AFJOG

ORIGINAL RESEARCH African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 2 | 2025 | Outcomes of Primary Sphincteroplasty for Obstetric Anal Sphincter Injuries in a Resource-limited Setting : A Prospective Case Series Figure 3: Flow diagram of study participants DISCUSSION Symptom Burden and Risk Correlation A total of 74 patients were booked for the perineal clinic for the duration of the study; however, only 28 (37.8%) attended. This is marginally higher than the follow-up rate of 26.2% previously reported by Paulsen C (24) . Risk factors for OASI identified in our study mirror global data, including primiparity, instrumental delivery, shoulder dystocia, and neonatal macrosomia (1,25–28) . The mean maternal age of 25.05 years (SD 5.70), closely matching figures reported by Juul (5) . The most prevalent risk factor was a large BMI. The relationship between BMI and OASI remains controversial. While Juul and Hirayama, found no significant association between BMI and OASI (5,29) , a U.S study observed a dose- dependent protective effect of higher BMI (30) . Ventouse delivery was the second most significant risk factor, accounting for 14% of cases – consistent with a previous study from Tygerberg Hospital (29) . Hirayama’s findings support this, with ventouse delivery associated with an OR of 5.59 for the occurrence of OASI in other African populations (5) . The majority of our patients were primigravid, consistent with existing literature (29) that suggest multiparous women have a lower incidence of OASI (58% in African cohorts) (6) . Although IOL has been associated with a 1.53-fold increased OASI risk in African studies (5) , the majority of our patients (72.73%) experienced spontaneous labour. Repair Where the method of repair was specified, the overlap technique was predominantly favoured. This aligns with Cochrane review findings, which demonstrated superior outcomes in faecal incontinence andurgencywith the overlap method (31) . However as the review noted no significant difference in outcomes for perineal pain, dyspareunia, or flatal incontinence between techniques, the large proportion of ongoing vaginal and sexual dysfunction reported in our study may be independent of repair technique. Notably, 45.45% of OASI cases were repaired within 24 hours of delivery, an encouraging figure considering the resource constraints commonly faced in public healthcare settings, where theatre prioritisation often favours emergency caesarean delivery. Most patients received both pre-operative and post-operative antibiotics, consistent with international recommendations (1) supporting the use of broad-spectrum antibiotics to reduce infection and wound dehiscence (1,32) . While Probst et al. reported no significant reduction in OASI-related complications with peripartum antibiotic administration (33) , no evidence of harm has been demonstrated. Therefore, despite conflicting evidence in the existing literature, a single prophylactic antibiotic dose remains a reasonable clinical practice. Symptoms Increasing severity of OASI grade is associated with poorer clinical outcomes, a trend consistently demonstrated in the literature (13,34) and similarly reflected in our findings. Bowel symptoms were reported in 18.18% of patients – a prevalence lower than that reported by Ramage et al (13) , but comparable to the 18% observed by Dietz et al. (35) . This suggests variability in symptom-burden across different populations and methodologies. Only one patient in our study was HIV-positive; notably, she reported AI symptoms and had the highest SMIS score (SMIS = 18) among the four symptomatic individuals. While previous studies have linked HIV-status to increased AI prevalence, (36) our sample size was too small to show any association. The mean SMIS in our study was 7.8, which is lower than the mean score of 11 reported by Dietz (35) possibly reflecting lower symptom severity and variation in follow-up timing. All four patients who reported AI symptoms had sustained 4th-degree OASI, a severity class consistently associated with higher rates of both faecal and anal incontinence (34) . Injury to the IAS, particularly in the context of grade 3c and 4th-degree OASI, has been demonstrated to significantly increase the risk of developing AI, with studies indicating approximately a 5-fold elevation in symptom likelihood (37) . This observed disparity may be attributable to the biomechanical forces at play during the healing of extensive (>50%) sphincter lacerations. Specifically, contractile forces during tissue repair may perpetuate gapping or misalignment of the EAS, potentially exacerbating the clinical presentation of incontinence. Conversely, only one patient with 3a tear remained asymptomatic supporting existing literature that 3a tears carry the most favourable prognosis with respect to continence (34) . Urinary symptoms were reported by 22.73% of patients 74 patients booked for perineal clinic 49 patients default (66.2%) 26meet inclusion criteria 28 patients attend (37.8%) 2 excluded 3 decline (11.5%) 23 consent to participate (88.5%) 22 patients' data collected and analysed 1 withdrewconsent after consulation 18 conservative management and follow-up 1 sphincteroplasty 3 discharged 6 attend follow-up 12 default follow-up 1 conservative management and follow-up 4 discharged 1 sphincteroplasty African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 2 | 2025 | 14