Received: 4 November 2017

DOI: 10.1002/nau.23537
| Accepted: 16 January 2018

ORIGINAL CLINICAL ARTICLE

Pelvimetry in nulliparous and primiparous women using 3 Tesla

magnetic resonance imaging

Franziska Hampel1,* | Peter Hallscheidt2 | Christof Sohn1 | Bettina Schlehe1 |

Kerstin A. Brocker1

1 Department of Obstetrics and Gynecology,

Medical School, University of Heidelberg,
Heidelberg, Germany
2 RadiologyDarmstadt, Alice-Hospital,
Darmstadt, Germany
Correspondence
Kerstin A. Brocker, MD, MSc, Department
of Obstetrics and Gynecology, Medical
School, University of Heidelberg, Im
Neuenheimer Feld 440, Heidelberg 69120,
Germany.
Email: kerstin.brocker@med.uni-
heidelberg.de
Aims: To perform pelvimetry in nulliparous and primiparous women using 3 Tesla
magnetic resonance imaging (3T MRI).
Methods: Twenty-five nulliparous volunteers and 25 primiparous women underwent
pelvic 3T MRI within one week after vaginal childbirth in a prospective clinical
single-center trial. The pelvimetric parameters interspinous distance (ISD),
intertuberous distance (ITD), sagittal outlet (SO), obstetric conjugate (OC), and
coccygeal curved length (CCL) were adapted from anthropometric measurements as
well as from sonographic and computed tomography-based pelvimetry performed on
high-resolution T2-weighted images. We compared the results of the two study
groups to one another, recent literature and postpartum-diagnosed levator ani muscle
(LAM) injuries.
Results: The mean values for primipara/nullipara were ISD 107 ± 8.3/105 ± 8.4 mm,
ITD 119.8 ± 10.2/118.4 ± 13.1 mm, OC 129.4 ± 10/130.8 ± 6.9 mm, SO 114.3 ± 7.8/
112.5 ± 8.9 mm, and CCL 37.3 ± 7.4/39 ± 8 mm. Significant differences (P < 0.05)
were found between the results for OC, SO, and CCL (primipara) and ISD, ITD and OC
(nullipara) and the values in the literature. No significant difference in pelvimetric
values was found between the groups. A significant correlation was found between the
pelvimetric parameters and five types of LAM injuries.
Conclusions: Two-dimensional 3T MRI combines high-resolution images with
objective pelvimetric measurements applicable in a postpartum setting. Our results
provide a good foundation for further MRI-based studies evaluating the bony pelvis
and its relation to LAM injuries during vaginal childbirth.

KEYWORDS
3 Tesla magnetic resonance imaging, levator ani muscle injury, pelvimetric measurements,
primiparous women, vaginal birth trauma

*Present address: Department of Internal Medicine, University Hospital

Basel, Petersgraben 4, Basel 4056, Switzerland.

The work was performed at: University of Heidelberg, Medical School, 1 | INTRODUCTION
Department of Obstetrics and Gynecology, Im Neuenheimer Feld 440,
Heidelberg 69120, Germany. Vaginal childbirth (VCB) is a common risk factor for pelvic
Fred Milani led the peer-review process as the Associate Editor responsi- floor disorders in women, especially pelvic organ prolapse
ble for the paper. and urinary incontinence.1,2 One of the main causes is injury
Neurourology and Urodynamics. 2018;1–7. wileyonlinelibrary.com/journal/nau © 2018 Wiley Periodicals, Inc. | 1
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| HAMPEL
to the levator ani muscle (LAM) complex. The LAM
represents an important part of the female pelvic floor
because it supports the pelvic organs and provides a passage
for the urethra, vagina, and rectum.3,4 Several studies using
transperineal ultrasound or magnetic resonance imaging
(MRI) have shown that VCB has a severe impact on the LAM
complex.5–7 The most well-known measurements for the
integrity of the pelvic floor are based mainly on soft tissue
reference points, but to detect and learn more about
cephalopelvic disproportions, established measurements of
the bony pelvis can be considered.8–10 Due to the attachment
of the LAM complex to the bony pelvis, sacrum and distal
spine, differences in pelvimetry may influence LAM trauma
during vaginal childbirth.4 Other than misfits between the
pelvic outlet and the fetal head detected using pelvimetry,
little is known about the actual relationship between bony and
soft tissue structures and their behavior during vaginal
childbirth.11–13 The commonly applied diagnostic tools in
pelvimetry are anthropometric measurements, computed
tomography (CT), and pelvic sonography. These tools have
numerous limitations, such as ionizing radiation during CT
and the absence of an overview of all organs in an
ultrasound.8,12,14,15 Because it provides high-resolution
images, 3 Tesla magnetic resonance imaging (3T MRI)
seems to be a useful alternative imaging modality for making
pelvimetric measurements and evaluating pelvic floor
muscles. Nevertheless, although it can completely and
simultaneously capture the pelvic structures, 3T MRI is
seldom used, and appropriate results published in this context
are scarce.16
Therefore, with this trial, we primarily aim to assess the
feasibility of performing and reproducing standard pelvi-
metric measurements obtained from ultrasound and/or CT in
nulli- and primiparous women using high-resolution 3T MRI.
We also aim to compare the results of the two groups to one
another and to reference values in the literature. Finally,
potential consistencies between pelvimetric measurements
and diagnosed postpartum LAM injuries are documented.
2 | MATERIALS AND METHODS
Two-dimensional MR images from a prospective cross-
sectional study on the morphological changes after a first
vaginal delivery were evaluated for pelvimetric measure-
ments. This study protocol and trial were approved by the
local ethics committee and designed in accordance of the
Declaration of Helsinki.7,17 The inclusion criteria were
primiparous women ≥18 years of age who had delivered
vaginally at term in the Department of Obstetrics and
Gynecology of the University of Heidelberg Medical School,
Germany and written, informed consent to participate in this
trial. The exclusion criteria were gestational age less than
ET AL.
36 + 0 weeks at delivery, age <18 years, known pelvic floor
dysfunction (eg, urinary or fecal incontinence, pelvic organ
prolapse) or prior pelvic floor reconstructive surgery, metal
implants, or claustrophobia. All primiparous women in the
study cohort delivered vaginally at term and underwent pelvic
3T MRI (Tim Trio, Siemens, Erlangen, Germany) within
1 week postpartum. LAM injuries in the primiparous study
group had been diagnosed and discussed previously.7
Potential consistencies between pelvimetric measurements
and previous LAM lesions in this group were documented. A
nulliparous healthy control group was recruited as a
reference.17 The inclusion criteria for this group were age
≥18 years, healthy and nulliparous condition, body mass
index < 30 kg/m2, and written informed consent to participate
in this study. The exclusion criteria were pelvic floor
dysfunction (eg, urinary or fecal incontinence, pelvic organ
prolapse) or previous pelvic floor surgery, pregnancy, age
<18 years, smoker, metal implants, or claustrophobia.
2.1 | Tesla magnetic resonance imaging
A T2-weighted turbo spin echo sequence in the sagittal and
coronal planes was used for pelvimetric measurements. The
measurements were performed by two authors with 2 and
10 years of experience in pelvic floor MRI using a PACS
workstation (Centricity PACS, GE Healthcare, Milwaukee,
USA). The means of both authors' measurements were
acquired after two-sided two-sample t-tests were performed.
2.2 | Pelvimetric measurement parameters
Five different pelvimetric measurements were chosen for
evaluation. The intertuberous distance (ITD), the interspinous
distance (ISD), the sagittal outlet (SO), and the obstetric
conjugate (OC) are well-established prenatal parameters used
to examine cephalopelvic disproportions in obstetrics and
have been shown to be transferrable to sectional imag-
ing.12,14,16 As a fifth parameter, we chose the coccygeal
curved length (CCL) to evaluate the possible impact of the
length of the coccyx on the parturient canal.18
The intertuberous distance affects the size of the pelvic
outlet and may disturb VCB in the presence of a cephalopelvic
disproportion. It can be assessed manually and is described as
the distance between the two ischial tuberosities.12,14,19 It was
measured as the narrowest distance in the coronal plane by
Lenhard et al14(Figure 1, panel A).
The interspinous distance is defined as the narrowest line
between the two ischiadic spines and is used to define the
height of the leading fetal part during labor.14 It was measured
in the coronal plane (Figure 1, panel B). A short interspinous
distance decreases the size of the pelvic outlet and
accordingly, of the parturient canal, which may lead to a
cephalopelvic disproportion.20
HAMPEL ET AL.
| 3

FIGURE 1 T2-weighted images of a nulliparous woman. The intertuberous distance (line) is measured as the shortest distance between both
ischiadic tuberosities (T) (coronal plane; panel A). The interspinous distance is measured as the smallest distance between the two ischiadic
spines (S) (coronal plane; panel B). The obstetric conjugate (line) is acquired in the sagittal plane between the symphysis (Sy) and the sacral
promontorium (panel C). The sagittal outlet marks the distance between the lower margin of the symphysis and the distal os sacrum (arrow-
headed line; panel C). The coccygeal curved length is calculated as the mean of the anterior and posterior lengths of the coccyx (Co; panel
D). U, uterus; S1, first sacral vertebral body

The sagittal outlet can also lead to a cephalopelvic
disproportion by affecting the size of the pelvic outlet and is
manually palpable.19 It is defined as the distance between the
distal margin of the pubic symphysis and the distal margin of
the last sacral vertebral body.14,16 It was measured in the
midsagittal plane (Figure 1, panel C).
The obstetric conjugate is defined as the narrowest line
between the upper edge of the pubic symphysis and the
ventrocaudal edge of the sacral promontorium. It was
measured in the midsagittal plane. A small OC was found
to be related to pelvic floor disorders such as stress
incontinence and pelvic organ prolapse by Handa et al21
(Figure 1, panel C).14
The coccygeal curved length combines information about
the length and angle of the coccyx.18 Because parts of the
LAM complex are inserted at the coccyx, this parameter was
added to the measurements made in this study to further
explore the possible effects of vaginal childbirth on soft
tissue. The ventral and dorsal shape of the coccyx was
measured from the sacrococcygeal joint to the distal edge of
the coccyx in the sagittal plane, and the measurements were
summed and divided by two following Woon et al18 (Figure 1,
panel D).
2.3 | Statistical analysis
Statistical analysis was performed using SPSS Statistics®
Version 23 Release 2015 (IBM SPSS Statistics for
Windows, IBM Corp., Armonk, NY). In addition to
descriptive analysis, a two-sided one-sample t-test was
used to compare the pelvimetric measurements to reference
values from the literature. Differences in the measurements
within the two groups and a possible correlation between
LAM injuries and pelvimetric dimensions were analyzed
using a two-sided two-sample t-test of unequal variances.
None of the acquired P-values (significance P < 0.05) were
adjusted for multiplicity, and therefore, they should be
interpreted descriptively.
4
| HAMPEL ET AL.

TABLE 1 Patient characteristics of the nulliparous and primiparous group were similar to the reference measurements, all other
study population parameters (the OC, the SO, and the CCL in the primiparous
Primipara Nullipara group and the ISD, the ITD, and the OC in the nulliparous
n = 25 n = 25 group) were found to be significantly different (P-value
Median age, years (IQR) 31 (26-36) 27 (24-30) <0.05) (Table 3).
Median body mass index, kg/m (IQR)2 Regarding the feasibility of measurements obtained from
the literature and performed on 3T MR images, all selected
Before pregnancy 21 (20-23) <27
parameters could be performed after being adapted to the
After delivery 26 (24-27) -
given anatomic landmarks. The ISD in the nulliparous group
Race
varied marginally between the two examiners (P = 0.044). No
Caucasian 22 25 significant differences could be found in the remaining
Asian 2 0 comparisons between the two examiners' measurements.
African 1 0 The levator ani muscle and its extension were identified
Other 0 0 and shown to be fully intact in all 25 nulliparous women,
Mode of delivery whereas five different types of injury directly concerning the
Regular vaginal delivery 20 -
pubovisceral muscle (PVM) were assessed by MR imaging in
the primiparous group (Supplement Table S1).7,17 Comparing
With vacuum extractor 4 -
these PVM injury types with the pelvimetric dimensions
With vacuum extractor 1 -
obtained here revealed a significant correlation between five
and forceps
injury types (left-sided pubovisceral muscle avulsion and the
Epidural anaesthesia 13 -
ITD (P < 0.045) and the OC (P < 0.002), left-sided PVM tear,
Birth weight, g (IQR) 3240 - and the ISD (P < 0.005), PVM hematoma, and the CCL
(3015-3655)
(P < 0.047), and right-sided PVM edema at the insertion to
the pubic bone and the OC (P < 0.033); (Supplement
Table S1, Figure 2).
3 | RESULTS

Between October 2011 and January 2013, a study population 4 | DISCUSSION

consisting of 25 nulliparous volunteers and 25 primiparous
women was recruited for this trial. Table 1 describes the
patients' characteristics.
Regarding the parameter evaluation, similar results were
obtained for all pelvimetric measurements when the nullipa-
rous and primiparous groups in our study were compared
(Table 2). Upon comparing each evaluated parameter to
results published in the literature, variations were found in
both groups. While the ISD (107.2 ± 8.3 mm) and the ITD
(119.8 ± 10.2 mm) in the primiparous group and the SO
(112.5 ± 8.9 mm) and the CCL (39 ± 8 mm) in the nulliparous
We set out to evaluate the application of five standard
pelvimetric measurements using 3T MRI performed on nulli-
and primiparous women. The following important facts were
demonstrated: 1) All five selected pelvimetric measurement
parameters were easily adaptable to 3T MRI; 2) No
significant difference was found in the pelvimetric parameters
between nulliparous women and primiparous women within
the study cohort; 3) The measured means of the interspinous
and intertuberous distances in primiparous women and of the
sagittal outlet and the coccygeal curved length in nulliparous

TABLE 2 Means and standard deviations (SDs) of the pelvimetric measurements (mm) performed in primiparous and nulliparous women
Mean (±SD) P-value* Confidence interval (%)
Parameter Primipara n = 25 Nullipara n = 25
ISD 107.2 (±8.3) 105.2 (±8.4) 0.394 −2.7/6.8
ITD 119.8 (±10.2) 118.4 (±13.1) 0.664 −5.2/8.2
OC 129.4 (±10) 130.8 (±6.9) 0.580 −6.2/3.5
SO 114.3 (±7.8) 112.5 (±8.9) 0.458 −3.0/6.5
CCL 37.3 (±7.4) 39 (±8) 0.451 −6.0/2.7

ISD, interspinous distance; ITD, intertuberous distance; OC, obstetric conjugate; SO, sagittal outlet; CCL, coccygeal curved length.
*Two-sided one-sample t-test.
HAMPEL ET AL.
| 5

TABLE 3 Means and standard deviations (SDs) of the pelvimetric measurements (mm) performed in both study groups and comparison of the
pelvimetric measurements to reference values from the literature, listed with the corresponding examination method and study population
Reference (examination method,
Mean (±SD) Mean (±SD) Confidence number and characteristics
Parameter study cohort references interval (%) P-value* of study population)
Primiparous ISD 107.2 ± 8.3 109.0 ± 7 −52/1.6 0.281 Lenhard et al14 (CT, n = 20,
women women of different parity
(n = 25) after normal vaginal delivery
within one week postpartum)
ITD 119.8 ± 10.2 120.0n± 0 −4.4/4 0.931
OC 129.4 ± 10 120.0 ± 9 5.3/13.5 0.000
SO 114.3 ± 7.8 121.0 ± 9 −9.9/−3.5 0.000
CCL 37.3 ± 7.4 42.0 ± 8 −7.8/−1.6 0.004 Woon et al18 (CT, n = 112, m/f adults
without history of sacral or
coccygeal area dysfunction)
Nulliparous ISD 105.2 ± 8.4 109.0 ± 6 −7.3/−0.4 0.031 Rizk et al16 (1.5 T-MRI, n = 11,
women white/European nulliparous women
(n = 25) with a mean age of 26.4 years ± 4.1
years)
ITD 118.4 ± 13.1 95.0 ± 9 17.9/28.8 0.000
OC 130.8 ± 6.9 112.6 ± 15.1 15.3/21 0.000 Xu et al12 (CT, n = 508, women
with myoma of the uterus scheduled
for surgery)
SO 112.5 ± 8.9 115.0 ± 10 −6.1/1.2 0.175 Rizk et al16 (1.5 T-MRI, n = 11,
white/European nulliparous women
with a mean age of 26.4 years ± 4.1
years)
CCL 39 ± 8 42.0 ± 8 −6.3/0.25 0.068 Woon et al18 (CT, n = 112, m/f adults
without history of sacral or
coccygeal area dysfunction)

ISD, interspinous distance; ITD, intertuberous distance; OC, obstetric conjugate; SO, sagittal outlet; CCL, coccygeal curved length; CT, computed tomography; m/f, male
and female; T, Tesla; MRI, magnetic resonance imaging.
*Two-sided one-sample t-test.

FIGURE 2 T2-weighted images of a 19-year-old primiparous woman with left-sided levator ani muscle avulsion (panel a, coronal plane,
arrow) who had given birth to a 3050-gram newborn (natural vaginal birth without instrument assistance). The levator ani muscle insertion at the
symphysis pubis (Sy) is drawn with a dashed line. Panel b shows the obstetric conjugate (line), which measures 117 mm in this woman, acquired
in the sagittal plane between the symphysis (Sy) and the sacral promontorium (Sp). The sagittal outlet measuring 114.75 mm is marked with a
dotted line. R, rectum; Ur, urethra; V, vagina
6
| HAMPEL
women were comparable to results in the recent literature
using other diagnostic tools, whereas the other measurements
differed significantly; and 4) For five injury types,
correlations were found between pelvimetric measurements
and PVM defects.
Numerous studies have demonstrated excellent LAM
evaluation with ultrasound, but this method has its limits
when obtaining pelvimetric measurements from a single
ultrasound image.2,5 Due to its large field of view and
standardized protocol, 3T MRI allows all relevant pelvic
structures to be captured for our evaluation, enabling a
reliable comparison among all participants. Compared to CT,
it offers sectional imaging without radiation. Compared to
1.5T MRI, it also allows excellent soft tissue contrast rating of
the muscles, ligaments, and edema of the pelvic floor. The
five measurements we adapted to the images produced with a
3 Tesla MR scanner from other diagnostic tools are
applicable, and the measurements are reproducible.
Regarding the evaluated pelvimetric parameters, no
significant differences between our nulliparous and primip-
arous groups were observed. On one hand, this does not
seem surprising because bones are high-density structures
whose dimensions are expected to remain stable despite
traumatic events, such as vaginal child birth. On the other
hand, variations in both groups due to hormonal influences
during pregnancy could have been expected; these could
have altered the ligaments and other bone-adherent soft
tissue.22
Comparing our 3T MRI results with reference values
obtained by other groups using different diagnostic tools
reveals that the interspinous and intertuberous distances in
the primiparous participants were comparable, as were the
sagittal outlet and the coccygeal curved length in the
nulliparous participants.12–14,16,23 Similar to data published
by Keller et al23 and Michel et al24 however, all pelvimetric
measurements showed outliers: in particular, the intertuber-
ous distance in both study groups (which ranged from 46 to
103 mm in primiparous women and from 86 to 141 mm in
nulliparous women). One potential explanation for these
outlying values is the large range of phenotypical variations of
the female pelvis, which may also explain the significantly
different measurements of the OC, SO, and CCL in
primiparous women and the ISD, ITD, and OC in nulliparous
women when the reference values are considered.11
Significant correlations (P < 0.05) were detected between
left-sided pubovisceral muscle avulsion and the intertuberous
distance and the obstetric conjugate, between a left-sided
pubovisceral muscle tear and the interspinous distance,
between pubovisceral muscle hematoma and the coccygeal
curved length, and between right-sided pubovisceral muscle
edema at the insertion at the pubic bone and the obstetric
conjugate. These correlations between pelvimetric measure-
ments and PVM injuries hint at possible causation, but further
ET AL.
studies with larger cohorts are needed to substantiate these
results, especially when considering future pelvic floor
disorders. The correlation between a smaller OC and PVM
avulsion in our cohort is in agreement with results obtained by
Handa et al21 who detected an association with a narrow OC
in a retrospective MRI trial evaluating 59 women with pelvic
floor disorders. The remaining comparisons did not detect any
connection between LAM defects and pelvimetric parameters
in the primiparous cohort, which is similar to the results of the
pelvic floor investigation published by Berger et al13
including the interspinous and intertuberous distances
measured using 1.5 T MRI.
We demonstrated that 3T MRI offers an alternative to
already established diagnostic techniques, such as CT and
sonography. However, we acknowledge several limitations in
our trial. Differences between study cohorts in the recent
literature (eg, Xu et al12 on preoperative myoma patients) and
the small study population limit broad comparisons to our
results or statistical analysis.14 The study populations from
which the reference values were obtained vary in size and
characteristics.12 Additionally, the impact of the newborns'
weight and head circumference, operative vaginal deliveries
and the participant's body mass index, which may influence
pelvimetric dimensions, were not further evaluated in this
cohort.25 Additionally, the possibility of the pelvic position
during VCB impacting the outcome of the birthing process, as
mentioned by Michel et al24 was not considered, nor were the
patients examined with (translabial) ultrasound for a direct
image comparison. More pelvimetric parameters and ana-
tomic findings that are mentioned in the literature were not
investigated in this study and could have an impact on the
LAM in the context of vaginal childbirth.11,14,18 Furthermore,
the authors are aware that the time required by and expense of
MRI may complicate its implementation in clinical practice
and the creation of larger study groups.
5 | CONCLUSIONS
3T MRI allows objective pelvimetric measurements due to its
high image quality, standardized protocol, and large field of
view, making it possible to simultaneously capture soft tissue
and bony elements. Despite its limitations in terms of cost and
widespread availability, 3T MRI offers an alternative to
common procedures, such as ultrasound, in complex cases
when simultaneous imaging of bones and soft tissue is
needed. The pelvimetric parameters measured are reproduc-
ible through 3T MRI. A significant relationship between
pelvimetric examination and pubovisceral muscle injuries
following vaginal birth was detected for five injury types. Our
results provide a good foundation for further MR studies
evaluating the bony pelvis and its relation to pubovisceral
muscle injuries during vaginal childbirth.
HAMPEL ET AL.
ACKNOWLEDGMENTS
This trial was self-funded.
ORCID
Kerstin A. Brocker http://orcid.org/0000-0002-3543-4381
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SUPPORTING INFORMATION
Additional Supporting Information may be found online in
the supporting information tab for this article.
How to cite this article: Hampel F, Hallscheidt P,
Sohn C, Schlehe B, Brocker KA. Pelvimetry in
nulliparous and primiparous women using 3 Tesla
magnetic resonance imaging. Neurourology and
Urodynamics. 2018;1–7.
https://doi.org/10.1002/nau.23537