Int Urogynecol J (2014) 25:1739–1740 DOI 10.1007/s00192-014-2457-z

CASE REPORT

Uterine prolapse during late pregnancy in a nulliparous woman Hiromi Ishida & Kazuhiro Takahashi & Hirohisa Kurachi

Received: 16 February 2014 / Accepted: 14 June 2014 / Published online: 8 July 2014 # The International Urogynecological Association 2014

Abstract A pregnancy that is complicated by a uterine prolapse is rare and primarily occurs in multiparous women during their first or second trimester. In the present report, we describe a case of a 31-year-old nulliparous woman who experienced sudden uterine prolapse at 38 weeks’ gestation without labor pains. The cervix was congested, the cervical mucosa was partially lacerated, and bleeding was noted; the protruding cervix could not be repositioned into her vagina. Although the cervical congestion worsened over time, she still did not experience any labor pains. She was delivered by emergency cesarean section. Following delivery, the prolapse promptly improved and did not recur before her 1-month postpartum examination. To our knowledge, this is the first case where uterine prolapse occurred in a nulliparous woman during late gestation. Keywords Uterine prolapse . Pregnancy . Nulliparous

Introduction The incidence of uterine prolapse in pregnancy is 1 per 10,000–15,000 pregnancies [1]. However, uterine prolapse commonly occurs in multiparous women during their first or second trimester. In the present report, we describe a case of a uterine prolapse during late pregnancy in a nulliparous woman.

This work was supported in part by a Grant-in-Aid for Scientific Research, No. 2390308 (to H.K.) and No. 23592433 (to K.T.) from the Ministry of Education, Culture, Sports, Science, and Technology of Japan H. Ishida : K. Takahashi (*) : H. Kurachi Department of Obstetrics and Gynecology, Yamagata University Faculty of Medicine, 2-2-2 Iidanishi, Yamagata 990-9585, Japan e-mail: [email protected]

Case report A 31-year-old, healthy, nulliparous woman who was successfully treated with clomiphene citrate and human chorionic gonadotropin because of the presence of an ovulatory disorder, became pregnant. She had been 14 years old at menarche. Her height and body weight were 168 cm and 61.5 kg respectively, and her BMI was 21.8. She had no surgical history or family history of connective tissue disease, and had not experienced any episodes of obstipation during pregnancy. There were no risk factors for uterine prolapse. Her prenatal examination had not revealed any abnormal findings. However, she presented to emergency department of our hospital at 38 weeks of gestation because of a uterine prolapse (Fig. 1). Her cervix was extremely congested, and the cervical mucosa was partially lacerated and bleeding. The entire uterine cervix and lower uterine segment were prolapsed and lying on the vulva; she was diagnosed with a stage 3 prolapse, according to the Pelvic Organ Prolapse Quantification system. We confirmed that her amniotic membrane had not ruptured and that there was no bleeding from the uterine cavity. During the pelvic examination, the internal os of the uterus was opened, with a one-finger width, and the fetus’ head was fixed at the −2 station. Cardiotocography showed the absence of uterine contractions and a baseline fetal heart rate of 130 bpm, with variability. Within 90 min of hospitalization, the uterine cervix congestion worsened and the bleeding increased. The patient did not experience any labor pains and the cervix had not matured. Because the uterine cervix was too immature for a vaginal delivery, we opted for an emergency cesarean section. A 3,230-g, female infant was delivered, with 1- and 5-min Apgar scores of 8 and 9; the pH of umbilical artery blood was 7.23. After the delivery, the uterine prolapse promptly improved, spontaneously. There was no uterine prolapse at her 1 month post-partum examination. The length of the distal-most edge

1740 Fig. 1 Third-degree uterine prolapse with a an edematous and bleeding cervix, and b external os of the uterus (arrowhead) deviated to the right

Int Urogynecol J (2014) 25:1739–1740

A

of the cervix was 7 cm, and the anterior and posterior walls of the vagina were well supported.

Discussion Pelvic organ prolapse causes symptoms that have an impact on a woman’s daily activities and negatively affect her quality of life. Factors believed to contribute to the development of pelvic organ prolapse include parity, advancing age, ethnicity, chronically increased intra-abdominal pressure, and connective tissue disorder [2]. Erata et al. reported that the relative risk of developing uterine prolapse was 2.48 (95 % confidence interval [CI], 0.69–9.38) in women who had given birth to one child, and increased to 4.58 (95 % CI, 1.64–13.77), 8.4 (95 % CI, 2.84–26.44), and 11.75 (95 % CI, 3.84–38.48) for women who had delivered 2, 3, or >3 children respectively compared with nulliparous women [2]. Uterine prolapse during pregnancy most frequently occurs in multiparous women, usually during early gestation, with the risk decreasing during late gestation because of uterine enlargement. This report describes a very rare case of uterine prolapse in a nulliparous woman during late gestation; besides pregnancy, the woman did not have any of the known risk factors for uterine prolapse. Connective tissue composition abnormalities are suspected to contribute to the development of pelvic organ prolapse, particularly since the connective tissue associated with the urogenital organs are sensitive to hormones. Thus, uterine prolapses in pregnant women may result from physiological increases in cortisol and progesterone levels, which lead to a concomitant softening and stretching of the pelvic tissues [3]. Uterine prolapse most commonly occurs up to and during the early part of the second trimester. Conservative management consisting of genital hygiene and bed rest in a slight Trendelenburg position should be considered the foremost treatment option. In an attempt to avoid potential intrapartum complications, the preferred mode of delivery may be elective cesarean section near term [4]. Most authors who have reported cases of uterine prolapse in pregnant women have

B

recommended conservative management during pregnancy followed by elective cesarean section [5]. To our knowledge, this report was the first case of a uterine prolapse during late pregnancy in a nulliparous woman. There is no evidence that nulliparous women who experience a uterine prolapse during their first pregnancy will be at an increased risk of recurrence during future pregnancies. However, these women should be carefully managed during the antepartum and intrapartum phases of subsequent pregnancies.

Conclusion Uterine prolapse in pregnancy is rare, but most commonly occurs in multiparous women. Our case indicates that uterine prolapse can occur in the nulliparous women during late pregnancy. Obstetricians should be familiar with these rare conditions.

Consent Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Conflicts of interest None.

References 1. Keettle WC (1941) Prolapse of uterus during pregnancy. Am J Obstet Gynecol 42:21–26 2. Erata YE, Kilic B, Güçlü S, Saygili U, Uslu T (2002) Risk factors for pelvic surgery. Arch Gynecol Obstet 267:14–18 3. Brown HL (1997) Cervical prolapse complicating pregnancy. J Natl Med Assoc 89:346–348 4. Partsinevelos GA, Mesogitis S, Papantoniou N, Antsaklis A (2008) Uterine prolapse in pregnancy: a rare condition an obstetrician should be familiar with. Fetal Diagn Ther 24:296–298 5. 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 27:297–302

Uterine prolapse during late pregnancy in a nulliparous woman.

A pregnancy that is complicated by a uterine prolapse is rare and primarily occurs in multiparous women during their first or second trimester. In the...
291KB Sizes 6 Downloads 5 Views