Int Urogynecol J DOI 10.1007/s00192-014-2595-3
REVIEW ARTICLE
Procidentia in pregnancy: a systematic review and recommendations for practice Zdenek Rusavy & L. Bombieri & R. M. Freeman
Received: 27 August 2014 / Accepted: 27 November 2014 # The International Urogynecological Association 2015
Abstract Introduction and hypothesis Pelvic organ prolapse (POP) in pregnancy is a rare condition with decreasing incidence and improved management and outcome world-wide recently. Systematic review of the literature for cases of POP in pregnancy published since 1990 was carried out to identify common factors in presentation, management and outcomes. One case from our own practice was added to the analysis. Methods An extensive search of the Pubmed/Medline, Scopus and Google Scholar databases was performed to identify all cases of POP in pregnancy since 1990. Published case reports of POP in pregnancy were reviewed and summarized in tables to find similarities in history, course, management and outcome of the pregnancies. Results Of the 43 cases and one case series, 41 case studies were eligible for analysis. Two types of POP in pregnancy were identified: preexisting is less common (14 vs 27 cases), often resolves during pregnancy (5 out of 14) and always recurs after delivery (14 out of 14); acute onset of POP in pregnancy rarely resolves in pregnancy (2 out of 27), but often resolves after delivery (18 out of 27). Most patients were managed with bed rest (20 out of 41), pessary (15 out of 41), manual reduction (6 out of 41) and local treatment (6 out of 41). The most common complications reported include
Z. Rusavy (*) Department of Obstetrics and Gynecology, Faculty of Medicine in Pilsen, Charles University in Prague, Alej Svobody 80, Pilsen 30460, Czech Republic e-mail: [email protected] L. Bombieri : R. M. Freeman Urogynaecology Unit, Women’s and Children’s Directorate, Plymouth Hospitals NHS Trust, Derriford Hospital, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
preterm labour (14 out of 41), cervical ulcerations (9 out of 41), infection (3 out of 41) and obstructed labour (4 out of 41). About a half of the women delivered vaginally (22 out of 41), caesarean section due to prolapse was required in 15 cases. Conclusions Two distinct entities were identified based on similarities regarding onset, course and outcome of POP in pregnancy. Concise recommendations for practice were derived from the analysis of case studies published since 1990. Keywords Pelvic organ prolapse . Pregnancy . Review . Recommendations
Introduction Pelvic organ prolapse (POP) in pregnancy is a rare event, with only 325 cases reported to date. The incidence of 1 case in 13, 000 to 15,000 [1, 2] has probably decreased considerably, which may be related to the decrease in parity over recent decades [3]. Additionally, the rate of adverse delivery outcomes has also decreased dramatically since the end of the last century, possibly due to changes in obstetric practice and advances in neonatology. Keettel described 9 maternal deaths associated with POP in pregnancy in 1925, 8 due to septicaemia and 1 due to uterine rupture [1]; however, no maternal fatalities have been reported since. The overall foetal mortality rate in women with POP in pregnancy was 22 % in 1941 [1]. However, 8 perinatal deaths have been reported since 1990 and these were all in developing countries [4–8]. In order to obtain reproducible information regarding the management of future patients, we looked at all cases reported in the past 25 years as obstetrics and urogynecology practice are more likely to be applicable to today’s practice. Given the low incidence of POP in pregnancy, a full case series would take many years to collect. Therefore, we performed a systematic review of all case reports published since 1990 to
Int Urogynecol J
identify common factors in presentation, management and outcomes, which may help with the management of future patients.
Materials and methods An extensive search of the Pubmed/Medline, Scopus and Google Scholar databases using the keywords “pregnancy”, “labor”, “delivery”, “prolapse”, and “procidentia” was performed. Subsequently, all referenced articles were reviewed in order to obtain additional cases. The systematic search was performed to identify individual cases published after 1990. The published case reports on POP in pregnancy were then thoroughly reviewed by the researchers and summarized in tables to allow comparison and find similarities in the history, course, management and outcome of the pregnancies. One unpublished case of POP in pregnancy from our own experience was added to the analysis. Concise recommendations for practice based on the analysis were devised. Cases from series with insufficient information regarding individual cases were not included in the analysis; however, their results were taken into account for the recommendations for good practice.
Results In total, 43 cases of POP in pregnancy and one case series of 49 patients from India [8] published since 1990 were identified in the literature. Two case studies were excluded for linguistic reasons (the articles were in Korean and Turkish). The case series was not included in the analysis as it did not provide sufficient information regarding individual cases. Two types of POP in pregnancy with common characteristics and outcome could be identified from the analysis of the published case studies: a pregnancy complicated by an acute onset of POP (in pregnancy) usually has a different aetiology, course and outcome from a pre-existing prolapse complicated by pregnancy. Of the 41 cases eligible for analysis, 14 were preexisting POP in pregnancy (Table 1) and 27 had an acute onset in pregnancy (Table 2). Aetiology and outcome Age and parity do not seem to be risk factors for POP in pregnancy (Tables 1, 2). POP in pregnancy in a nulliparous woman was reported in 4 cases; in 1 the POP predated the pregnancy [10]. The acute onset of POP occurred most frequently in the second trimester, although in 5 cases it was first observed in labour [22, 25, 30, 32, 34]. POP can resolve spontaneously in pregnancy with the growth of the uterus in the second trimester as the uterus becomes an abdominal organ. This phenomenon is five times more frequent in the
case of a preexisting POP (5 out of 14 vs 2 out of 27). In 4 cases the POP worsened over the course of the pregnancy, also more frequently in the case of preexisting POP (3 out of 14 vs 1 out of 27). After delivery, the preexisting POP recurred or persisted in all cases. On the contrary, the POP with acute onset in pregnancy resolved spontaneously or at least improved after delivery in 18 of the 27 cases. Caesarean section seems to be protective against the persistence or recurrence of POP after delivery in cases of acute onset; it persisted in 1 out of 12 patients with acute onset of POP in pregnancy who delivered by caesarean section, and 5 out of 15 patients with acute onset who delivered vaginally. Management and mode of delivery The reports show that most patients were managed with bed rest (20 out of 41), pessary (15 out of 41), manual reduction (6 out of 41) and local treatment (6 out of 41) and 1 case was managed successfully with gasless laparoscopic uterine suspension at the 13th week of pregnancy (with a good pregnancy outcome) [18]. Bed-rest was commonly associated with inpatient care and the Trendelenburg position. The patients with preexisting POP were managed more frequently with a pessary than patients with acute onset of POP (8 out of 14 vs 7 out of 27), possibly because the women were already used to pessary treatment before pregnancy. The use of a ring/Mayer/Dumontpallier pessary was reported in 8 cases, doughnut in 4 cases and a Gellhorn in 2 cases. The type of pessary was not reported in 3 cases. The pessaries were frequently expelled as the pregnancies progressed and the treatment of POP in pregnancy with a pessary in the published cases frequently failed because the pessary fell out. Few case reports have reported of self-management of a ring pessary [5, 27]. Local therapy with glycerin and an antiseptic agent have been applied when ulcerations and excoriations of the prolapsed cervix have arisen and in some cases antibiotics administered [7, 24, 28, 32, 35]. In 1 case [25], caesarean section was successfully avoided after application of concentrated topical magnesium sulphate to reduce the oedema of a prolapsed cervix that could not be reduced. Gauze soaked in a solution of 20 g magnesium sulphate in 50 ml of normal saline was applied, resulting in reduction. The prolapse was then “held back” with magnesium sulphate-soaked gauze during the first stage of labour. No clinical signs or symptoms of systemic absorption of magnesium were observed [25]. As an alternative, Dührssen incisions (i.e. three surgical incisions corresponding to the 2, 6 and 10 o’clock positions [8]) have been used to an incompletely dilated cervix to facilitate vaginal delivery with an oedematous and incarcerated cervix, in reports from India (29 cases) [8, 30, 34]. Of all the cases analyzed, 22 women delivered vaginally, more frequently those with a new onset of POP in pregnancy
0
1
South Korea 2001 28
2006 35
2006 30
2010 44
2011 35 2011 36
2011 36 2011 35
2012 35 2013 24 2013 34
2013 30
2014 36
Taiwan
Turkey
USA
Finland Finland
Nepal Pakistan
Spain Turkey Japan
Japan
UK
Ring pessary, bed rest, tocolysis Shelf pessary self-management
None Bed rest, ring pessary, local treatment, ice packing after delivery Pessary Bed rest, manual reduction Bed rest, tocolysis
Bed rest, local treatment, manual reduction, pessaries (ring, donut and Gellhorn) None Pessary
None
Bed rest
Donut pessary, bed rest Pessary
LSCS lower segment caesarean section
1
1
1 3 1
5 1
1 2
2
5
1
1997 29
USA
Age Parity Management
Year
None reported None reported
Cervical oedema, ulceration, preterm labour, obstructed labour Infection
None reported
None reported
None reported
Complications
Term vaginal delivery
None
Term vaginal delivery Decubitus ulcer, stillbirth Term assisted vaginal delivery Oedema, cervical laceration, urinary retention, hydronephrosis, stillbirth Term vaginal delivery Imminent preterm labour Term LSCS (POP) Oedema, incarceration Preterm LSCS (placenta Imminent preterm labour praevia) Term vaginal delivery Imminent preterm labour
Term LSCS (POP) Term LSCS (POP)
Preterm caesarean hysterectomy + sacrocolpopexy Term vaginal delivery
Term LSCS (malposition of fetus) Term caesarean hysterectomy
Term vaginal delivery
Mode of delivery
Cases of pelvic organ prolapse (POP) in pregnancy in women with preexisting POP published after 1990
Country
Table 1
3,500
3,092
3,250 2,920 2,932
3,200 2,400
3,150 3,030
3,515
2,300
2,610
3,420
2,410
Worsened in pregnancy Worsened in pregnancy
No resolution Not reported No resolution
No resolution In the second trimester
After 18 weeks After 24 weeks
At 30 weeks
Worsened in pregnancy No resolution
No resolution
At 20 weeks
[10]
[9] (case 3)
Reference
POP persisted
POP persisted
POP persisted POP recurred POP persisted
POP persisted POP persisted
POP persisted POP persisted
POP recurred
Unpublished case
[17] (case 4)
[15] [16] [17] (case 1)
[14] [14] (2nd pregnancy) [6] [5]
[13]
Concomitant POP [11] surgery Concomitant POP [12] surgery
Not reported
POP persisted
Birth Resolution of POP Follow-up weight during the (g) pregnancy
Int Urogynecol J
2010
2010
2010
2011
2012
2013
Turkey
Greece
Turkey
Singapore
India
France
2010
Turkey
2008
USA
2009
2008
2009
2007
Gran Canaria, Spain Greece
India
2007
UK
Turkey
2007
Greece
2009
2005
Italy
USA
2002
2009
37
2002
Israel
Israel
2009
32
2000
USA
Turkey
36
1999
Japan
Morocco
31
1997
USA
39
26
26
29
31
36
21
27
19
38
19
32
33
35
25
42
33
30
25
25
1997
USA
Age
Year
2
0
2
2
2
2
3
1
1
1
0
2
1
0
4
2
2
2
4
2
1
1
2
1
Parity
Manual self-reduction, antibiotics Tocolysis, pessary (ring, Gellhorn) No antenatal care, Duhrssen incision on cervix Pessary (Dumontpallier), local treatment, antibiotics
Bed rest
Bed rest
Bed rest, Trendelenburg, antibiotics
Duhrssen incision on cervix
Antibiotics, ring pessary self-management Intermittent manual self-reduction, antibiotics No antenatal care
Pessary, local treatment, tocolysis Antibiotics, bed rest, Trendelenburg, tocolysis, corticosteroids Manual reduction after local MgSO4 treatment Bed rest, manual reduction
None reported
Bed rest, Trendelenburg
Bed rest
Bed rest, pessary (Mayer)
None reported
Bed rest, doughnut pessary, tocolysis Bed rest, doughnut pessary, tocolysis Laparoscopic gasless uterine supension at 13 weeks Bed rest, labour induction
Management
Cervical ulceration, obstructed labour
Term LSCS (obstructed labour)
Term vaginal delivery
Cervical oedema, bleeding, obstructed labour Imminent preterm labour, urinary retention Entrapped head
None reported
Urinary tract and cervical infection, premature labour, neonatal death None reported
Elongated cervix, entrapped head
Term LSCS (bleeding), prophylactic UA ligation Term LSCS (obstructed labour)
Term vaginal delivery
Term vaginal delivery
Premature vaginal delivery
Term vaginal delivery
PROM, obstructed labour
PPROM, chorioamnionitis
Preterm vaginal delivery
Preterm LSCS (obstructed labour)
Cervical oedema, ulceration
None reported
Ulceration, pain, preterm labour Cervical oedema, ulceration, suspected PPROM, preterm labour Cervical oedema, abrasions
Cervical oedema
Cervical oedema
None reported
Cervical oedema, ulceration
Cervical oedema, ulceration
None reported
Term vaginal delivery
Term vaginal delivery
Preterm vaginal delivery
Preterm LSCS (POP, breech) Preterm LSCS (POP)
Term LSCS (abnormal CTG) Term LSCS (maternal request) Term LSCS (POP)
Term LSCS (POP)
Term induced vaginal delivery Term LSCS (POP)
Term vaginal delivery
Imminent preterm labour, bleeding, cervical oedema None reported
Imminent preterm labour
Term vaginal delivery Preterm vaginal delivery
Complications
Mode of delivery
Cases of POP with onset in pregnancy published after 1990
Country
Table 2
3,700
3,200
2,100
3,100
2,960
3,650
3,300
860
2,700
3,100
N/R
3,200
13
41
12
35
32
16
10
37
35
Second trimester
16
24
First trimester
31
1,900
2,410
32
40
21
24
26
10
16
13
29
26
POP onset (GA in weeks)
2,400
N/A
3,050
3,150
N/A
N/A
3,500
3,520
2,100
3,000
Birth weight (g)
POP worsened
Not reported
None
Not reported
None
None
None
Not reported
None
None
None
After 28 weeks
None
None
None
Not reported
None
None
None
None
At 16 weeks
Surgery
None
None
Resolution of POP during the pregnancy
POP persisted
POP improved
POP improved
POP improved
POP resolved
POP persisted
POP persisted
POP improved
POP resolved
POP recurred
POP resolved
POP resolved
POP recurred
POP resolved
Not reported
POP resolved
POP resolved
POP resolved
POP resolved
Not reported
POP resolved
POP resolved
POP persisted
POP improved
Follow-up
[35]
[34]
[33]
[32]
[31]
[7] (case 2)
[7] (case 1)
[30]
[29]
[28]
[27]
[26]
[25]
[24]
[23]
[22]
[21]
[20]
[3] (case 2)
[3] (case 1)
[19]
[18]
[9] (case 2)
[9] (case 1)
Reference
Int Urogynecol J
[17] (case 2)
[17] (case 3)
POP resolved
POP resolved
(3 out of 14 vs 9 out of 27), and 15 patients delivered via caesarean section (5 out of 14 vs 10 out of 27). Others had a caesarean section for other obstetric indications. Complications
MgSO4 magnesium sulphate, CTG cardiotocography, PPROM preterm premature rupture of membranes, PROM premature rupture of membranes
None 20 5,116
14 Bed rest, tocolysis
Preterm vaginal delivery
Imminent premature labour 1
0
2013 Japan
36
2013 Japan
36
Bed rest, tocolysis
Term LSCS (cephalopelvic disproportion)
2,445
None
[4] POP resolved 26
Cervical oedema, stillbirth—foetal strangulation on the pessary Imminent abortion 2013 India
35
3
Local treatment, bed rest, ring pessary
Preterm vaginal delivery
1,600
None
Reference POP onset (GA in weeks) Complications Year Country
Table 2 (continued)
Age
Parity
Management
Mode of delivery
Birth weight (g)
Resolution of POP during the pregnancy
Follow-up
Int Urogynecol J
Complications of POP in pregnancy are common and they have been well reviewed [36]. Maternal or foetal death can result from a lack of care and uterine ischaemia, infection, acute urinary retention or obstructed labour. This is now rare in developed countries because of better access to medical care. No maternal deaths have been reported since 1990. Of the cases available for review, only 4 foetal deaths occurred and these were all in developing countries [4–7]. The most common complications reported since 1990 include the preterm onset of labour (14 out of 41), cervical ulcerations (9 out of 41), infection (3 out of 41) and obstructed labour requiring a caesarean section because of the prolapsed, oedematous and often incarcerated cervix (4 out of 41; Tables 1, 2). Premature onset of labour was reported in approximately a third of the pregnancies (4 out of 14 and 10 out of 27) with tocolysis resulting in successful term delivery in some cases. It was more successful in cases of preexisting POP (2 out of 14) than in acute onset of POP (1 out of 27; Tables 1, 2). Overall, the pregnancies resulted in a preterm delivery in 11 out of a total of 41 cases of POP in pregnancy (27 %). Significantly more cervical ulcerations were reported among patients with new onset of POP in pregnancy compared with preexisting POP (7 out of 27 vs 2 out of 14), while infection (1 out of 14 vs 2 out of 27) and obstructed labour (1 out of 14 vs 3 out of 27) rates were low and comparable.
Discussion The systematic review of the literature identified two types of POP in pregnancy: POP presenting before pregnancy is less common and often resolves during pregnancy, but recurs after delivery. In such cases, management with a pessary is easier because the patients are usually already familiar with this treatment modality and in the case of preterm onset of labour, tocolysis has been shown to be successful. Acute onset of POP in pregnancy is more common. The uterus usually remains prolapsed throughout the entire pregnancy, but resolves after delivery. This might be due to a different aetiology compared with pre-pregnancy POP. This type of prolapse is most frequently caused by a history of trauma to the pelvic floor or congenital disorder that weakens the pelvic floor support. Prolapse developing in pregnancy is more likely to be due to an escalation of the physiological changes in pregnancy that lead to weakening of pelvic organ
Int Urogynecol J
support [37]. This would explain why the prolapse almost always recurs or persists in patients with pre-pregnancy prolapse, but spontaneously resolves in those developing during pregnancy. It would also explain the possible protective effect of a caesarean section in patients with acute onset of POP in pregnancy and not in those with pre-pregnancy POP. Self-management of a pessary, where the patient can remove and reinsert the pessary as she wishes, is a preferable way of managing prolapse as it has advantages for the patient, including the ability to replace it if it falls out, and less frequent follow-ups are required [38]. Furthermore, frequent removal, washing and replacement may reduce the risks of ulceration, decubitus infection and preterm labour. It is generally easy to learn and safely performed [39] and has already been described during pregnancy [5, 27]. However, in most cases the ring pessary is not capable of preventing the pregnant uterus from prolapsing and the use of a space-occupying pessary is required. Self-management of a shelf or Gellhorn pessary is considerably more challenging for women than a ring, but is feasible [40] and in pregnancy it may be easier because of a more capacious vagina. There appears to be a high incidence of POP in India, possibly because of the high prevalence of risk factors, e.g. parity, malnutrition, short interval between consecutive pregnancies and increased strain on the support of the uterus [8]. It has been suggested that the outcome of the pregnancies is also less favourable owing to poor access to healthcare in some areas [8]. Of the 8 perinatal deaths reported since 1990, 5 occurred in India. Pandey et al. performed a retrospective study on the mode of delivery and pregnancy outcome among women with POP in pregnancy (not distinguished according to its onset) over a 3year period. In this study, only 6 of the 48 women were delivered by caesarean section. In 32 of the remaining 42 women who delivered vaginally, Dührssen’s incision was required. Pandey et al. demonstrated that Dührssen’s incisions are a safe and valid option for minimizing complications from prolapse in labour and reduced the need for caesarean section. Unfortunately, owing to the lack of information on individual cases provided in this report [8], the cases could not be included in this systematic review. Likewise, Eddib et al. [13] reported the differences in the two types of POP in pregnancy, but the number of case reports (9) was insufficient for analysis and conclusions [13]. A recent review dealing with uterine prolapse in pregnancy focused rather on POP alone and was not performed systematically [36] and so was not included in the analysis either. Despite the fact that the incidence of POP in pregnancy is generally decreasing, clinicians should be aware of the condition and management. Recognition and protection of the cervix from local trauma, infection and pre-term labour are
important. Although surgical management had been reported, conservative treatment, including bed-rest and/or pessary treatment, has been the mainstay of therapy and can result in an uneventful pregnancy and spontaneous delivery.
Recommendations for practice &
& &
& & &
&
&
&
Early recognition and treatment of POP in pregnancy is important to prevent cervical oedema, ulceration or infection of the protruded cervix that could lead to a preterm delivery. Local treatment with antiseptics and emollients may be beneficial in cases of ulceration. Topical application of concentrated MgSO4 antenatally and intrapartum can be considered to reduce cervical oedema and resolve incarceration or the inability to reduce the prolapse manually [25] Patients can be managed in the community, but if this is unsuccessful or if there are other pregnancy complications, then in-patient care is recommended. Bed-rest, Trendelenburg position, avoidance of heavy lifting and manual reduction of the prolapse is usually required. POP can be successfully managed by a pessary throughout the pregnancy until the onset of labour. Owing to a more capacious vagina rings frequently fall out and thus space-occupying pessaries are indicated, self-management is feasible. Laparoscopic uterine suspension in early pregnancy has been reported. This should be considered with caution and only when conservative measures fail and prolonged bedrest is impossible. As mentioned, this is on the basis of 1 case report only [18]. Women with severe prolapse (stages III and IV) are at an increased risk of caesarean section because of obstructed labour; however, vaginal delivery is not contraindicated. In some cases, the Dührssen incision to the cervix can be considered. However, these reports are from India only and there are none from elsewhere recommending its use. It may be an option in an “emergency” situation when there is not enough time to undertake caesarean section, e.g. rapid delivery. Primary caesarean section is an option in cases of severe POP with onset in pregnancy, as it seems to be protective against POP persistence after delivery.
Acknowledgements The stay of the first author in Plymouth Hospitals NHS Trust, UK, was supported by the Faculty of Medicine in Pilsen, Charles University in Prague. Conflicts of interest None.
Int Urogynecol J
References 1. Keettel WC (1941) Prolapse of the uterus during pregnancy. Am J Obstet Gynecol 42:121–126 2. Kibel I (1944) Pregnancy at term in prolapsed uterus. Am J Obstet Gynecol 47:703–704 3. Horowitz ER, Yogev Y, Hod M, Kaplan B (2002) Prolapse and elongation of the cervix during pregnancy. Int J Gynaecol Obstet 77(2):147–148 4. Gupta A, Hooda R, Nanda S (2013) Perinatal loss: a rare complication of vaginal ring pessary used for prolapse in pregnancy. J Gynecol Surg 29(5):260–261 5. Yousaf S, Haq B, Rana T (2011) Extensive uterovaginal prolapse during labor. J Obstet Gynaecol Res 37(3):264–266. doi:10.1111/j. 1447-0756.2010.01366.x 6. Pantha S (2011) Repeated pregnancy in a woman with uterine prolapse from a rural area in Nepal. Reprod Health Matter 19(37):129– 132. doi:10.1016/S0968-8080(11)37554-4 7. Kart C, Aran T, Guven S (2011) Stage IV C prolapse in pregnancy. Int J Gynaecol Obstet 112(2):142–143. doi:10.1016/j.ijgo.2010.10.006 8. Pandey K, Arya S, Pande S (2013) Pregnancy with uterine prolapse: Duhrssen’s incision still valid in today’s scenario? Emerging 13(81.2):29 9. Brown HL (1997) Cervical prolapse complicating pregnancy. J Natl Med Assoc 89(5):346–348 10. Chun SS, Park KS (2001) Birth of a healthy infant after in vitro fertilization and embryo transfer in patient of total uterine prolapse. J Assist Reprod Genet 18(6):346–348 11. Jeng C-J, Lou C-N, Lee F-K, Tzeng C-R (2006) Successful pregnancy in a patient with initially procidentia uteri. Acta Obstet Gynecol Scand 85(4):501–502 12. Meydanli MM, Üstün Y, Yalcin OT (2006) Pelvic organ prolapse complicating third trimester pregnancy. Gynecol Obstet Invest 61(3): 133–134 13. Eddib A, Allaf MB, Lele A (2010) Pregnancy in a woman with uterine procidentia: a case report. J Reprod Med 55(1–2):67–70 14. De Vita D, Giordano S (2011) Two successful natural pregnancies in a patient with severe uterine prolapse: a case report. J Med Case Rep 5:459 15. Veciana Colillas M, Monje Beltran ML, Vicedo Madrazo EM, Marqueta Sánchez JM (2012) Prolapso genital en una gestante con antecedente de accidente de tráfico y lesión perineal severa. Prog Obstet Ginecol 55(5):232–234 16. Ozyer S, Uzunlar O, Payasli A, Toğrul C, Beşli M, Danişman N (2012) Repeated term pregnancies in a young patient with pelvic organ prolapse. Clin Exp Obstet Gynecol 40(1):159–161 17. Miyano N, Matsushita H (2013) Maternal and perinatal outcome in pregnancies complicated by uterine cervical prolapse. J Obstet Gynaecol 33(6):569–571 18. Matsumoto T, Nishi M, Yokota M, Ito M (1999) Laparoscopic treatment of uterine prolapse during pregnancy. Obstet Gynecol 93(5 Pt 2):849 19. Sawyer D, Frey K (2000) Cervical prolapse during pregnancy. J Am Board Fam Pract 13(3):216–218 20. Guariglia L, Carducci B, Botta A, Ferrazzani S, Caruso A (2005) Uterine prolapse in pregnancy. Gynecol Obstet Investig 60(4):192–194 21. Daskalakis G, Lymberopoulos E, Anastasakis E, Kalmantis K, Athanasaki A, Manoli A, Antsaklis A (2007) Uterine prolapse complicating pregnancy. Arch Gynecol Obstet 276(4):391–392
22. Chandru S, Srinivasan J, Roberts AD (2007) Acute uterine cervical prolapse in pregnancy. J Obstet Gynaecol 27(4):423–424. doi:10. 1080/01443610701325721 23. Eguiluz Gutiérrez-Barquín I, Barber Marrero MÁ, Martín Martínez A, Cazorla Betancor M, García Hernández JÁ (2008) Gestación y prolapso uterino. Prog Obstet Ginecol 51(12):742–744 24. Partsinevelos G, Mesogitis S, Papantoniou N, Antsaklis A (2008) Uterine prolapse in pregnancy: a rare condition an obstetrician should be familiar with. Fetal Diagn Ther 24(3):296–298 25. Lau S, Rijhsinghani A (2008) Extensive cervical prolapse during labor: a case report. J Reprod Med 53(1):67–69 26. Boufettal H, Noun M, Hermas S, Samouh N (2009) Prolapsus gestationnel: un cas exceptionnel. Gynecol Obstet Biol Reprod (Paris) 38(6):531–532 27. Buyukbayrak EE, Yilmazer G, Ozyapi AG, Kars B, Karsidag AY, Turan C (2010) Successful management of uterine prolapse during pregnancy with vaginal pessary: a case report. J Turk Ger Gynecol Assoc 11(2):105–106. doi:10.5152/jtgga.2010.010 28. Sit A, Fu H (2009) To push or not to push?: the patient had not disclosed a problem that would complicate labor. Am J Obstet Gynecol 201(1):120, e121 29. Toy H, Camuzcuoğlu H, Aydın H (2009) Uterine prolapse in a 19 year old pregnant woman: a case report. J Turk Ger Gynecol Assoc 10(3):184 30. Sangwan N, Rajotia N, Duhan N, Sirohiwal D, Khaneja N (2009) Uterocervical prolapse in labour. JK Sci 11(4):214 31. Varras M (2010) Uterocervical prolapse during pregnancy. Am J Case Rep 11:83–86 32. Cingillioglu B, Kulhan M, Yildirim Y (2010) Extensive uterine prolapse during active labor: a case report. Int Urogynecol J 21(11): 1433–1434. doi:10.1007/s00192-010-1151-z 33. Mohamed-Suphan N, Ng RKW (2012) Uterine prolapse complicating pregnancy and labor: a case report and literature review. Int Urogynecol J 23(5):647–650 34. Ghose S, Samal S, Coumary S (2012) Utero-vaginal prolapse in primigravida: a case report. Int J Reprod Contracept Obstet Gynecol 1(1):50–51 35. Pizzoferrato A, Bui C, Fauconnier A, Bader G (2012) Advanced uterine prolapse during pregnancy: pre-and postnatal management. Gynecol Obstet Fertil 41(7–8):467–470 36. Tsikouras P, Dafopoulos A, Vrachnis N, Iliodromiti Z, Bouchlariotou S, Pinidis P, Tsagias N, Liberis V, Galazios G, Von Tempelhoff GF (2014) Uterine prolapse in pregnancy: risk factors, complications and management. J Matern Fetal Neonatal Med 27(3):297–302. doi:10. 3109/14767058.2013.807235 37. O’Boyle AL, O’Boyle JD, Calhoun B, Davis GD (2005) Pelvic organ support in pregnancy and postpartum. Int Urogynecol J 16(1):69–72 38. Jelovsek JE, Maher C, Barber MD (2007) Pelvic organ prolapse. Lancet 369(9566):1027–1038. doi:10.1016/S0140-6736(07) 60462-0 39. Kolle D, Kunczicky V, Uhl-Steidl M, Pontasch H (1998) Safety and acceptance of self application of cubic pessaries and urethral ring pessaries. Gynakol Geburtshilfliche Rundsch 38(4):242–246 40. Hanson LA, Schulz JA, Flood CG, Cooley B, Tam F (2006) Vaginal pessaries in managing women with pelvic organ prolapse and urinary incontinence: patient characteristics and factors contributing to success. Int Urogynecol J Pelvic Floor Dysfunct 17(2):155–159. doi:10. 1007/s00192-005-1362-x
REVIEW ARTICLE
Procidentia in pregnancy: a systematic review and recommendations for practice Zdenek Rusavy & L. Bombieri & R. M. Freeman
Received: 27 August 2014 / Accepted: 27 November 2014 # The International Urogynecological Association 2015
Abstract Introduction and hypothesis Pelvic organ prolapse (POP) in pregnancy is a rare condition with decreasing incidence and improved management and outcome world-wide recently. Systematic review of the literature for cases of POP in pregnancy published since 1990 was carried out to identify common factors in presentation, management and outcomes. One case from our own practice was added to the analysis. Methods An extensive search of the Pubmed/Medline, Scopus and Google Scholar databases was performed to identify all cases of POP in pregnancy since 1990. Published case reports of POP in pregnancy were reviewed and summarized in tables to find similarities in history, course, management and outcome of the pregnancies. Results Of the 43 cases and one case series, 41 case studies were eligible for analysis. Two types of POP in pregnancy were identified: preexisting is less common (14 vs 27 cases), often resolves during pregnancy (5 out of 14) and always recurs after delivery (14 out of 14); acute onset of POP in pregnancy rarely resolves in pregnancy (2 out of 27), but often resolves after delivery (18 out of 27). Most patients were managed with bed rest (20 out of 41), pessary (15 out of 41), manual reduction (6 out of 41) and local treatment (6 out of 41). The most common complications reported include
Z. Rusavy (*) Department of Obstetrics and Gynecology, Faculty of Medicine in Pilsen, Charles University in Prague, Alej Svobody 80, Pilsen 30460, Czech Republic e-mail: [email protected] L. Bombieri : R. M. Freeman Urogynaecology Unit, Women’s and Children’s Directorate, Plymouth Hospitals NHS Trust, Derriford Hospital, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
preterm labour (14 out of 41), cervical ulcerations (9 out of 41), infection (3 out of 41) and obstructed labour (4 out of 41). About a half of the women delivered vaginally (22 out of 41), caesarean section due to prolapse was required in 15 cases. Conclusions Two distinct entities were identified based on similarities regarding onset, course and outcome of POP in pregnancy. Concise recommendations for practice were derived from the analysis of case studies published since 1990. Keywords Pelvic organ prolapse . Pregnancy . Review . Recommendations
Introduction Pelvic organ prolapse (POP) in pregnancy is a rare event, with only 325 cases reported to date. The incidence of 1 case in 13, 000 to 15,000 [1, 2] has probably decreased considerably, which may be related to the decrease in parity over recent decades [3]. Additionally, the rate of adverse delivery outcomes has also decreased dramatically since the end of the last century, possibly due to changes in obstetric practice and advances in neonatology. Keettel described 9 maternal deaths associated with POP in pregnancy in 1925, 8 due to septicaemia and 1 due to uterine rupture [1]; however, no maternal fatalities have been reported since. The overall foetal mortality rate in women with POP in pregnancy was 22 % in 1941 [1]. However, 8 perinatal deaths have been reported since 1990 and these were all in developing countries [4–8]. In order to obtain reproducible information regarding the management of future patients, we looked at all cases reported in the past 25 years as obstetrics and urogynecology practice are more likely to be applicable to today’s practice. Given the low incidence of POP in pregnancy, a full case series would take many years to collect. Therefore, we performed a systematic review of all case reports published since 1990 to
Int Urogynecol J
identify common factors in presentation, management and outcomes, which may help with the management of future patients.
Materials and methods An extensive search of the Pubmed/Medline, Scopus and Google Scholar databases using the keywords “pregnancy”, “labor”, “delivery”, “prolapse”, and “procidentia” was performed. Subsequently, all referenced articles were reviewed in order to obtain additional cases. The systematic search was performed to identify individual cases published after 1990. The published case reports on POP in pregnancy were then thoroughly reviewed by the researchers and summarized in tables to allow comparison and find similarities in the history, course, management and outcome of the pregnancies. One unpublished case of POP in pregnancy from our own experience was added to the analysis. Concise recommendations for practice based on the analysis were devised. Cases from series with insufficient information regarding individual cases were not included in the analysis; however, their results were taken into account for the recommendations for good practice.
Results In total, 43 cases of POP in pregnancy and one case series of 49 patients from India [8] published since 1990 were identified in the literature. Two case studies were excluded for linguistic reasons (the articles were in Korean and Turkish). The case series was not included in the analysis as it did not provide sufficient information regarding individual cases. Two types of POP in pregnancy with common characteristics and outcome could be identified from the analysis of the published case studies: a pregnancy complicated by an acute onset of POP (in pregnancy) usually has a different aetiology, course and outcome from a pre-existing prolapse complicated by pregnancy. Of the 41 cases eligible for analysis, 14 were preexisting POP in pregnancy (Table 1) and 27 had an acute onset in pregnancy (Table 2). Aetiology and outcome Age and parity do not seem to be risk factors for POP in pregnancy (Tables 1, 2). POP in pregnancy in a nulliparous woman was reported in 4 cases; in 1 the POP predated the pregnancy [10]. The acute onset of POP occurred most frequently in the second trimester, although in 5 cases it was first observed in labour [22, 25, 30, 32, 34]. POP can resolve spontaneously in pregnancy with the growth of the uterus in the second trimester as the uterus becomes an abdominal organ. This phenomenon is five times more frequent in the
case of a preexisting POP (5 out of 14 vs 2 out of 27). In 4 cases the POP worsened over the course of the pregnancy, also more frequently in the case of preexisting POP (3 out of 14 vs 1 out of 27). After delivery, the preexisting POP recurred or persisted in all cases. On the contrary, the POP with acute onset in pregnancy resolved spontaneously or at least improved after delivery in 18 of the 27 cases. Caesarean section seems to be protective against the persistence or recurrence of POP after delivery in cases of acute onset; it persisted in 1 out of 12 patients with acute onset of POP in pregnancy who delivered by caesarean section, and 5 out of 15 patients with acute onset who delivered vaginally. Management and mode of delivery The reports show that most patients were managed with bed rest (20 out of 41), pessary (15 out of 41), manual reduction (6 out of 41) and local treatment (6 out of 41) and 1 case was managed successfully with gasless laparoscopic uterine suspension at the 13th week of pregnancy (with a good pregnancy outcome) [18]. Bed-rest was commonly associated with inpatient care and the Trendelenburg position. The patients with preexisting POP were managed more frequently with a pessary than patients with acute onset of POP (8 out of 14 vs 7 out of 27), possibly because the women were already used to pessary treatment before pregnancy. The use of a ring/Mayer/Dumontpallier pessary was reported in 8 cases, doughnut in 4 cases and a Gellhorn in 2 cases. The type of pessary was not reported in 3 cases. The pessaries were frequently expelled as the pregnancies progressed and the treatment of POP in pregnancy with a pessary in the published cases frequently failed because the pessary fell out. Few case reports have reported of self-management of a ring pessary [5, 27]. Local therapy with glycerin and an antiseptic agent have been applied when ulcerations and excoriations of the prolapsed cervix have arisen and in some cases antibiotics administered [7, 24, 28, 32, 35]. In 1 case [25], caesarean section was successfully avoided after application of concentrated topical magnesium sulphate to reduce the oedema of a prolapsed cervix that could not be reduced. Gauze soaked in a solution of 20 g magnesium sulphate in 50 ml of normal saline was applied, resulting in reduction. The prolapse was then “held back” with magnesium sulphate-soaked gauze during the first stage of labour. No clinical signs or symptoms of systemic absorption of magnesium were observed [25]. As an alternative, Dührssen incisions (i.e. three surgical incisions corresponding to the 2, 6 and 10 o’clock positions [8]) have been used to an incompletely dilated cervix to facilitate vaginal delivery with an oedematous and incarcerated cervix, in reports from India (29 cases) [8, 30, 34]. Of all the cases analyzed, 22 women delivered vaginally, more frequently those with a new onset of POP in pregnancy
0
1
South Korea 2001 28
2006 35
2006 30
2010 44
2011 35 2011 36
2011 36 2011 35
2012 35 2013 24 2013 34
2013 30
2014 36
Taiwan
Turkey
USA
Finland Finland
Nepal Pakistan
Spain Turkey Japan
Japan
UK
Ring pessary, bed rest, tocolysis Shelf pessary self-management
None Bed rest, ring pessary, local treatment, ice packing after delivery Pessary Bed rest, manual reduction Bed rest, tocolysis
Bed rest, local treatment, manual reduction, pessaries (ring, donut and Gellhorn) None Pessary
None
Bed rest
Donut pessary, bed rest Pessary
LSCS lower segment caesarean section
1
1
1 3 1
5 1
1 2
2
5
1
1997 29
USA
Age Parity Management
Year
None reported None reported
Cervical oedema, ulceration, preterm labour, obstructed labour Infection
None reported
None reported
None reported
Complications
Term vaginal delivery
None
Term vaginal delivery Decubitus ulcer, stillbirth Term assisted vaginal delivery Oedema, cervical laceration, urinary retention, hydronephrosis, stillbirth Term vaginal delivery Imminent preterm labour Term LSCS (POP) Oedema, incarceration Preterm LSCS (placenta Imminent preterm labour praevia) Term vaginal delivery Imminent preterm labour
Term LSCS (POP) Term LSCS (POP)
Preterm caesarean hysterectomy + sacrocolpopexy Term vaginal delivery
Term LSCS (malposition of fetus) Term caesarean hysterectomy
Term vaginal delivery
Mode of delivery
Cases of pelvic organ prolapse (POP) in pregnancy in women with preexisting POP published after 1990
Country
Table 1
3,500
3,092
3,250 2,920 2,932
3,200 2,400
3,150 3,030
3,515
2,300
2,610
3,420
2,410
Worsened in pregnancy Worsened in pregnancy
No resolution Not reported No resolution
No resolution In the second trimester
After 18 weeks After 24 weeks
At 30 weeks
Worsened in pregnancy No resolution
No resolution
At 20 weeks
[10]
[9] (case 3)
Reference
POP persisted
POP persisted
POP persisted POP recurred POP persisted
POP persisted POP persisted
POP persisted POP persisted
POP recurred
Unpublished case
[17] (case 4)
[15] [16] [17] (case 1)
[14] [14] (2nd pregnancy) [6] [5]
[13]
Concomitant POP [11] surgery Concomitant POP [12] surgery
Not reported
POP persisted
Birth Resolution of POP Follow-up weight during the (g) pregnancy
Int Urogynecol J
2010
2010
2010
2011
2012
2013
Turkey
Greece
Turkey
Singapore
India
France
2010
Turkey
2008
USA
2009
2008
2009
2007
Gran Canaria, Spain Greece
India
2007
UK
Turkey
2007
Greece
2009
2005
Italy
USA
2002
2009
37
2002
Israel
Israel
2009
32
2000
USA
Turkey
36
1999
Japan
Morocco
31
1997
USA
39
26
26
29
31
36
21
27
19
38
19
32
33
35
25
42
33
30
25
25
1997
USA
Age
Year
2
0
2
2
2
2
3
1
1
1
0
2
1
0
4
2
2
2
4
2
1
1
2
1
Parity
Manual self-reduction, antibiotics Tocolysis, pessary (ring, Gellhorn) No antenatal care, Duhrssen incision on cervix Pessary (Dumontpallier), local treatment, antibiotics
Bed rest
Bed rest
Bed rest, Trendelenburg, antibiotics
Duhrssen incision on cervix
Antibiotics, ring pessary self-management Intermittent manual self-reduction, antibiotics No antenatal care
Pessary, local treatment, tocolysis Antibiotics, bed rest, Trendelenburg, tocolysis, corticosteroids Manual reduction after local MgSO4 treatment Bed rest, manual reduction
None reported
Bed rest, Trendelenburg
Bed rest
Bed rest, pessary (Mayer)
None reported
Bed rest, doughnut pessary, tocolysis Bed rest, doughnut pessary, tocolysis Laparoscopic gasless uterine supension at 13 weeks Bed rest, labour induction
Management
Cervical ulceration, obstructed labour
Term LSCS (obstructed labour)
Term vaginal delivery
Cervical oedema, bleeding, obstructed labour Imminent preterm labour, urinary retention Entrapped head
None reported
Urinary tract and cervical infection, premature labour, neonatal death None reported
Elongated cervix, entrapped head
Term LSCS (bleeding), prophylactic UA ligation Term LSCS (obstructed labour)
Term vaginal delivery
Term vaginal delivery
Premature vaginal delivery
Term vaginal delivery
PROM, obstructed labour
PPROM, chorioamnionitis
Preterm vaginal delivery
Preterm LSCS (obstructed labour)
Cervical oedema, ulceration
None reported
Ulceration, pain, preterm labour Cervical oedema, ulceration, suspected PPROM, preterm labour Cervical oedema, abrasions
Cervical oedema
Cervical oedema
None reported
Cervical oedema, ulceration
Cervical oedema, ulceration
None reported
Term vaginal delivery
Term vaginal delivery
Preterm vaginal delivery
Preterm LSCS (POP, breech) Preterm LSCS (POP)
Term LSCS (abnormal CTG) Term LSCS (maternal request) Term LSCS (POP)
Term LSCS (POP)
Term induced vaginal delivery Term LSCS (POP)
Term vaginal delivery
Imminent preterm labour, bleeding, cervical oedema None reported
Imminent preterm labour
Term vaginal delivery Preterm vaginal delivery
Complications
Mode of delivery
Cases of POP with onset in pregnancy published after 1990
Country
Table 2
3,700
3,200
2,100
3,100
2,960
3,650
3,300
860
2,700
3,100
N/R
3,200
13
41
12
35
32
16
10
37
35
Second trimester
16
24
First trimester
31
1,900
2,410
32
40
21
24
26
10
16
13
29
26
POP onset (GA in weeks)
2,400
N/A
3,050
3,150
N/A
N/A
3,500
3,520
2,100
3,000
Birth weight (g)
POP worsened
Not reported
None
Not reported
None
None
None
Not reported
None
None
None
After 28 weeks
None
None
None
Not reported
None
None
None
None
At 16 weeks
Surgery
None
None
Resolution of POP during the pregnancy
POP persisted
POP improved
POP improved
POP improved
POP resolved
POP persisted
POP persisted
POP improved
POP resolved
POP recurred
POP resolved
POP resolved
POP recurred
POP resolved
Not reported
POP resolved
POP resolved
POP resolved
POP resolved
Not reported
POP resolved
POP resolved
POP persisted
POP improved
Follow-up
[35]
[34]
[33]
[32]
[31]
[7] (case 2)
[7] (case 1)
[30]
[29]
[28]
[27]
[26]
[25]
[24]
[23]
[22]
[21]
[20]
[3] (case 2)
[3] (case 1)
[19]
[18]
[9] (case 2)
[9] (case 1)
Reference
Int Urogynecol J
[17] (case 2)
[17] (case 3)
POP resolved
POP resolved
(3 out of 14 vs 9 out of 27), and 15 patients delivered via caesarean section (5 out of 14 vs 10 out of 27). Others had a caesarean section for other obstetric indications. Complications
MgSO4 magnesium sulphate, CTG cardiotocography, PPROM preterm premature rupture of membranes, PROM premature rupture of membranes
None 20 5,116
14 Bed rest, tocolysis
Preterm vaginal delivery
Imminent premature labour 1
0
2013 Japan
36
2013 Japan
36
Bed rest, tocolysis
Term LSCS (cephalopelvic disproportion)
2,445
None
[4] POP resolved 26
Cervical oedema, stillbirth—foetal strangulation on the pessary Imminent abortion 2013 India
35
3
Local treatment, bed rest, ring pessary
Preterm vaginal delivery
1,600
None
Reference POP onset (GA in weeks) Complications Year Country
Table 2 (continued)
Age
Parity
Management
Mode of delivery
Birth weight (g)
Resolution of POP during the pregnancy
Follow-up
Int Urogynecol J
Complications of POP in pregnancy are common and they have been well reviewed [36]. Maternal or foetal death can result from a lack of care and uterine ischaemia, infection, acute urinary retention or obstructed labour. This is now rare in developed countries because of better access to medical care. No maternal deaths have been reported since 1990. Of the cases available for review, only 4 foetal deaths occurred and these were all in developing countries [4–7]. The most common complications reported since 1990 include the preterm onset of labour (14 out of 41), cervical ulcerations (9 out of 41), infection (3 out of 41) and obstructed labour requiring a caesarean section because of the prolapsed, oedematous and often incarcerated cervix (4 out of 41; Tables 1, 2). Premature onset of labour was reported in approximately a third of the pregnancies (4 out of 14 and 10 out of 27) with tocolysis resulting in successful term delivery in some cases. It was more successful in cases of preexisting POP (2 out of 14) than in acute onset of POP (1 out of 27; Tables 1, 2). Overall, the pregnancies resulted in a preterm delivery in 11 out of a total of 41 cases of POP in pregnancy (27 %). Significantly more cervical ulcerations were reported among patients with new onset of POP in pregnancy compared with preexisting POP (7 out of 27 vs 2 out of 14), while infection (1 out of 14 vs 2 out of 27) and obstructed labour (1 out of 14 vs 3 out of 27) rates were low and comparable.
Discussion The systematic review of the literature identified two types of POP in pregnancy: POP presenting before pregnancy is less common and often resolves during pregnancy, but recurs after delivery. In such cases, management with a pessary is easier because the patients are usually already familiar with this treatment modality and in the case of preterm onset of labour, tocolysis has been shown to be successful. Acute onset of POP in pregnancy is more common. The uterus usually remains prolapsed throughout the entire pregnancy, but resolves after delivery. This might be due to a different aetiology compared with pre-pregnancy POP. This type of prolapse is most frequently caused by a history of trauma to the pelvic floor or congenital disorder that weakens the pelvic floor support. Prolapse developing in pregnancy is more likely to be due to an escalation of the physiological changes in pregnancy that lead to weakening of pelvic organ
Int Urogynecol J
support [37]. This would explain why the prolapse almost always recurs or persists in patients with pre-pregnancy prolapse, but spontaneously resolves in those developing during pregnancy. It would also explain the possible protective effect of a caesarean section in patients with acute onset of POP in pregnancy and not in those with pre-pregnancy POP. Self-management of a pessary, where the patient can remove and reinsert the pessary as she wishes, is a preferable way of managing prolapse as it has advantages for the patient, including the ability to replace it if it falls out, and less frequent follow-ups are required [38]. Furthermore, frequent removal, washing and replacement may reduce the risks of ulceration, decubitus infection and preterm labour. It is generally easy to learn and safely performed [39] and has already been described during pregnancy [5, 27]. However, in most cases the ring pessary is not capable of preventing the pregnant uterus from prolapsing and the use of a space-occupying pessary is required. Self-management of a shelf or Gellhorn pessary is considerably more challenging for women than a ring, but is feasible [40] and in pregnancy it may be easier because of a more capacious vagina. There appears to be a high incidence of POP in India, possibly because of the high prevalence of risk factors, e.g. parity, malnutrition, short interval between consecutive pregnancies and increased strain on the support of the uterus [8]. It has been suggested that the outcome of the pregnancies is also less favourable owing to poor access to healthcare in some areas [8]. Of the 8 perinatal deaths reported since 1990, 5 occurred in India. Pandey et al. performed a retrospective study on the mode of delivery and pregnancy outcome among women with POP in pregnancy (not distinguished according to its onset) over a 3year period. In this study, only 6 of the 48 women were delivered by caesarean section. In 32 of the remaining 42 women who delivered vaginally, Dührssen’s incision was required. Pandey et al. demonstrated that Dührssen’s incisions are a safe and valid option for minimizing complications from prolapse in labour and reduced the need for caesarean section. Unfortunately, owing to the lack of information on individual cases provided in this report [8], the cases could not be included in this systematic review. Likewise, Eddib et al. [13] reported the differences in the two types of POP in pregnancy, but the number of case reports (9) was insufficient for analysis and conclusions [13]. A recent review dealing with uterine prolapse in pregnancy focused rather on POP alone and was not performed systematically [36] and so was not included in the analysis either. Despite the fact that the incidence of POP in pregnancy is generally decreasing, clinicians should be aware of the condition and management. Recognition and protection of the cervix from local trauma, infection and pre-term labour are
important. Although surgical management had been reported, conservative treatment, including bed-rest and/or pessary treatment, has been the mainstay of therapy and can result in an uneventful pregnancy and spontaneous delivery.
Recommendations for practice &
& &
& & &
&
&
&
Early recognition and treatment of POP in pregnancy is important to prevent cervical oedema, ulceration or infection of the protruded cervix that could lead to a preterm delivery. Local treatment with antiseptics and emollients may be beneficial in cases of ulceration. Topical application of concentrated MgSO4 antenatally and intrapartum can be considered to reduce cervical oedema and resolve incarceration or the inability to reduce the prolapse manually [25] Patients can be managed in the community, but if this is unsuccessful or if there are other pregnancy complications, then in-patient care is recommended. Bed-rest, Trendelenburg position, avoidance of heavy lifting and manual reduction of the prolapse is usually required. POP can be successfully managed by a pessary throughout the pregnancy until the onset of labour. Owing to a more capacious vagina rings frequently fall out and thus space-occupying pessaries are indicated, self-management is feasible. Laparoscopic uterine suspension in early pregnancy has been reported. This should be considered with caution and only when conservative measures fail and prolonged bedrest is impossible. As mentioned, this is on the basis of 1 case report only [18]. Women with severe prolapse (stages III and IV) are at an increased risk of caesarean section because of obstructed labour; however, vaginal delivery is not contraindicated. In some cases, the Dührssen incision to the cervix can be considered. However, these reports are from India only and there are none from elsewhere recommending its use. It may be an option in an “emergency” situation when there is not enough time to undertake caesarean section, e.g. rapid delivery. Primary caesarean section is an option in cases of severe POP with onset in pregnancy, as it seems to be protective against POP persistence after delivery.
Acknowledgements The stay of the first author in Plymouth Hospitals NHS Trust, UK, was supported by the Faculty of Medicine in Pilsen, Charles University in Prague. Conflicts of interest None.
Int Urogynecol J
References 1. Keettel WC (1941) Prolapse of the uterus during pregnancy. Am J Obstet Gynecol 42:121–126 2. Kibel I (1944) Pregnancy at term in prolapsed uterus. Am J Obstet Gynecol 47:703–704 3. Horowitz ER, Yogev Y, Hod M, Kaplan B (2002) Prolapse and elongation of the cervix during pregnancy. Int J Gynaecol Obstet 77(2):147–148 4. Gupta A, Hooda R, Nanda S (2013) Perinatal loss: a rare complication of vaginal ring pessary used for prolapse in pregnancy. J Gynecol Surg 29(5):260–261 5. Yousaf S, Haq B, Rana T (2011) Extensive uterovaginal prolapse during labor. J Obstet Gynaecol Res 37(3):264–266. doi:10.1111/j. 1447-0756.2010.01366.x 6. Pantha S (2011) Repeated pregnancy in a woman with uterine prolapse from a rural area in Nepal. Reprod Health Matter 19(37):129– 132. doi:10.1016/S0968-8080(11)37554-4 7. Kart C, Aran T, Guven S (2011) Stage IV C prolapse in pregnancy. Int J Gynaecol Obstet 112(2):142–143. doi:10.1016/j.ijgo.2010.10.006 8. Pandey K, Arya S, Pande S (2013) Pregnancy with uterine prolapse: Duhrssen’s incision still valid in today’s scenario? Emerging 13(81.2):29 9. Brown HL (1997) Cervical prolapse complicating pregnancy. J Natl Med Assoc 89(5):346–348 10. Chun SS, Park KS (2001) Birth of a healthy infant after in vitro fertilization and embryo transfer in patient of total uterine prolapse. J Assist Reprod Genet 18(6):346–348 11. Jeng C-J, Lou C-N, Lee F-K, Tzeng C-R (2006) Successful pregnancy in a patient with initially procidentia uteri. Acta Obstet Gynecol Scand 85(4):501–502 12. Meydanli MM, Üstün Y, Yalcin OT (2006) Pelvic organ prolapse complicating third trimester pregnancy. Gynecol Obstet Invest 61(3): 133–134 13. Eddib A, Allaf MB, Lele A (2010) Pregnancy in a woman with uterine procidentia: a case report. J Reprod Med 55(1–2):67–70 14. De Vita D, Giordano S (2011) Two successful natural pregnancies in a patient with severe uterine prolapse: a case report. J Med Case Rep 5:459 15. Veciana Colillas M, Monje Beltran ML, Vicedo Madrazo EM, Marqueta Sánchez JM (2012) Prolapso genital en una gestante con antecedente de accidente de tráfico y lesión perineal severa. Prog Obstet Ginecol 55(5):232–234 16. Ozyer S, Uzunlar O, Payasli A, Toğrul C, Beşli M, Danişman N (2012) Repeated term pregnancies in a young patient with pelvic organ prolapse. Clin Exp Obstet Gynecol 40(1):159–161 17. Miyano N, Matsushita H (2013) Maternal and perinatal outcome in pregnancies complicated by uterine cervical prolapse. J Obstet Gynaecol 33(6):569–571 18. Matsumoto T, Nishi M, Yokota M, Ito M (1999) Laparoscopic treatment of uterine prolapse during pregnancy. Obstet Gynecol 93(5 Pt 2):849 19. Sawyer D, Frey K (2000) Cervical prolapse during pregnancy. J Am Board Fam Pract 13(3):216–218 20. Guariglia L, Carducci B, Botta A, Ferrazzani S, Caruso A (2005) Uterine prolapse in pregnancy. Gynecol Obstet Investig 60(4):192–194 21. Daskalakis G, Lymberopoulos E, Anastasakis E, Kalmantis K, Athanasaki A, Manoli A, Antsaklis A (2007) Uterine prolapse complicating pregnancy. Arch Gynecol Obstet 276(4):391–392
22. Chandru S, Srinivasan J, Roberts AD (2007) Acute uterine cervical prolapse in pregnancy. J Obstet Gynaecol 27(4):423–424. doi:10. 1080/01443610701325721 23. Eguiluz Gutiérrez-Barquín I, Barber Marrero MÁ, Martín Martínez A, Cazorla Betancor M, García Hernández JÁ (2008) Gestación y prolapso uterino. Prog Obstet Ginecol 51(12):742–744 24. Partsinevelos G, Mesogitis S, Papantoniou N, Antsaklis A (2008) Uterine prolapse in pregnancy: a rare condition an obstetrician should be familiar with. Fetal Diagn Ther 24(3):296–298 25. Lau S, Rijhsinghani A (2008) Extensive cervical prolapse during labor: a case report. J Reprod Med 53(1):67–69 26. Boufettal H, Noun M, Hermas S, Samouh N (2009) Prolapsus gestationnel: un cas exceptionnel. Gynecol Obstet Biol Reprod (Paris) 38(6):531–532 27. Buyukbayrak EE, Yilmazer G, Ozyapi AG, Kars B, Karsidag AY, Turan C (2010) Successful management of uterine prolapse during pregnancy with vaginal pessary: a case report. J Turk Ger Gynecol Assoc 11(2):105–106. doi:10.5152/jtgga.2010.010 28. Sit A, Fu H (2009) To push or not to push?: the patient had not disclosed a problem that would complicate labor. Am J Obstet Gynecol 201(1):120, e121 29. Toy H, Camuzcuoğlu H, Aydın H (2009) Uterine prolapse in a 19 year old pregnant woman: a case report. J Turk Ger Gynecol Assoc 10(3):184 30. Sangwan N, Rajotia N, Duhan N, Sirohiwal D, Khaneja N (2009) Uterocervical prolapse in labour. JK Sci 11(4):214 31. Varras M (2010) Uterocervical prolapse during pregnancy. Am J Case Rep 11:83–86 32. Cingillioglu B, Kulhan M, Yildirim Y (2010) Extensive uterine prolapse during active labor: a case report. Int Urogynecol J 21(11): 1433–1434. doi:10.1007/s00192-010-1151-z 33. Mohamed-Suphan N, Ng RKW (2012) Uterine prolapse complicating pregnancy and labor: a case report and literature review. Int Urogynecol J 23(5):647–650 34. Ghose S, Samal S, Coumary S (2012) Utero-vaginal prolapse in primigravida: a case report. Int J Reprod Contracept Obstet Gynecol 1(1):50–51 35. Pizzoferrato A, Bui C, Fauconnier A, Bader G (2012) Advanced uterine prolapse during pregnancy: pre-and postnatal management. Gynecol Obstet Fertil 41(7–8):467–470 36. Tsikouras P, Dafopoulos A, Vrachnis N, Iliodromiti Z, Bouchlariotou S, Pinidis P, Tsagias N, Liberis V, Galazios G, Von Tempelhoff GF (2014) Uterine prolapse in pregnancy: risk factors, complications and management. J Matern Fetal Neonatal Med 27(3):297–302. doi:10. 3109/14767058.2013.807235 37. O’Boyle AL, O’Boyle JD, Calhoun B, Davis GD (2005) Pelvic organ support in pregnancy and postpartum. Int Urogynecol J 16(1):69–72 38. Jelovsek JE, Maher C, Barber MD (2007) Pelvic organ prolapse. Lancet 369(9566):1027–1038. doi:10.1016/S0140-6736(07) 60462-0 39. Kolle D, Kunczicky V, Uhl-Steidl M, Pontasch H (1998) Safety and acceptance of self application of cubic pessaries and urethral ring pessaries. Gynakol Geburtshilfliche Rundsch 38(4):242–246 40. Hanson LA, Schulz JA, Flood CG, Cooley B, Tam F (2006) Vaginal pessaries in managing women with pelvic organ prolapse and urinary incontinence: patient characteristics and factors contributing to success. Int Urogynecol J Pelvic Floor Dysfunct 17(2):155–159. doi:10. 1007/s00192-005-1362-x
