CHALLENGES IN MANAGEMENT OF UTERINE PROLAPSE IN PREGNANCY

1. CHALLENGES IN MANAGEMENT OF UTERINE PROLAPSE IN PREGNANCY Presented by Dr Moses Mwei Dr Benjamin Shayo Dr BarikiMchome 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; • 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 • 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 11 & 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