Prolapse Problems Before and after Pregnancy
From the Woman's Diagnostic Cyber - Frederick R. Jelovsek MD
   
Can you go thru pregnancy
with severe prolapse?
Prolapse is uncommon in pregnancy. There is a risk of premature
labor. Most of the time it is treated with a pessary (Smith-Hodge
type) and that can help carry things through but decreased activity and
bed rest are also key treatments. There have been some surgical
treatments of prolapse with subsequent pregnancy. I've included some
abstracts below that might be helpful.
Brown HL:
Cervical prolapse complicating pregnancy.
Natl Med Assoc 1997 May;89(5):346-348
Department of Obstetrics-Gynecology, Louisiana State University
Medical Center, New Orleans, USA.
Uterine cervical prolapse concurrent with pregnancy is rare. This
article reports three cases of second-degree cervical prolapse during
pregnancy. Two women developed prolapse in the late second trimester
while one women had preexisting prolapse. Both women with prolapse
developing during midpregnancy were treated unsuccessfully with a
vaginal pessary to maintain cervical placement. Premature labor
occurred in both of these women, resulting in one preterm birth.
Although cervical prolapse is rarely encountered in pregnancy, the
threat of preterm labor and delivery warrants close observation.
*****
Hill PS
Uterine prolapse complicating pregnancy. A case report.
J Reprod Med 1984 Aug;29(8):631-633
A patient developed uterine prolapse during pregnancy. Conservative
management consisted of bed rest and use of a pessary. A viable infant
was delivered at 30 weeks' gestation following premature rupture of
the membranes. A review of the literature suggests that maintaining
conservative treatment of these patients throughout pregnancy can
result in uneventful, normal, spontaneous delivery.
*****
Kovac SR, Cruikshank SH:
Successful pregnancies and vaginal deliveries after sacrospinous
uterosacral fixation in five of nineteen patients.
Am J Obstet Gynecol 1993 Jun;168(6 Pt 1):1778-1783
Department of Obstetrics and Gynecology, St. John's Mercy Hospital,
St. Louis, Missouri.
OBJECTIVE: We sought to determine whether sacrospinous
uterosacral ligament fixation restores the uterus to its normal
anatomic position, preserving uterine function and allowing future
childbearing.
STUDY DESIGN: This study was undertaken at two separate
medical centers. Women with symptomatic uterovaginal prolapse who
desired either uterine preservation or future childbearing were
included.
RESULTS: We successfully performed sacrospinous fixation of
the uterosacral ligaments in 19 patients. Five patients have since
been delivered vaginally (for a total of six deliveries). Normal
anatomic restoration was accomplished in all but one patient.
CONCLUSIONS: Sacrospinous uterosacral ligament fixation is an
acceptable surgical means to care for symptomatic uterovaginal
prolapse in women desiring uterine preservation or future
childbearing. To our knowledge, this is the first report of successful
pregnancies and vaginal deliveries after sacrospinous uterosacral
fixation.
I'm glad you gave us more of the story.
It makes sense that after a certain time, the uterus gets too wide
in its diameter to drop down into the pelvis. Apparently the time your
first doctor elevated the uterus and baby out of the pelvis, it was
just at the right time that the uterus was getting big enough to rest
on the pelvic brim (inlet to the pelvic bone).
With the second doctor, elevation didn't work until a certain time,
again when the uterus was big enough. What was the time in the last
pregnancy (in weeks) when the pregnancy stayed up? (The 1st one was 15
weeks, was the second episode about the same time?
Abdominal vs vaginal prolapse surgery and future vaginal delivery
If you are having a pregnancy, are you planning on having a vaginal delivery? The
reason I ask is that vaginal delivery can break or significantly weaken
the stitches and material holding the uterus up. It does not always so this but to some extent, your surgery may be
somewhat temporary.
Are the symptoms, pelvic/vaginal pressure or low back pain, that you have from the prolapse pretty bad? Is the uterus coming down
to the opening of the vagina or outside the vagina? Most women put off the surgery
until they are done with childbearing so they will minimize the number of surgical
procedures they will have for this relaxation. Sometimes it really needs to be done
however. If the symptoms are bad then you will need to have something done now.
What are your main worries?
Suspension of the uterus can be accomplished both vaginally and abdominally but usually
they are different procedures. Vaginally the uterus is usually attached to a vaginal
pelvic structure called the sacrospinous ligament. Abdominally the uterus (cervix
attachment) is attached to the sacrum, a pelvic bone above the tail bone, the pelvic muscles or the uterus
can be attached to the anterior abdominal wall. All of the procedures can accomplish
suspending the uterus long enough to get pregnant and deliver. There are also some
vaginal procedures to attach the cervix to the anterior abdominal wall. I can't tell
specifically what your doctor would choose as a procedure. In general the abdominal
approaches have better success for long term cure of prolapse but that in women who are not having further deliveries.
A rule of thumb is that the best procedure is the approach your doctor is most comfortable and experienced with.
It depends on how averse you are to surgery. If you only want one surgical procedure,
it would be best to wait until after another pregnancy assuming your current symptoms are not severe.
Ask your doctor how likely he thinks it is that the surgery he plans will need to be
repeated within 5 years after a delivery because the uterus or the bladder or rectum
will drop down again and cause significant problems.
Cystocele after delivery but want another pregnancy
Sometimes the catheter can be blocked off by the head of the baby being so tight that urine does not come out the catheter. Sometimes you are not getting enough fluids in the IV and don't form enough urine. Sometimes with pushing, the urine leaks around the catheter and nothing comes out in the bag.
After delivery is sounds as if the catheter was not draining and your bladder overdistended. This may have been due to a blood clot in the catheter or a kinking. It did not cause a cystocele but it was likely responsible for making your bladder without feeling to void.
There is no way of knowing what was the best course except in retrospect. In retrospect, a C-section might have given you less bladder problems but you can have other problems from C-sections.
The cervix was not completely dilated. This is a sign that the babies head and the pelvis were a tight fit but many women deliver sucessfully in this situation by just pushing the lip up over the head with pushing.
There is no way of knowing which women will have prolapse problems from pushing in the 2nd stage of labor with our current knowledge and technology. Doctors are reluctant to perform C-sections on all women to prevent those few percent that develop immediate prolapse problems.
You can have vaginal or abdominal repair without hysterectomy to re-attach the cervix and upper vagina to the uterosacral ligaments, or the sacrum, or the sacrospinous ligament, i.e., to some tough tissue that is unlikely to stretch or break later. Initial recovery takes about 6 weeks and you should lift no more than 10 lbs for an additional 6 weeks. No more strenuous impact aerobics or sports for months.
Pessaries can help in the short term until you finish pregnancies but they are not usually a long term solution at your age.
Usually not except there can be a risk of preterm labor. Once the pregnancy gets past about 18-20 weeks, the uterus stays up and prolapse is not a problem.
Pregnancy won't change too much more what has loosened already. Labor and pushing are the main culprits thought to cause prolapse and pelvic support defects.
Yes. This can be quite helpful in early pregnancy so you don't have so much discomfort. Usually a Smith-Hodge type of pessary is used.
It is better to have the repair after your last pregnancy unless symptoms are too much of a daily problem.
No. The pelvic exam is much more accurate than any imaging studies.
Does postpartum prolapse improve over time?
Yes. Many prolapses present right after pregnancy and show some improvement as time goes on. They seem to be the worst at 3 months then slowly improve by about one grade for about a year, sometimes more. Then, over time, they may very slowly worsen but have a dramatic worsening at menopause. Caucasian women with red hair seem to have the worst degree of prolapse and do not improve at all.
8 Months postpartum, rectocoele and uterine prolapse
The changes you describe are consistent with some degree of cystocele and rectocoele with a degree of uterine prolapse. If the doctor looked at it and thought it was not too serious, it does not sound like any surgery is indicated at this time, but you need to be the judge of that. It may not get worse with a subsequent pregnancy although sometimes it can.
Be sure to give this some more time after delivery. There will still be some more healing and you can help it with Kegel exercises and perhaps use weighted vaginal cones. There is also a pelvic floor nerve stimulation therapy available although many insurance companies do not yet cover it. You may need to begin working with a gynecologist who does pelvic relaxation treatment rather than your general Ob-Gyn. You do not have to have a hysterectomy when you have surgical repair of cystocele, rectocoeles, or any uterine prolapse. However, it is usually advisable to wait until after you have had all the children you want to have the repairs.
You might want to visit the following web site which is a group of young women like yourself who developed these problems following childbirth: Prolapse following childbirth
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