Management of Pelvic Organ

Prolapse in Pregnancy

Tyas Priyatini
Urogynecology Reconstructive Division
Obsteric and Gynecologic Departement
 Introduction

• Rare condition 1:10.000-15.000 pregnancies

• Can be pre-existance or manifest at course of
pregnancy
• Complication: cervical infection, abortion,
preterm labour, urinary retention, UTI.
• Recommendation regarding management is
scarce
 Risk Factors
• Increasing age
• Parity
• Obesity
• Connective tissue disorders
• Raised intra-abdominal pressure
• Previous vaginal delivery
• Pregnancy itself
Pathophysiology
Decrease
Progesterone muscle
tone P
E
P Hormonal
Collagen L P
r Relaxin
changes V R
e
I O
g
y C L
n Posture
Increase A
a
pressure O P
n Biomechanical to pelvic
Increase R S
floor
c intraabdominal G E
pressure
A
N
Trauma to levator ani muscle, nerve, and fascia from
previous delivery.
Diagnosis

• Chief complaint
• Severity
• Voiding and
defecation problems
• Obstetric history
• Familly history
Point Description Range of Values
Aa Anterior vaginal wall 3 cm proximal to the hymen -3cm to + 3 cm
Ba Most Distal position of the remaing upper anterior vaginal wall -3 cm to + tvl
C Most distal edge of the cervix or vaginal cuff scar
D Posterior fornix
Ap Posterior vaginal wall 3 cm proximal to the hymen -3cm to +3 cm
Bp Most distal position of the remaining upper posterior vaginal wall -3 cm to + tvl

Genital Hiatus (GH) measured from middle of external urethral meatus to posterior midline hymen
Perineal body (Pb) measured from posterior margin of GH to middle of anal opening

POP stages criteria

Stage 0 Aa, Ap, Ba, Bp, = -3 cm and C or D ≤ - (tvl-2) cm
Stage I Stage 0 criteria not met and leading edge < -1cm
Stage II Leading edge ≥-1 cm but ≤ +1 cm
Stage III Leading edge > +1cm but ≤ + (tvl-2)
Stage IV Leading edge ≥ +9tvl-2)
Bump RC, The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction.
Am J Obstet Gynecol. 1999;176;175
 Complications

Voiding difficulty Failure to Haemorrhage

Intrapartum
Antenatal

Postpartum
Defecation progress Symptomatic
difficulty Cervical distocia prolapse
Urinary retention Cervical
Cervical erossion laceration

Bleeding Uterine rupture

Miscariage
Preterm labour
 Antenatal Mangement
• Mainly conservative symptomatic relief
• Hygiene
• Rest preferably in a semi-Trendelenburg
position
• Lifestyle Modification: avoidance of heavy
lifting, treating chronic cough, treating
constipation and Kegal exercises
• Pessary
Do we need Surgical management
antenatally ?
Most Cases doesn’t
Matsumoto et all: modified
laparoscopic Gilliam uterine
suspension procedure, whereby
the round ligaments were fixed
bilaterally to the rectus fascia
with the aid of silicon sheets.
The patient went on to have a
spontaneous vertex delivery at
term.
Selected cases who
failled conservative
treatment
Pirtea et all, Laparoscopic
sacrohysteropexy in 12 weeks
of gestational age.
Patient underwent cesarean
Section on 39 weeks of
gestation
 Intrapartum management

Is Cesarean Section really necessary?

 Obstetrics indication
 No evidence of protective effect of CS
 Individualized
• Do we need to do
cesarean hysterectomy
continue with
sacrocolpopexy or
sacrohysteropexy
following CS?

• Patient’s preference on
future fertility
• Postpartum spontaneous
recovery are possible
 Postpartum management
• Mainly conservative symptomatic relief
• Hygiene
• Lifestyle Modification: avoidance of heavy lifting,
treating chronic cough, treating constipation and
Kegal exercises
• Pessary
• Reevaluation after 3-6 months postpartum
 Take Home messages

• Relatively rare, but need to be identified

for proper mangement and avoidance of
complications
• Antenatal management mainly
Conservative with pessary and lifestyle
modifications
• Individualized approach