So I'd like to welcome our first presenter of this session up to the podium, Dr. Blomquist. And I'd also like to just announce that this paper won the best overall paper award, so congratulations. Thank you and thanks for the opportunity to present our work. We'd also like to thank the NICHD for support of our work. So we know that pelvic floor disorders are associated with childbirth. For example, there are previous studies that show that PFDs are strongly associated with parity, and previous work from our group has shown that PFDs are more common 5 to 10 years after a vaginal delivery than after a C-section. However, very little is known about how the sexual exposures affect the course and progression of PFDs across a woman's life. To help fill that void, our objectives were to describe the incidence of PFDs in the first two decades after childbirth and to identify maternal and obstetrical characteristics associated with patterns of incidence later in life. The data for this study are from the Mother's Outcome After Delivery Study, which is a prospective cohort study of Paris women. Participants were recruited 5 to 10 years after their first delivery and were followed annually for up to nine years. Recruitment was based on mode of delivery, and the groups were matched based on age and years since first delivery. At each annual visit, participants completed questionnaires, including the EPIC, and they also had a physical exam, including the POPQ exam. Our primary exposure of interest was delivery mode. Participants were categorized based on their delivery across all their births, The cesarean delivery group included women who delivered all their children by cesarean. The spontaneous vaginal delivery group included women who had at least one vaginal delivery, but no operative vaginal deliveries. And the operative vaginal delivery group included women who had at least one forcep or vacuum delivery. We also considered the size of the genital hiatus, as it has been shown to be associated with prolapse progression. Other covariates assessed included race, parity, age at first delivery, and BMI. Our outcomes included the four PFDs. Participants were considered to have SUI, OAB, or AI if their EPIC scores were above the previously validated threshold or if they reported prior treatment for that disorder. Prolapse was defined as prolapse beyond the hymen on the POPQ exam or a history of surgery for prolapse. We had a total of 1,528 participants who contributed 7,804 person years. The median age at enrollment was 38.3, and our median duration of follow-up was 11 years from first delivery. So for our first objective, to look at the incidence of pelvic floor disorders, we considered the first delivery as the time of origin. So for this analysis, we included participants who had the disorder at study entry, as well as those who developed the disorder during the observation period. We then used conventional log-normal models to estimate cumulative incidence. Here you see the cumulative incidence curves for each PFD over time. So on the x-axis is time from first delivery in years, and on the y-axis is cumulative delivery. In each curve, the gray line represents the reference group, which is spontaneous vaginal delivery. The blue line represents those who had at least one operative vaginal delivery, and the orange line represents those who had only cesarean birth. Note that for each disorder, the cumulative incidence is highest in the operative vaginal delivery group and the lowest in the cesarean only group. And these between-group differences are most notable for prolapse. Here we see the corresponding hazard function curves. As expected, based on cumulative incidence, the hazard is highest for each disorder in the operative vaginal delivery group and lowest in the cesarean only group. There are also some important temporal differences here. For SUI and AI, there's a very sharp rise in hazard in the first five years after delivery. In contrast, for prolapse, the peak hazard is estimated to occur 20 years after first delivery. Also note that the between-group differences is sustained over time for prolapse, whereas that is not the case for the other disorders. For our second objective, we used hazard ratios to study the association between maternal and obstetrical characteristics and the incidence of PFDs. For this analysis, we excluded participants who already had the disorder at study entry, as they could not provide prospective data to model hazard. So for this analysis, we considered five years from first delivery as the time of origin. We then used staggered entry methods to deal with the fact that participants could have joined the study anywhere between five and ten years after the first delivery. And classical semi-parametric proportional hazard models were used. So hazard ratios were calculated for each PFD based on mode of delivery, as well as other maternal and obstetric characteristics. As you can see here, relative to spontaneous vaginal delivery, C-section was associated with a lower hazard of SUI, OAB, and prolapse. And operative vaginal delivery was associated with a higher hazard of AI and prolapse. Black woman had a lower hazard of AI. Increasing parity was associated with a higher hazard of prolapse. And obesity was associated with a higher hazard of SUI and AI. Now I also mentioned that we wanted to look at the genital hiatus as an exposure. But as we know, GH may be associated with mode of delivery, and in fact may actually be in the causal pathway between delivery mode and PFDs. Therefore, we could not consider it a confounder, and we did not include it in our multivariable model. Here you see the bivariable model. Relative to a GH of less than 2.5, a GH of greater than or equal to 3.5 was associated with a higher hazard of each of the PFDs, especially prolapse with a hazard of almost 12. To study this fact a little bit further, we then stratified this based on mode of delivery. As you can see here, relative to a GH of less than or equal to 2.5, a GH of greater than or equal to 3 was associated with a higher hazard of prolapse in each of the three delivery groups. So regardless of mode of delivery, GH remained a strong predictor of prolapse. I'm just showing for the sake of time the prolapse data here. So in conclusion, cumulative incidence of PFDs is significantly associated with mode of delivery. There's interesting differences in the time course of the four PFDs, and the size of the general hiatus is significantly associated with the hazard of prolapse regardless of delivery mode. We acknowledge that the use of dichotomous definitions may be an oversimplification. We have limited follow-up to look at patterns of hazard in older women, and our sample size was not sufficient to explore some risk factors. Our primary strengths include the longitudinal study design, the use of validated tools, and statistical methods and models to account for time-varying measures and to maximize the use of all of our data. Thank you. Thank you. Thank you. Brilliant presentation. Could you, as your group surmised, what the connection might be between overactive bladder syndrome and an enlarged hiatus? I'm very curious. You know, that's a good question. Whether or not it's just the change in the anatomy, although that was not a real strong association with overactive bladder syndrome. Joan, beautiful presentation, important contribution to the literature. Within the operative delivery cohort, were you able to distinguish between the vacuum deliveries and the forceps deliveries? So in this, we did not separate them out. We had in that group 81 were vacuum deliveries and 97 were forceps, and 7 actually had at least one of each. Previous work showed that vacuum delivery was actually less likely to be associated with these than forceps. So if anything, we would expect a higher impact. But just for numbers, we kept everything together in this analysis. Thank you. Vachem Anasiem from Boston. Thank you so much. I enjoyed your presentation. Two little questions. I would have liked to see time since last delivery as opposed to time since first delivery. My other question is, were those SUI and OAB patients pure SUI or OAB or there was overlap? I.e., is it any SUI, any OAB, which could have included mixed patients? The definitions were based on the EPIC scores. So even if someone had SUI, they also could have had OAB. So it could include some mixed patients in each of those as well. And, yeah, it would be interesting to look at time since last delivery, although we do think that most of the damage to the pelvic floor at least occurs at the time of the first delivery. So that's why we chose to look at that. We have time for one more question. So were you able to look at remissions over time? How did you account for remissions in your incidence rates? So we did not look at remissions, and we know that PFDs can kind of change over time. But once they had the disorder, we considered that they had it. So we did not look at that. Yeah. Thank you. Thank you. We'd like to present you with this certificate. And I think we want to take some pictures here. Sorry. Thank you so much. All right. Our next paper is Paper 21. Dr. Ananda Kanti from the University of Michigan. We are grateful for this opportunity to share our work. I appreciate the contributions of my co-authors as well as the Michigan Pelvic Floor Research Group. I'm actually currently a fourth-year undergraduate student at Michigan. Thank you. We have no financial disclosures. In this video of prolapse, we can see that the prolapse is very easily visible, and we can also see that the opening of the hiatus is very evident. Ballooning and descent of the pelvic organs can also be seen, but it is not currently measured by our quantification system. In this MRI of prolapse, we can see the downward motion of the pelvic organs, and this has not been quantified much. Typically, prolapse is assessed through openings in the levator, through the levator hiatus and the urogenital hiatus. The phenomenon of the levator bowl is something that our group has been studying recently. The levator ani-muscles form a bowl-like floor to the abdominal pelvic cavity, and the deepening of this bowl has been assessed through the mid-sagittal bowl area, and this has been shown to be 67% larger in prolapsed women. The bowl volume at rest is something that has also been measured by Hoyt's group, and this has been done at rest. And as with all prolapse measurements, we would ideally like to do this at maximal valsalva. Our primary question was to compare prolapsed women with control women to see whether the levator bowl volume while straining, as opposed to rest, is larger with prolapse. Our secondary question was to see how this 3D measure, because it is complicated, how it correlates with known 2D measures, and those are the area, the levator hiatus, and the urogenital hiatus. Our study design included recruiting 20 women with normal support who were the control group, and 20 women with prolapse equally distributed between anterior and posterior prolapse, defined by having a prolapse at least one centimeter below the hymen. They were combined into one prolapse group because we didn't see any statistically significant differences. 3D stress MRI was taken at maximal strain that captured the full width of the MRI, and we took all measurements at rest and at maximal valsalva. Looking at the demographics, we didn't see any statistically significant differences across groups in age, BMI, height, vaginal delivery, or race. How we defined the area and our other measures, the levator hiatus was defined from the pubic bone to the levator plate, and the urogenital hiatus from the pubic bone to the front of the perineal body. The levator bowl area was bordered by the skip line, the levator plate, and the anal sphincter complex. We constructed the 3D volume by using the same landmarks and tracing the landmarks across all slices of MRI on both sides using 3D slicer software that has been previously used for the pelvic floor. This software can also quantify the volume, and we did the same measurements in prolapse women as you can see here. This is further examples of our 3D volumes at rest and at strain. Going into our results answering our primary question, the levator bowl volume, the average levator bowl volume, has been shown to be 35% difference between control and prolapse women at rest, and that difference is 53% while straining. We also saw a 62% increase from rest to strain in control women, and almost doubling the volume upon straining in prolapse women with an 83% increase. Looking at the correlation of the volume at strain versus at rest, we saw an R-squared value of 0.22, signifying that only 22% of the straining volume can be explained by the resting value. Because the volume is a complicated 3D measurement, we wanted to see what the best proxy for the volume is, so first we evaluated the area and saw an R-squared value of 0.74, so 74% of the volume can actually be explained by the area, so this is a moderately strong correlation. And we also wanted to see how the hiatus measures relate to the volume, and for the levator hiatus we saw an R-squared value of 0.63, and urogenital hiatus we saw an R-squared value of 0.57, so about half of the volume can be explained by the hiatuses. Briefly going into our discussion, our strengths are that this is a novel measure of the bowl volume at strain, there was close supervision of MRI, and our cases and controls were defined well. Some limitations are that this was a case control study, not a population-based sample. We had a small sample size, although we were still able to see significant results, and there is not currently inter-rater reliability, but we are working on it. Our key findings, our primary finding was that in prolapsed patients, the strain bowl volume was approximately 83% larger than the resting bowl volume, and the resting bowl volume only accounts for approximately 25% of variation in strain bowl volume. Looking at the correlation, we saw that the strain bowl area was the best predictor of the strain bowl volume, with an R-squared value of 74%. The significance of our findings are that the resting bowl volume and the straining bowl volume are two distinct measures. A new area as we look at surgical outcomes are to see whether surgery changes the bowl volume or the ability to resist strain. And lastly, the bowl area is a reasonable parameter for the complicated levator bowl volume measurement at maximal straining. Thank you, and I look forward to your questions. I'm not an expert on this area, but something that we have talked about is the iliococcygeal muscle, and how it's a very important muscle in the body, and it's a very important muscle in the brain, and it's a very important muscle in the brain, and it's a very important muscle in the brain, and it's a very important muscle in the brain, and it's a very important muscle in the brain, and it's a very important muscle in the brain, and it's a very important muscle in the brain, and it's a very important muscle in the brain, and something that we have talked about is the iliococcygeal muscle, and how the deepening of the levator bowl leads to bulging of that muscle, and so I think that's an area that could be corrected, and I'm sure Dr. Lancy, I don't know if you have anything to add on that. That was a great answer. Yeah, I think Lahari did a great job with answering that. You know, we all know that there are some patients that persist in having pressure symptoms, even though their POTQ looks a lot better after surgery, and we're wondering whether this may be part of the phenomenon that we really don't know yet how to correct, and with denervation of the levators and failure of the levator muscles, that's one of the things that leads to this deepening bowl volume, and I think Lahari's done a great job in providing a mechanism now to be able to quantify that so that we can look preoperatively and postoperatively and see what the predictors are. Great. All right. Thank you. Good work. Congratulations. All right, so next we have Dr. Victoria Honda coming up to the podium. I just want to say how super great it is to follow a college senior. My son is a senior at Michigan, to put that in perspective. So that was a great job. All right. So I'm going to talk again about something having to do with the levator ani muscle and how it relates to pelvic floor disorders. I want to thank the NICHD for supporting this work, So levator ani muscle avulsion is something that's probably familiar to the people in this room. It's thought to be largely a complication of obstetrical vaginal delivery and is seen after something like 10 or 20 percent of vaginal deliveries. We know that the incidence seems to be higher among women who have had a forceps delivery, and we also know from some case control studies that this is significantly higher associated with prolapse, and that's why it's clinically important. But some unanswered questions that I hope to address, number one, what is the incidence of prolapse after levator avulsion, which that has not yet been discerned from case control studies? Number two, is levator avulsion significantly associated with other pelvic floor disorders? And then number three, thinking about the mechanism of prolapse, of pelvic floor disorders? And then number three, thinking about the mechanism of how these things might be associated, how does the avulsion impact levator structure and function with time? So you heard Dr. Blomquist just present data from the Mother's Outcomes After Delivery Study. This is a supplementary study. Women in the Mother's Outcomes After Delivery Study were recruited for that study five to 10 years after delivery and followed annually for pelvic floor disorders as she described. In this supplementary study, we considered only the women who'd had a vaginal birth, and we assessed levator ani-muscle avulsion with 3D transperineal ultrasound. So we aimed to recruit all the women in the cohort who had at least one vaginal delivery, of which there were 550, assessed avulsion on 3D transperineal ultrasound. The study personalities visits, those assessing pelvic floor disorders, were masked to both avulsion and symptoms as well as obstetrical history. Prolapse was assessed on POPQ and defined here as beyond the hymen. And the other pelvic floor disorders were assessed with the EPIC questionnaire. That included pelvic organ prolapse symptoms, stress incontinence, OAB, and AI. Here's our recruitment diagram. We had 550 eligible women. We enrolled 454. Ten declined, and 86 had no study visit during that period. We had interpretable ultrasounds in all but one. And levator avulsion was diagnosed in 15 percent, which was within the range we expected in this cohort of women who had all had at least one vaginal delivery. So our first question, what is the incidence of prolapse after levator avulsion? And we found prolapse beyond the hymen in 55 percent of these women, not all of whom were symptomatic. We found that the relative odds for prolapse beyond the hymen was increased fourfold. And this elevated odds remained significant after controlling for the important confounders, including age, race, history of macrosomic baby or prolonged second stage, and forceps delivery. So our second question was, is levator avulsion associated with other pelvic floor disorders? In this table, you can see the pelvic floor disorders listed by row, and the no avulsion and avulsion in the columns. And there's the data I already gave you. Prolapse symptoms, which were less common than prolapse beyond the hymen, similarly were significantly associated with levator avulsion. But here's the surprise. Many of the other pelvic floor disorders were really associated with levator avulsion. If you look, for example, at stress incontinence, 29 percent versus 32 percent could not be more null. OAB, as you heard earlier from the question Dr. Sand raised, in this cohort, there was maybe an association with levator avulsion, but it was not statistically significant. And then our third question, how does avulsion impact levator structure and function? So we looked at three things, levator hiatus area on ultrasound, the genital hiatus on POPQ exam, and pelvic muscle strength, which was measured with perineometry. For those of you who don't do ultrasound of the levator hiatus, here's a picture of the hiatus. You can use the ultrasound tool to draw the circumference, and then the ultrasound software calculates the area for you. So that's the hiatus area I'm talking about. And so for what we found comparing the no levator avulsion and avulsion groups, no levator avulsion, the hiatus area was 25 centimeters squared. That was very significantly increased in the levator avulsion group, as was the size of the genital hiatus, which on strain was three in women who didn't have an avulsion and four in women who had an avulsion. And their pelvic muscle strength was also significantly less in women that had an avulsion. So in summary, here's all of our findings on one slide. Eleven years from vaginal birth, the incidence of prolapse after levator avulsion was about 55 percent, very useful clinical information. The avulsions were not significantly associated in this cohort with SUI, OAB, and AI, although maybe a suggestion of a signal there for OAB. And levator avulsion seems to have a significant impact on levator structure and function 11 years from delivery. Some strengths, this study was 11 years from delivery. Most of the other studies that have looked at any of this stuff is really very short term. We had an adequate sample size. We had valid and rigorous assessment of the outcomes and exposures. The examiners were masked, and the participants were all volunteers as opposed to care-seeking women. I would say that time frame was also a weakness. We'd really like to know how this affects things 20 and 30 years out, so that's a weakness. SUI, OAB, and AI were assessed with symptoms rather than some more objective measure. And other factors like nerve injury, which could contribute, were not assessed here. And I'd like to conclude by thanking our entire research team and the 454 moms who contributed to this research, and I'm happy to take your questions. APPLAUSE Hello, I'm Jeff Hardesty from Loma Linda. Thank you, it was wonderful stuff and a great follow-up. Have you looked at maternal age at either first delivery or last delivery and how this correlates with the findings you're seeing with these pelvic floor disorders? We did see in this study that maternal age was associated with avulsion, but it wasn't otherwise associated with it. I mean, aging is associated with all these pelvic floor disorders, so we considered it a confounder in these analyses. I don't know if I'm answering your question. I was wondering if the older patient who delivers her first baby that's, say, 37, does she have less of a chance of this or more chance of that compared to a 22-year-old who delivers? Is there a recovery or are there some other factors? So we did see an association of age at first delivery and the presence of the avulsion, but we didn't have enough data about whether it modified changes over time further. Thank you. Becky? It had prolapses about 20% and had an avulsion and had prolapses about 55%, which I just presented. Okay. So, yeah, it's a two-by-two table the other way around. And then what are some other potential mechanisms for a wide and general hiatus besides an avulsion in your mind? Say it again. Other potential explanations for a wide and general hiatus besides levator avulsion? Oh, that's a good question. I think there's probably, first of all, there's probably normal variations. There may be racial differences in muscle configuration, you know, either based on pelvic shape or other differences. I don't know. That's a good question. Do you have a theory? I wonder how much of it's connective tissue, as John might have alluded to, also, as you say, normal anatomic variation. Yeah, yeah. I think really the important question there, I mean, I think the bad news for women with avulsion is that they do seem to be this high-risk group. But I think that for the people in this room, the good news is we have a long time to intervene for these women. Like, I don't know what that intervention is today, but I would challenge people in this room that that's something we could do that would really advance the health of women because unless you want to do a C-section on every single woman, you're not going to prevent childbirth injury. But if you have 20 years, like Dr. Blomquist said, to prevent that peak incidence of prolapse, you know, that's really an opportunity for intervention. And maybe these are the markers we should be looking for. My question is about intervention. Are our current standard techniques of posterior coporaphy effective at reducing the genital hiatus size when elevator avulsion is present? So I think that's one of many really important questions. I think that, you know, some of our work that, as Dr. Blomquist presented, relates the genital hiatus to some of these outcomes. I wouldn't want the people in this room, and of course not the people outside this room, to think that what they need to be doing is a lot of, you know, narrowing of the genital hiatus to prevent prolapse. But where does that fit or some other surgical techniques? I think those are really important questions. I don't know the answers. I think we have time for one more question. This is beautiful work. I just want to mention Dr. Guess had shown that in postpartum patients one year out, that if they didn't return their weight back to baseline for every BMI increase by one point, there was a change in the .AA and the genital hiatus. So I think you're right. Looking at the timing of these things is very important. And I think we missed that immediate postpartum period. Thank you. Yes, I agree. I think weight is, you know, a very important risk factor, particularly for urinary incontinence and anal incontinence, and probably an important opportunity for intervention as well. Right. And we're probably missing all the evulsions that Dr. DeLancey is showing on the MRI. So I think if we don't look early, we might miss it then. And I think that's our window of opportunity. So this is a beautiful study. Thank you. Thank you. Congratulations. So I'd like to welcome Dr. Hamner to the podium. And I'd like to say also that this paper won the best basic science paper. And just so that everybody knows, the two presentations are being combined into one. Thank you. Pregnancy and vaginal delivery are known independent risk factors for the development of pelvic organ prolapse. There are conflicting reports as to whether second-degree or greater obstetrical lacerations contribute to the development of symptomatic prolapse later in life. As more data accumulate indicating poor long-term outcomes from surgical interventions, understanding the pathogenesis of prolapse and recovery of the pelvic floor after delivery are important in developing preventative measures. Fibrillatory effects of pregnancy and delivery on the vaginal matrix have been previously linked to decreased expression of fibulin 5, a major cellular glycoprotein that not only promotes elastogenesis in the female reproductive tract, but also suppresses vaginal MMP9. Thus, absence or decreased fibulin 5 may lead to increased MMP9 and poor recovery of the vaginal elasticity after partruition. Florian Rodriguez et al. reported that actinonin, a protease inhibitor, blocked injury-induced degradation of fibulin 5 and improved biomechanical properties in the vaginal wall in non-pregnant animals. The potential role of protease inhibition on recovery of the vaginal wall after partrution or obstetrical injury is not known. The objectives of this study were to use an animal model to evaluate postpartum recovery of the vaginal wall with and without obstetrical injury. Further, we sought to quantify effects of the protease inhibitor actinonin on vaginal fibulin 5 content, elastic fibers, collagen content, biomechanics, and healing of the partulent vagina. Female sprog dolly rats were used to obtain time-pregnant animals. A subset of late-pregnant rats were anesthetized prior to delivery on day 22 of gestation, and a modified speculum was placed to visualize and generate a simulated obstetrical laceration. Injection of phosphate-buffered saline, which is a neutral buffer acting as a control, or 200 microliters of actinonin was injected locally at the time of injury. Animals were sacrificed at multiple time points between four hours to seven days postpartum, and the vaginal tube was harvested and opened to visualize and dissect the injured posterior vagina. Immunoblot analysis of the non-injured vaginal wall shown here revealed that fibulin 5 was highly expressed in the vaginal matrix, predominantly as a 65-kilodalton protein with some lower molecular weight bands. In contrast with the non-pregnant vagina, fibulin 5 content was decreased dramatically during late pregnancy. Quantification revealed that fibulin 5 decreased 93% in the late-pregnant vagina. And this profound decrease in vaginal fibulin 5 was maintained from four to 72 hours postpartum, and increasing to non-pregnant levels by seven days after a normal delivery. Next, we sought to determine if simulated obstetrical injury affected recovery of vaginal fibulin 5 after partuition. The graph demonstrates the pattern of fibulin 5 after vaginal delivery and increasing at D7. After injury, a small burst in fibulin 5 occurs, but is strikingly decreased at the longer time point of seven days. After injury, the small fibulin 5 burst occurs, but is strikingly decreased after seven days, and the actinonin administration, as depicted here with the red bars, ameliorated injury and delivery-induced loss of fibulin 5 at 12 hours and at seven days. Fibulin 5 levels, however, were only partially rescued by actinonin relative to the non-pregnant levels. Since fibulin 5, an elastic fiber organizer, was downregulated during pregnancy and the early postpartum period, we were led to investigate the effects of delivery, injury, and injury with actinonin on vaginal elastic fibers. This image demonstrates long and healthy elastic fibers of the vaginal wall in a normal pregnancy. Elastic fiber length and area decreased three days after injury, which was partially rescued with actinonin. Clearly, some damaged fibers still remained. To investigate the effect of vaginal delivery with injury on matrix homeostasis of the vaginal wall, trichrome stains were conducted. This image demonstrates the area of injury on postpartum day three after obstetrical injury. The dashed yellow line represents the area of injury. Three days after injury, the vaginal wall has a persistent large defect, and acute area of chronic inflammation is present, with evidence of collagen dissolution. Actinonin administration resulted in complete closure of the wound at three days with a smaller and more organized inflammatory reaction. Quantification of the area of injury revealed that the size of injury increased from 24 hours to three days and was still present to a lesser degree at seven days. Actinonin, shown here in red, decreased the size of injury over tenfold at the three-day period but did not show significant effect at seven days. To determine the effects of injury with and without actinonin on fibulin 5 and histomorphology, and if this translated to functional effects on the vaginal wall, we quantified biomechanical properties. Stiffness is an index of resistance to deformation in kilopascals per millimeter. The asterisk demonstrates an 82% decrease in stiffness in the pregnant vagina relative to uninjured nonpregnant controls. Without injury, stiffness gradually recovered to nonpregnant levels by seven days. Injury, shown here in blue, had a significant impact on biomechanical recovery of the vaginal wall with a 74% loss of stiffness at three days after injury. This was consistent with our findings histologically, and actinonin rescued injury-induced loss of stiffness with near-complete recovery at three days post-injury. Immunohistochemistry of the vaginal wall was performed and collagen subtype 1, which fluoresces in green in the first row, and collagen 3, which fluoresces in red in the second row, were evaluated. Findings revealed that collagen type 1 was predominant, but that the ratio of collagen 1 to 3 maintained stable throughout all time points. Three days after injury, it is easy to appreciate the rather dramatic loss of collagen 1 in green and collagen 3 in red at the site of injury. Immunostaining of both collagens increased with actinonin and is likely to contribute to improvement in biomechanical properties at three days. Taken together, this work using biomechanics, histomorphology, and protein regulation revealed that the connective tissues of the vaginal wall are vulnerable to injury during pregnancy and the early postpartum period. Although we need long-term follow-up studies in the injury model, our results presented here indicated that actinonin may represent an early intervention to accelerate recovery of the vaginal wall from traumatic vaginal delivery. Thank you. Applause.

pelvic floor disorders

pregnancy

childbirth

incidence

vaginal delivery

cesarean delivery

prolapse