ORIGINAL�ARTICLE ABSTRACT Objective: To check the frequency of stress urinary incontinence and to assess the awareness about pelvic floor muscle training for stress urinary incontinence among pregnant women. Study Design: Cross sectional observational study. Place and Duration of Study: The study was conducted from April 02, 2017 to July 30, 2017, at the department of Obstetrics and Gynecology Islamic International Medical College, Pakistan Railway Teaching Hospital, Rawalpindi. Materials and Methods: A total of 322 pregnant women between gestational ages of 12 to 38 weeks were selected by convenience sampling technique. A structured closed questionnaire was used for data collection. All data were analyzed in SPSS version 21 and percentages and mean were calculated. Results: The frequency of stress urinary incontinence among our study population was 32.9%. Awareness about pelvic floor muscle training was seen in only 9% of women in general and 27% of women suffering from stress urinary incontinence. Conclusion: Frequency of stress urinary incontinence in our pregnant population is high. Awareness about pelvic floor muscle training and its benefits is very scant and very few pregnant women suffering from stress urinary incontinence are doing pelvic floor muscle training. This highlights the need of improving antenatal care. Key Words: Pelvic Floor Muscle Training (PFMT), Pregnancy, Stress Urinary Incontinence (SUI). women suffer in silence and do not report symptoms unless questioned, which prevents the exact incidence of stress urinary incontinence difficult to assess. Pregnancy, childbirth and aging all are the risk 7,8 factors. Weak pelvic floor other than stress urinary incontinence, can also lead to fecal incontinence, prolapse of pelvic structures and sexual difficulties. Pelvic floor muscle training (PFMT) is repetitively selective voluntary contraction and relaxation of specific pelvic muscles. Pelvic floor muscle training (PFMT) raises bladder, prevents decent in bladder neck during increased abdominal pressure. It is the first line conservative treatment for prevention of stress urinary incontinence in women during 9,10 pregnancy and afterwards and is considered safe. There is evidence from literature, Cochrane review, that pelvic floor muscle training can prevent stress urinary incontinence up to six months following delivery. Studies have not revealed any detrimental effect of pelvic floor muscle training on the process 11,12 of labor and delivery. The objectives of this study is to check the frequency of stress urinary incontinence in pregnant women because most women do not report the problem considering it related to pregnancy and childbirth and are unaware of the benefits pelvic floor muscle training can Introduction Stress urinary incontinence (SUI) is involuntary leakage of urine with physical activity. It occurs when intravesical pressure exceeds urethral closure pressure in the absence of detrusor muscle contraction. It may also occur due to bladder neck hypermobility or poor urethral closure pressure. It interferes with women's quality of life and is the commonest cause of incontinence among women of 1, 2, 3 all ages and during pregnancy. The reported prevalence of stress urinary incontinence during 4, 5, 6 pregnancy in literature varies from 17.9% to 71%. This variation can be due to different selection criteria and definitions used in studies. Quality of life of more than 50% pregnant women is effected which 2 worsens with advancement of pregnancy. Many Pelvic Floor Muscle Training to Prevent Stress Urinary Incontinence in Pregnancy Rubab Riaz, Fareesa Waqar, Saadia Sultana Correspondence: Dr. Rubab Riaz Department of Gynecology and Obstetrics Islamic International Medical College Riphah International University, Islamabad E-mail: rubabriaz2004@gmail.com Department of Gynecology and Obstetrics Islamic International Medical College Riphah International University, Islamabad Funding Source: NIL; Conflict of Interest: NIL Received: Mar 02, 2017; Revised: June 03, 2017 Accepted: Oct 05, 2017 Pelvic Floor Muscle Training In PregnancyJIIMC 2017 Vol. 12, No.4 177 provide. Increased frequency and low awareness about stress urinary incontinence and pelvic floor muscle training is expected ,respectively, in our population due to repeated pregnancies, poor nutrition and failure to seek help by considering it non amendable and shameful. Materials and Methods A cross sectional study was conducted over 4 months periods from April 02 to July 30, 2017 at the department of obstetrics and gynecology in Islamic International Medical College, Pakistan Railway Teaching Hospital Rawalpindi. Sample size calculation yielded 322 women done by WHO creative research system survey software, assuming that the percentage of incontinent women in the study population would be 50% with 5% estimated error and a confidence level of 95%. Women were selected by convenience sampling technique. Permission from institution's ethical committee was taken before conducting the study. A modified questionnaire for stress urinary incontinence diagnosis (QUID) was used for data collection, frequency of stress urinary incontinence and 9 awareness about pelvic floor muscle training. The questionnaire for urinary incontinence diagnosis had 3 sections, Section 1 included demographic variables, and section 2 had questions for stress urinary incontinence diagnosis. Section 3 was about women's awareness and knowledge of pelvic floor muscle training with pictorial details in Urdu. Informed consent was taken and questionnaire was completed by interviewing women visiting clinic for routine antenatal care (study population). All women between gestational ages 12 to 38 weeks were included in the study. Exclusion criteria included women diagnosed with urinary tract infection, preterm labor and preterm premature ruptured membranes. All women who reported mild to severe symptoms of stress urinary incontinence were considered as incontinent. The data from questionnaire was entered in SPSS version 21 and results were calculated in percentages and mean with standard deviation for demographic variables. Results Age range of our study population was between 18 years to 43 years, mean age was 29.16 ± 4.946 years. Mean BMI was 26.97 ± 2.002. Eighty two percent of women were Parity 1 and above. Study results showed that 32.9% of pregnant women suffered from stress urinary incontinence ranging from mild to severe form. Fifty percentage of women suffering from stress urinary incontinence were above the age of 30 years and BMI above 30 was seen in 70% of women suffering from stress urinary incontinence .Chronic constipation and cough was seen in only 1% of effected women (table 1). Nine percent of women in general had awareness about pelvic floor muscle training, while awareness about pelvic floor muscle training in effected women was 27% out of which only 3% were performing of it. Table I: Frequency of Risk Factors among Women with Stress Urinary Incon�nence Discussion The study shows that 3 out of 10 pregnant women in our population is suffering from stress urinary incontinence. The women do not complaint about the problem during routine ante natal visit until inquired and they also lack knowledge and benefits about pelvic floor muscle training. Advanced age, obesity and multiparty is seen as a risk factor for stress urinary incontinence in our study. Literature backs aging, parity and obesity as known risk factors for stress urinary incontinence. One study reports 20% increase in urethral 13 hypermobility following first vaginal delivery. According to Norwegian EPINCOT study, association with cesarean section is also noticeable and 14 comparable to risk in nulliparous. Poor knowledge and motivation about pelvic floor muscle training seen in the study can be due to multiple reasons. One reason can be the busy antenatal clinic, where less time is given to hear all complaints from the women and less time given to provide extra teachings. Another reason can be the pelvic floor muscles which are not visible, so women do not know the right way to perform the exercise. Also anemia, protein and other nutritional deficiencies are common in our population and can make it difficult Pelvic Floor Muscle Training In PregnancyJIIMC 2017 Vol. 12, No.4 178 15 for women to hold muscles. Pelvic floor muscle training is considered free of cost, safe and effective method to prevent and treat stress urinary incontinence in pregnancy and post-partum. A cochrane review summarized the results of 5 randomized trials and shows that women undergoing intensive pelvic floor muscle training in early pregnancy were 56% less likely to report urinary incontinence in late pregnancy and around 30% less likely to report urinary incontinence in 6 16 months postpartum. A meta-analysis reports improvement in stress urinary incontinence ranging from 48% to 93% with effective pelvic floor muscle training (6-8 second contraction, 3 sets of 8-12 contraction, and 2-4 days per week). The response is 17 seen in one to three weeks. Evidence shows that at least 8 to12 weeks of pelvic floor muscle training is 18,19 required to see the good results. Health education in the form of antenatal class is beneficial and some centers recommend teaching pelvic floor muscle training as early as 10 weeks in the booking antenatal 20 class. Limitation of our study is that the level of severity for stress urinary incontinence is not defined. This study is useful as it identifies the frequency and importance of inquiring about symptoms of stress urinary incontinence and we plan to review our policy of routine antenatal care. Conclusion The study concludes that frequency of stress urinary incontinence is not far less than the prevalence seen elsewhere in the world, around 3 out of 10 pregnant women. Awareness about pelvic floor muscle training in pregnant women is very scant. Pregnancy provides women an opportunity to visit a health care provider multiple times, discuss issues effecting quality of life and get teachings like pelvic floor muscle training. But our antenatal teaching is falling behind in this particular area and require revision. REFERENCES 1. Sang BB. Risks factors for development of stress urinary incontinence during pregnancy in primigravidae: a review of literature. Eur j Obstet gynecol reprod biol. 2014; 178: 27- 34. 2. Sansawang B, Sangsawang N. Stress urinary incontinence in pregnant women: a review of prevalence, pathophysiology and treatment. Int urogynecol j. 2013; 24: 901-12. 3. Lamin E, Parilo LM. Pelvic floor muscle training: underutilization in USA. Cur Urology Rep. 2016; 17: 10. 4. Ozerdogan N, Begi NK. Urinary incontinence: its prevalence, risk factors and effects on quality of life of women living in a region of turkey. Gyneco Obstet Invest. 2004; 58: 245-50. 5. Tingthong W, Buppasiri P. Prevalence of urinary incontinence in pregnant women at 37 tertiary care hospitalsin Khonkaen province. Thai J Obstet Gynecol. 2014; 22: 37-43. 6. Hansen BD, Suare J. Urinary incontinence during pregnancy and 1 year after delivery in primigravidae women compared with controlled group of multiparaous women. Neuro Urol Urodyn. 2012; 31: 475-80. 7. Paival L , Ferla L. Pelvic floor muscle training in group vs individual or home treatment of women with urinary incontinence: systemic review and meta-analysis. Int Urogynecol. 2017; 2: 351-9. 8. Macintosh L, Anderson E. Conservative treatment of stress urinary incontinence in women. A 10 year (2004-2013) scoping. Review of literature. Urol nurs. 2015; 35: 179-86. 9. Catherine S, Bradley MD. The questionnaire for urinary incontinence diagnosis (QUID): Validity and responsiveness to change in women undergoing non-surgical therapies for treatment of stress predominant urinary incontinence. Neuro urol urodyn. 2010; 25: 727-34. 10. Sahakia J. Stress incontinence and pelvic floor exercises in pregnancy. Br j nurs. 2012; 21: 10-2. 11. Bo K. Effects of antenatal PFMT on labor and birth. Obstet Gynecol. 2009; 113: 1279-84. 12. Boyle R, Hay S. Pelvic floor muscle training for prevention and treatment of urinary and stress incontinence in pregnant women and women who have recently given birth. Cochrane. 2012. 13. Dickie Kj, Shek Kl. The relationship between urethral mobility and parity. BJOG. 2010; 117: 1220-4. 14. Rontveil G. Urinary incontinence after vaginal delivery or cesarean section. N Engl J Med. 2003; 348: 900-7. 15. Oliveira CD, Seleme M. Urinary incontinence in pregnancy and its relation with sociodemographic variables and quality of life. Rev Assoc Med Bras. 2013; 59: 460-6. 16. Bo K. To do or not to do? Pelvic floor muscle training during pregnancy and after child birth. Journal of the association of chartered physiotherapist in women's health. 2011; 108: 13-7. 17. Petricia BN. Pelvic floor muscle training and adjunctive therapies for the treatment of SUI in women: a systemic review. B M C women's health. 2006; 6: 11. 18. Bo K, Murkved S. Effects of pelvic floor muscle training during pregnancy and softer child birth on prevention and treatment of urinary incontinence: a systemic review. B J Sports. 2012; l48: 4. 19. Charles P. Pelvic floor muscle training for incontinence during pregnancy. BJOG. 2012; 119: 1270-80. 20. National collaborating center for women and child health (UK). Antenatal care: Routine care for the healthy pregnant women. London: RCOG press. 2008. Pelvic Floor Muscle Training In PregnancyJIIMC 2017 Vol. 12, No.4 179 Page 17 Page 18 Page 19