pregnancy in uterine prolapse by dr shashwat jani

Dr. Shashwat Jani. M. S. ( Obs – Gyn ), FIAOG.

Diploma in Advance Laparoscopy.

Consultant Assistant Professor, Smt. N.H.L. Municipal Medical College.

Sheth V. S. General Hospital , Ahmedabad.

Mobile : +91 99099 44160. E-mail : drshashwatjani@gmail.com

Introduction

Prolapse of uterus is a commonly encountered clinical condition seen in Indian settings, where delivery by untrained personnel is still quite common in the society.

The incidence of uterine prolapse in India is much more common, estimated to deliveries.

Certain myths related to labour, premature bearing down, maternal malnutrition, etc. are different etiological factors that underlie this condition.

However, conception with uterine prolapse makes a lady to stand in the high-risk category due to the pertaining risk factors of abortion, preterm labour, etc.

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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Uterine prolapse occurring for the 1st time during pregnancy is rare , occurring in 10000 to 15000 deliveries.

In Multiparous, after 2 FTND – 8 Times and after 4 FTND – 12 Times more chances of developing prolapse.

Most of literatures mentioning Uterine prolapse in pregnancy consist of Case reports prior to 1970, when condition was more common due to high parity.

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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Etiology

1. Multiparity

2. Congenital elongation of cervix

3. H/O fall , trauma

4. Neuro muscular disorders

5. Pelvic floor muscle weakness

6. Malnutrition / Obesity

7. H/o Instrumental delivery in previous childbirth.

8. Smoking , Chronic cough or Constipation

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Effects On Prolapse

Aggravation of Morbid anatomical changes in prolapse , such as …

• Marked hypertrophy & oedema of the cervix.

• 1st degree prolapse 2nd degree prolapse

• Cystocele & rectocele becomes pronounced

• Aggravation of S.U.I.

Mainly during early pregnancy due to weight of gravid uterus & increased vascularity.

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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Copious vaginal discharge and decubitus ulcer

( Cervix remain outside the introitus ) .

Chances of incarceration , if uterus fails to rise above pelvis by 16th week of pregnancy.

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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Prolapse & Infertility

• Difficulty in intercourse.

• Altered and distorted cervical anatomy

• Hostile cervical mucus for sperm entry

• Chronic P.I.D.

• Oedematous & Hypertrophied cervix

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Effects on pregnancy

Increased chances of … • Discomfort & Pelvic pain

• Bleeding

• Abortion

• Preterm labour

• Cervical infection leads to fibrosis

• PPROM

• Chorioamnionitis

• Constipation

• Retention of urine may require catheterization

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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During Labour

Increased chances of … • Early rupture of membrane • Cervical dystocia Secondary arrest around 5 – 6 cm , which was previously managed by Duhrssen’s Cervical Incision with or without forceps , but nowadays C.S. is preferred. • Prolonged labour due to non dilatation of cervix &

obstruction due to sagging cystocele & rectocele. • Operative interference

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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During Puerperium

• Sub involution

• Uterine sepsis

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Management

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Divided into…

1. During Pregnancy

2. during labour

3. during Post Partum period

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During Pregnancy

Symptoms are pronounced in early pregnancy.

If the cervix is outside the introitus :

• Cx is to be replaced inside vagina and kept in position by ring pessary.

• The pessary is to be kept until 18 – 20th weeks of pregnancy when the body of the uterus will be sufficiently enlarged to sit on the brim of the pelvis.

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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Pessary

• Various pessaries are available.

• Most suitable ring pessary of proper sized should be used.

• Before reposition of pessary , must be cleaned with antiseptic solution.

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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Remember

• Should be frequently removed , once in a week for couple of hours to prevent incarceration of pessary & infection.

• Rubber ring pessary is preferred.

• The tone of levator ani muscles must be good to keep pessary in situ.

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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When the pelvic floor is

too much lax…

• Bed rest with foot end raised ( about 20 cm ) and sometime indwelling Urinary catheter is kept.

• To relieve oedema & congestion ---

Cover the prolapsed mass with gauze soaked with glycerine & acriflavine.

It also prevents the infection.

• Continue Rx upto 20 weeks till prolapsed mass is reduced. Then allow pt. to walk.

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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• If reposition is not possible & there is incarceration , termination may be indicated.

• If the Cx remains outside the introitus even in later months, then preferable to admit at 36 weeks.

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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An Alternative option

All the conventional modalities of Rx

- Bed rest

- Tampons

- Pessary

Causes discomfort , pain , infection , dysuria and prolonged bed rest.

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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Introital Tightening

• Performed under strict aseptic precaution

• Lithotomy

• Local anesth. ( 1 % lignocaine ) infiltrated around introitus.

• Tiny stab incision of 2mm is made at posterior fourchette & just below the urethra.

24-Dec-17

Dr Shashwat Jani. +91 99099 44160.

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• Large curved round body needle with Vicryl no. 1 is inserted through the incision made on Anterior Vaginal wall& is passed submucosally in a semicircular fashion, half a cm deep & half a cm lateral & then brought through the posterior incision at the fourchette.

• A similar stich is taken on the opposite side. • Now, the sutures are tied to together to

tighten the introitus leaving 2 finger space at the vulval introitus & for drainage of vaginal discharge, cevical examination & intercourse.

• 5 – 6 knots are tied & stiches are buried under vaginal mucosa which is then sutured with chr. Catgut no 1 – 0 .

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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Advantages

• Daycare procedure

• Very simple & safe

• Under local anesth with total duration of 3 – 5 minutes.

• Analgesic & Antibiotic cream for local application.

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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During Labour

• Pt. should be in bed to facilitate replacement of the prolapsed cervix inside the vagina.

• Intravaginal plugging soaked with glycerine & acriflavine helps in reduction of cervical oedema but also facilitates dilatation.

• Prophylactic antibiotic

• Manual stretching of the cervix or pushing up the cystocele or rectocele past the presenting part during uterine contractions facilitates progressive descent of the head.

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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• In deeply engaged head with thin & undilated cervix, delivery by Duhrssen’s incision at 2 & 10 o’ clock positions F/b Forceps or Vaccum delivery.

• If the head is high up & cervix is thick , oedematous & undilated – C.S. is preferred.

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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U. V. Prolapse with Cord Prolapse

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Some articles on Google Laparoscopic sling in 2nd trimester

(modified Gilliam suspension )

Cesarean hysterectomy with vault suspension at Sacral Promontory.

Cesarean with Sling

Cervical Encirclage in 2nd trimester.

NOT PROVEN & NOT RECOMMENDED

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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During Puerperium

• Lie flat in bed

• If mass is still outside Cover with Gauze of Glycerine & Acriflavine.

• If subinvolution Ring pessary till involution.

• Prophylactic Antibiotics.

• After 3 months, if surgical repair is required.

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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• Perineal exercises.

• High protein diet, iron, multivitamin and calcium supplementation

• Avoid strenuous activities that lead to a state of high intra-abdominal pressure.

• Treatment of Cough & Constipation

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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Take Home Message

The management of pregnancy associated with uterine prolapse is highly individualized and varies according to the symptomatology, clinical findings, age and reproductive status.

It would be more difficult to manage primary postpartum hemorrhage caused by uterine atony in women presenting with uterine prolapse during pregnancy because uterine prolapse can interfere with the effective application of manual uterine compression

24-Dec-17 Dr Shashwat Jani. +91 99099 44160.

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24-Dec-17 29 Dr Shashwat Jani.

9909944160.