalis attachment seen among the African-American nulliparous women may impact the development of pelvic floor dysfunction. These findings need further study. (c) 2005 Mosby, Inc. All rights reserved.