1. CHALLENGES IN MANAGEMENT OF UTERINE PROLAPSE IN PREGNANCY
Presented by
Dr Moses Mwei
Dr Benjamin Shayo
Dr Bariki Mchome
8th June 2017

2. CASE REPORT

3. DEMOGRAPHIC INFO. Patient Name: S. M Age: 26 Sex: Female
Adress: Nyumba ya mungu- Moshi

4. 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

5. HPI Abdominal pain-Since conception Gradual onset Mild
Localised Suprapubic
No radiation
No abvious aggrevating or relieving factor

6. 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

7. 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

8. GENERAL EXAM FGC Mild pallor Afebrile No oedema Temp 37.2
B.P 110/78 mmHg

9. 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

11. Per abdomen examination
Fundal height – 27 cm
Estimated fetal size- 2kg
Lie- longitudinal
Presentation – Breech

12. 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

13. Obstetric u/sound
BPP- 8/8
GA- 32 Weeks
EFW- 1.8 KG
Placenta- fundal

14. 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

15. Follow up plan Discharge plan -Kegel exercise
-Avoid risk activities(Carrying heavy objects etc)
-Follow up after 6 month for reevaluation and definitive treatment

16. INTRODUCTION
The herniation of genital organs into or beyond the vaginal walls
Symptoms can impact
Daily activities
Sexual dysfunction
Exercise
Body image and sexuality

17. Types POP is arbitrary divided into; Uterine procidentia
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

18. Ant. Vag wall prolapse

19. Apical prolapse

20. Post wall prolapse

21. 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)

22. 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)

23. ..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

24. Normal pelvic floor anatomy

25. Risk factors Advancing age Overweight and Obesity
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

26. 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)

27. Diagnosis and Evaluation
Diagnosed on pelvic exam
Medical history is important especially in treatment choice decisions.
Classification systems
Baden-Walker (1972)
POP-Q (1996)

28. ..the Baden-Walker Halfway system
Lacks precision and reproducibility but effective in clinical settings

29. 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.

30. 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

32. 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

33. 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

34. 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

35. Conservative management
Desirable for grade & III
Patient has other comorbidities risk for surgery
Contraindication
Short vagina length
Large introitus
Previous vaginal surgery

36. Surgery Goals -Provide mechanical support -Suspension -Obliterative
-Surgical excision-NOT VERY EFFECTIVE!!!

37. Suspension procedures
Material used
Synthetic material-Mesh (Polyprolene mesh)
-Graft
Xenograft
Allograft-Harvested rectus fascia

38. Uterosacral suspension

39. Sacrospinous suspension

40. Sacral culpopexy

41. Provide support/strengthening

42. Obliterative

43. 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

44. Uterine prolapse in pregnancy
Management
-Reduce risk of complication
Enhance fetal lung maturation
Tocolytic until viability attained
Bed rest
Pessaries if presents early

45. THE END