CHALLENGES IN MANAGEMENT

OF UTERINE PROLAPSE IN
PREGNANCY
Presented by
Dr Moses Mwei
Dr Benjamin Shayo
Dr Bariki Mchome
8th June 2017
CASE REPORT
 DEMOGRAPHIC INFO.
• Patient Name: S. M
• Age: 26
• Sex: Female
• Adress: Nyumba ya mungu- Moshi
 PRESENTING COMPLAINT
• Patient came in as a referral from Mawenzi
regional hospital
• Complaints of slight abdominal pains and
progressive protrusion of a mass per vagina
 HPI
• Abdominal pain-Since conception
Gradual onset
Mild
Localised Suprapubic
No radiation
No abvious aggrevating or relieving factor
 HPI………..ct
• The mass protruding per vagina was
progressively increasing in size from the
time the patient first noticed it. It was not
painful in touch but was associated with
discomfort on walking.
• No aggreviating or relieving factors were
reported.
• No associated pv bleeding or discharge was
reported
 OBSTETRIC HX
• G3 P2 L2
• With the history of two spontaneous vaginal
deliveries at home.
• 1st delivery -2009, Bwt 4kg, a/w
• 2nd delivery – 2012, Bwt 3kg, a/w
• 3rd pregnancy- Index
• LNMP- Unknown
 GENERAL EXAM
• FGC
• Mild pallor
• Afebrile
• No oedema
• Temp 37.2
• B.P 110/78 mmHg
 PV EXAM
• FGM done
• Cervix prolapsed past introitus, normal
anterior and posterior walls
• Smooth surface with no decubitus ulcer
• Pelvic assessment couldn’t be performed
due to obstruction by the mass
• Baden walker classification grade 3
 Per abdomen examination
• Fundal height – 27 cm
• Estimated fetal size- 2kg
• Lie- longitudinal
• Presentation – Breech
 Initial plan
• Admit Obstetric ward
• Hb- Hb- 6.6g/dl, BTX- 2 units -given
• IM Dexamethasone 6mg 12hourly- 24hrs
• IM MgSO4 6G STAT
• Nifedipine 10mg OD for 3 days
• Obstetric u/sound
• Haematinics
 Obstetric u/sound
• BPP- 8/8
• GA- 32 Weeks
• EFW- 1.8 KG
• Placenta- fundal
 Subsequent management
• Patient stayed in the ward for two weeks and
an elective c/section + BTL was done at GA
(LUSS) of 34 weeks.
• INTRA OP- LFI, 2KG, Scored 8 in 1st minute and
10 in 5th minute
• BTL was done
 Follow up plan
• Discharge plan
-Kegel exercise
-Avoid risk activities(Carrying heavy
objects etc)
-Follow up after 6 month for reevaluation
and definitive treatment
 INTRODUCTION
• The herniation of genital organs into or
beyond the vaginal walls
• Symptoms can impact
–Daily activities
–Sexual dysfunction
–Exercise
–Body image and sexuality
 Types
• POP is arbitrary divided into;
 Anterior vaginal compartment prolapse eg cystocele
 Apical compartment prolapse eg uterine, vaginal vault,
enterocele
 Posterior compartment prolapse eg rectocele

• Uterine procidentia
 Hernia of all three compartments through the vaginal
introitus
Ant. Vag wall prolapse
Apical prolapse
Post wall prolapse
 The POP Burden
• Affects 50% of parous women with a 10-20%
life time risk for surgical repair
• Half of women >50 yrs affected with a lifetime
prevalence risk of 30-50%
• A common indication for gynecological
surgeries in the western world

Barber & Maher, (2013); Subak LL, (2001)

• Prevalence difficult to ascertain
– Different classification systems
– Symptomatic vs Asymptomatic
– Worldwide
• 3-6% based on symptoms
• 41 – 50% on clinical findings
• In low income countries mean prevalence is
19.7% (3.4 – 56.4%)

• In Africa, largely remains unknown.

• Ethiopia 55.1% vs 6.3%
• Ghana 12.1%
• Tanzania ??
Walker & Gunasekera, (2010 );Megabiaw et al, (2013)
 ..relevant anatomy
• Pelvic support is provided by pelvic floor
muscles and connective tissues in bony pelvis
• Levator ani (pubococcygeus, puborectalis,
iliococcygeus) → firm, elastic base for support.

• Endopelvic fascia condensations eg

uterosaccral, cardinal ligaments and arcus
tendineus fascia →correct positioning of pelvic
organs
Normal pelvic floor anatomy
 Risk factors
• Obstetric
– Parity
– Mode of delivery; vaginal vs cesarean
• Advancing age
• Overweight and Obesity
• Chronic elevated intra-abdominal pressure
– Chronic cough, constipation, heavy lifting
• Connective tissue disorders
– eg Ehlers-Danlos
 Clinical Manifestations
• Specific symptoms
– Vaginal bulge/something falling out of vagina
– Vaginal or pelvic pressure
• Associated symptoms
– Urinary e.g. incontinence in early stages vs.
obstructive in late stages
– Defecatory e.g. constipation, fecal
urgency/incontinence
– Sexual dysfunction (fear, discomfort,
embarrassment)
 Diagnosis and Evaluation
• Diagnosed on pelvic
exam
• Medical history is
important especially in
treatment choice
decisions.
• Classification systems
– Baden-Walker (1972)
– POP-Q (1996)
..the Baden-Walker Halfway system

Lacks precision and reproducibility but effective in

clinical settings
 POP-Quantification test
• The POP classification system of choice of
– The International Continence Society (ICS)
– The American Urogynecologic Society (AUGS),
– The Society of Gynecologic Surgeons
• Proven to have interobserver and
intraobserver reliability
• Site-specific, quantitatively measuring various
points creating a topographic map of vagina.
• Uses a fixed reference point – hymenal
remnants, called point zero (0)
• Positive (+) values outside the vagina
(hymenal remnants)
• Negative (-) values inside the vagina
• Site specific defined points referenced to the
place of the hymenal remnants
 POP-Q Staging
• Stage 0 – no prolapse
• Stage I – most distal portion of prolapse >1 cm
above level of hymen
• Stage II – most distal portion between 1 cm
above and 1 cm below the hymenal plane
• Stage III – most distal portion > 1 cm below plane
of hymen but does not protrude further than 2
cm less than tvl in cm
• Stage IV – complete eversion of tvl, usually cervix
or cuff being leading edge
 MANAGEMENT OF UTERINE
PROLAPSE
• Goal of treatment
-Alleviate symptoms
-Restore anatomical structure
-Restore/Preserve sexual function
• Choice of treatment depends on
-Symptoms severity
-Prolapse severity
-Fertility desire
 MNGT OF UTERINE PROLAPSE
• Conservative management
-Asymptomatic patient
-Grade I & II
-Patient desire
-Address risky condition( Heavy weight
lifting, coughing, constipation, Obesity etc)
-Employ use of Kegel exercise
Conservative management
• Desirable for grade 11
& III
• Patient has other
comorbidities risk for
surgery
Contraindication
• Short vagina length
• Large introitus
• Previous vaginal
surgery
 Surgery
• Goals
-Provide mechanical support
-Suspension
-Obliterative
-Surgical excision-NOT VERY EFFECTIVE!!!
 Suspension procedures
• Material used
Synthetic material-Mesh (Polyprolene
mesh)
-Graft
Xenograft
Allograft-Harvested rectus fascia
Uterosacral suspension
Sacrospinous suspension
Sacral culpopexy
Provide support/strengthening
Obliterative
 Uterine prolapse in pregnancy
• Limited data-Rare event
• Potential complication from C/reports
-Preterm delivery 60% of case-RDS,IUFD
-↑ Risk of infection
-↑ Risk of inversion
-Potential risk of PPH
 Uterine prolapse in pregnancy
• Management
-Reduce risk of complication
Enhance fetal lung maturation
Tocolytic until viability attained
Bed rest
Pessaries if presents early
THE END