Laparoscopic Promontohysteropexy During Pregnancy

Uterine Prolapse in Pregnancy: A Review

Importance

Although not a common occurrence, uterine prolapse during pregnancy can have significant effects for pregnancy outcomes and quality of life of maternal patients. Most data about management exist as case reports; a review of these cases provides some guidance about treatment options.

Objectives

This review examines current literature about uterine prolapse during pregnancy to assess current information about this condition, prevalence, diagnosis, management, and outcomes.

Evidence Acquisition

Electronic databases (PubMed and Embase) were searched using terms "uterine prolapse" AND "pregnancy" AND "etiology" OR "risk factors" OR "diagnosis" OR "therapy" OR "management" limited to the English language and between the years 1980 and October 31, 2022.

Results

Upon review of 475 articles, 48 relevant articles were included as well as 6 relevant articles found on additional literature review for a total of 54 articles. Of those articles, 62 individual cases of uterine prolapse in pregnancy were reviewed including pregnancy complications, mode of delivery, and outcomes. Prevalence was noted to be rare, but much more common in second and subsequent pregnancies. Most diagnoses were made based on symptomatic prolapse on examination. Management strategies included bed rest, pessary use, and surgery (typically during the early second trimester). Complications included preterm delivery, patient discomfort, urinary retention, and urinary tract infection. Delivery methods included both cesarean and vaginal deliveries.

Conclusions

Although a rare condition, uterine prolapse in pregnancy is readily diagnosed on examination. Reasonable conservative management strategies include observation, attempted reduction of prolapse, and pessary use; if these measures fail, surgical treatment is an option.

Relevance

Our review compiles literature and known cases of uterine prolapse during pregnancy and current evidence about prevalence, diagnosis, management, outcomes, and complications of uterine prolapse during pregnancy in order to inform our target audience in their clinical practice.

A laparoscopic procedure for the treatment of uterine prolapse during pregnancy: A case series

OBJECTIVE

To demonstrate the outcomes of pregnancies with uterine prolapse who have undergone laparoscopic suspension via a new approach during the first and second trimesters.

DESIGN

Retrospective case series study.

PATIENTS

Three patients who had undergone surgical procedures for uterine prolapse during pregnancy.

INTERVENTIONS

Laparoscopic treatment of uterine prolapse involves a procedure called 'vaginal assisted laparoscopic sacrocervicopexy'. The complications and difficulties of each case are described.

RESULTS

The patients underwent surgical procedures at 12, 14 and 16 weeks of pregnancy. All cases were delivered at term. As the gestational age increased, the operation became more difficult and the operation time was prolonged. The patient who delivered vaginally was complicated with shoulder dystocia.

CONCLUSION

Three successful cases of uterine prolapse surgery during pregnancy are reported. Surgery can be performed during pregnancy if absolutely necessary, and does not need to be delayed until the postpartum period.

[Cesarean section and perineal protection: CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]

OBJECTIVE

The endpoint was to assess the interest of planned cesarean section in primary and secondary obstetrical perineal prevention.

METHODS

This is a review of the literature about the impact of the mode of delivery in urinary incontinence (UI), anal incontinence (AI), pelvic organ prolapse (POP), sexual disorders de novo or prior to delivery and history of obstetric anal sphincter injuries (OASI).

RESULTS

The studies about UI, AI and sexual disorders report a potential protective impact of cesarean section but with a possible selection bias and an inadequate comparability of the groups. Randomized trials do not report any protective effect of planned cesarean section for these 3 disorders. The literature about POP reports a higher risk for the women who delivered vaginally but still with a possible selection bias et there is no randomized trial for this outcome. About the secondary prevention of OASI, there is no evidence in the literature for a benefit of a systematic planned cesarean section for all women. For symptomatic women, the mode of delivery has to be discussed individually. In secondary prevention of UI, AI, POP and sexual disorders, there is no evidence in the literature for a benefit of planned cesarean section even if there is a history of surgical procedure for the disorder.

CONCLUSION

Planned cesarean section is not recommended in order to prevent primary or secondary obstetrical perineal disorders except for symptomatic OASI for whom an individual discussion about the mode of delivery is recommended.

Laparoscopic Sacrohysteropexy in a Woman at 12 Weeks' Gestation

STUDY OBJECTIVE

To demonstrate laparoscopic sacrohysteropexy for a case of uterine prolapse in a 12 weeks, 3 days pregnant woman. To our knowledge this is the first case of laparoscopic sacrohysteropexy performed at 12 weeks of gestation to be reported in literature.

DESIGN

A step-by-step explanation of the surgical procedure (Canadian Task Force classification III).

SETTING

Maltepe University Hospital.

PATIENT

A 37-year-old pregnant woman.

INTERVENTION

Laparoscopic sacrohysteropexy. Institutional Review Board ruled that approval was not required for this study.

MEASUREMENTS AND MAIN RESULTS

Uterine prolapse is very rare condition, manifesting in an estimated 10 000 to 15 000 pregnancies [1]. The management plan must be individualized, and the obstetrician should aware of possible complications, such as preterm labor, high incidence of abortion, cervical ulceration, and cervical dystocia. In general, bedrest, good genital hygiene, and pessary use is recommended. Alternatively, in cases where conservative solutions have failed, laparoscopic surgery in the pregnant patient may be considered. To date, only 1 case of laparoscopic promontohysteropexy at 10th weeks of gestation was reported by Pirtea et al [2]. A 37-year-old woman, at 12 weeks and 3 days of gestation, with stage III pelvic organ prolapse was referred to our clinic. Conservative management with pessary failed. The patient underwent laparoscopic sacrohysteropexy after written informed consent form was obtained. In exploration, uterine manipulation was difficult because of softness and large size of the uterus. First, the sigmoid colon was suspended at the abdominal wall to gain an adequate surgical field. The promontorium was dissected and the parietal peritoneum incised on the right pelvic side wall after ureter visualization. A polypropylene mesh was fixed to the cervix at the level of the uterosacral ligaments. The other edge of the mesh was fixed at the level of the promontory using the Uplift device (Neomedic International, Barcelona, Spain). Then, the peritoneum was sutured to cover the mesh. The patient was discharged 2 days after surgery. At the examination the pelvic floor was detected to be normal. The patient delivered a healthy baby weighing 3030 g by cesarean section at 38 weeks of gestation. The position of the mesh was controlled during surgery. There was no peritoneal fold detected on the cervical part of mesh; however, no adhesion was observed.

CONCLUSION

Laparoscopic sacrohysteropexy may be an alternative and safe approach, if conservative treatment fails, for pelvic organ prolapse during pregnancy.