Womens Health

Uterine Prolapse Problems 

From the Woman's Diagnostic Cyber - Frederick R. Jelovsek MD

 

Can you go thru pregnancy with severe prolapse?

I am a 36 year old married mother of three that is considering having a fourth child. After the birth of our first child (10.5 pounds), I have suffered with increasing uterine prolapse (now considered severe). The last two pregnancies have gone well except for the first three months when bladder problems occur.

A gynecological surgeon that would do the eventual repair and hysterectomy has recommended against another pregnancy because of the less likely success of his repair work as the prolapse becomes even more severe. Do you have any feedback or know of someone else that has gone through a 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 found your response to be a little bit surprising. I understand that severe prolapse with a pregnancy (or at this young of age) is rare and I can only guess that it was caused by heredity (my mother and grandmother had this problem after children but not as severe) and the hard, long labor of my first 10.5 pound son. Otherwise, I am an active, non-obese (5'10" , 145 pound) woman with no history of excessive lifting.

What I did find surprising was the mention of bed rest and premature births in pregnancies with prolapse. With my second pregnancy I suffered from a blocked urethra (cause unknown to me at the time) around the 15th week and sought treatment from the discomfort. Luckily (or so my doctor tells me), I came in late at night instead of waiting and had my doctor empty 2 liters from my bladder. He recognized the cause right away - a baby trapped below the pelvic bone due to my lax ligaments (prolapse) and manually pushed the baby up into the pelvic cavity. This was uncomfortable, but worked fine and there were no further problems during my pregnancy. I delivered vaginally a healthy baby after being induced at 41 weeks.

With my third pregnancy my new doctor and I watched for signs of the blocked urethra and then she tried the manual 'push up' method. Unfortunately it did not work (the uterus kept slipping back down) and I had to resort to self-catherization as pessaries didn't seem to stay. After a couple of more weeks the doctor was able to push the uterus up and have it stay. I resumed normal activity until 39 weeks when I was again induced and delivered another healthy baby.

My question is, did the doctors that were listed in the abstracts even try to push the uterus up? My doctor (who was a high risk doctor with the University of Wisconsin - Madison) said my trapped baby was very rare, but seemed to know just what to do. If they could not get the baby up, I can see the need for bed rest, and likelihood of premature labor. But once the baby is up, I continued normal activity.

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?

I'm not certain about the number of weeks with the third child, but I do know that we had to try at several appointments before the baby stayed up. My guess is that is was eventually around 16-17 weeks. While uncomfortable, it was not that painful and certainly was worth it considering that I was not limited to bed rest. It sounds as if I may have indeed been lucky to have a doctor that tried this maneuver the first time.

 

Abdominal vs vaginal prolapse surgery and future vaginal delivery

I have been scheduled for surgery in two months. I have found a pelvic support surgeon who will be operating on me. I have a uterine prolapse, and will be keeping the uterus. I wish to have another child. I was told by the doctor that he is skilled in any type of entry. I choose to do this vaginally. I have heard that there is a debate whether surgery will last longer if it was done abdominally. He said he is doing the same work no matter which way he goes in. That the long term results will be the same. I am wondering if you have the same opinion?

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.

I want to make sure I am doing the right thing.

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.

I will be getting the uterus stitched up with a man made material and it will be attached to the back of the abdominal wall. He said this is stronger that way instead of just the stitches. Also one week before my surgery I have to go in for urodynamic testing, depending on those results I may need to have a tuck or two on the bladder. I am worried and want to know if all this sounds correct to you. Please inform me of your thoughts.

What are your main worries?

I would like to be able to delivery vaginally. I have a prolapse which the cervix comes about 1 1/2 inches beyond the opening of the vagina. I had asked the doctor about another normal childbirth. I have two children now both vaginal births. He said that if I have a fairly easy delivery I have the same chances as any one to have this birth and come out still altogether. I was told that If I have a child the way my prolapse is then I could expect to stay off my feet for a few months until the baby grew enough not to cause that pressure so much. I then chose to have the surgery before the pregnancy. I am worried the most about my choice for vaginal surgery vs abdominal. I still wonder if the doctor was right by saying no matter what way he enters he will still be doing the same work inside so it did not matter how he enters. Do you agree with this?

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.

Do you think I should have the surgery before or after a birth?

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.

I do want a vaginal birth and I do not want to have this surgery again that is why I am worried and I would just like your opinion.

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

I am 34 years old. I am 5'3" and 115-118. I don't smoke and I am in great health. I have 2 sons and would love to have another child. I have had 3 pregnancies. The first I miscarried, the second I had a C-section, and the third was VBAC. The C-section was because of a long labor (24 hours) that failed to progress after 10 hours. I had no complications and was out of the hospital on the third day.

Now, for the cause of my problem (as I believe it). With my last pregnancy I was counseled on the benefits of VBAC deliveries before even seeing a doctor. After 11 days (yes days) of regular contractions, my water finally broke. I was admitted to the hospital and after 10 hours of labor I was again failing to progress and I was told there was a "lip" in the way. With great effort from the hospital staff, I was able to push for 6 more hours with the doctor sitting by the bedside. All seemed to be going OK until I heard "STOP PUSHING." The baby's heart monitor had gone flat and in a mater of seconds, forceps were used to deliver the baby during which time my body bounced from the table (this all seemed so violent). I realize this was necessary to save my son, and I am thankful to everyone for that. The repair was done by two young trainees who did not appear to be very experienced. Also, I had a catheter in for over 16 hours with no urine in it. The next day I stood up and it was like a large water balloon exploded. After that I had little to no bladder control.

It took many months before I had any feeling in this area and several more before I could stop wearing a pad for urine loss. I do Kegels several times a day and still must wear a panty liner for occasional stress incontinence. Since the birth, I have been telling the doctors that I do not feel normal. The answer is always "Women do not feel "normal after having a child". Then I began to see a bulge coming from my vagina. I was still told that I'm OK. I had no idea what a uterine prolapse was (I had to research this on myself). Finally, last month I saw another doctor who told me I had a cystocele. I went back 2 weeks later and that doctor and another with him agreed that I do have a uterine prolapse. They advised me to have a hysterectomy.

I have several questions:


1) Why was there no urine in the catheter for some 16 hours during the labor and delivery?

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.

2) Should I have had another C section with this last pregnancy when the labor failed to progress again after 10 hours of labor?

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.

3) What did they mean by a "lip" was in the way?

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.

4) Would a C-section after the first 10 hours of labor have prevented my urinary and prolapse problems now? If so, why would they not have done this?

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.

5) I don't want a hysterectomy! Are there no other options?

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.

6) We would like to have another baby soon. We do plan on another cesarean delivery. During the pregnancy, could the fetus be harmed in any way from the prolapse?

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.

7) Could I be harmed in any way? Can getting pregnant worsen the condition?

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.

8) Could I wear a pessary to help support the uterus during the pregnancy?

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.

9) Should I consider having surgery to repair the prolapse before I get pregnant? - my concern with surgery first is that the pregnancy would damage the repair - could It?

It is better to have the repair after your last pregnancy unless symptoms are too much of a daily problem.

I can see ¼ inch of my cervix on bad days. They have classified me with a grade III uterine prolapse and grade II cystocele but I do not feel I was given a thorough exam to determine this. Is there a test or ultrasound I could have to see if it may be a elongated cervix or prolapse?

No. The pelvic exam is much more accurate than any imaging studies.

 

Does postpartum prolapse improve over time?

Have you ever seen a marked improvement in prolapse after the postpartum period is complete? For instance, if a patient has a moderate prolapse (3 of 4) have you ever seen one that healed well and became more of a mild prolapse?

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

I have a 8 month old daughter and about 8 weeks after my delivery I noticed something protruding into my vagina from my rectum. I had to apply pressure to the back wall of my vagina to be able to defecate. I did some reading and found that this is called a rectocele. A few days later I noticed that my cervix was a lot lower and the front wall of my vagina bordering my bladder was also protruding. Of course this all totally freaked me out.

My labor was 12 hours long and nothing really unusual happened except that I was put into labor when I was 10 days past my due date and that I wasn't dilating very well and the doctor stretched my cervix somehow. I also didn't have to have an episiotomy. My daughter weighed 7 lbs 1 oz. I am only 23 years old and this is my first child so I am thinking-this can't be normal for someone this young to have this sort of problem. I went to see my doctor and she made it sound like it was no big deal. I feel that my doctor is not being straight with me and would appreciate a second opinion.

Is this problem unusual? All of the things I have read have led me to believe that only a hysterectomy will solve this problem. Is this true? If I have another child--will it be considered a high risk pregnancy? Is there a possibility of bed rest? And what about delivery? If one child did this to me, then what would happen if I delivered another vaginally.

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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