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Uterine prolapse in pregnancy: case report and description of pessary
574
Communications
in brief
Uterine prolapse Case report and pessary DESMOND
BLUETT,
M.R.C.S., London,
in pregnancy: description of
M.B.,
M.R.C.O.G. England
CA s E s o F uterine prolapse associated with pregnancy are uncommon, and the incidence is probably about one case in 10,000 deliveries. Most publications originate from the American literature, and 194 collected cases were reported by Marcus and Brant.2 The condition is not usually evident before the thirty-fourth week of gestation, and simple elongation and hypertrophy of the cervix must be distinguished from actual prolapse in pregnancy. Treatment in most cases consists of prolonged rest in bed and the use of various forms of pessary. Subsequent measures following delivery range from surgical repair to abdominal or vaginal hysterect0my.l Mrs. E. R., a 26-year-old, gravida 4, para 3 patient, had experienced no previous difficulty in labor and her largest baby had weighed 8 pounds, 4 ounces. when first
Fig.
She gave examined
1. Photograph
no history of prolapse, at the twenty-second
of
pessary
used
for
and week
prolapse.
in her fourth pregnancy, no evidence of prolapse was recorded. Her weight at that time was 107 pounds, blood pressure 115/85 mm. Hg, with a hemoglobin of 10.4 Gm. per cent and negative serologic test. At 32 weeks’ gestation the prrsentation was cephalic and the fetal heart audible. There was an associated iron deficiency When examined by a specialist for the anemia. first time at 36 weeks, the fetus was found to occupy the right occipitoanterior position and the head was engaged. It was noted that the cervix uteri was elongated and eroded, lying 10 cm. outside the vulva. The patient admitted to stress incontinence during the entire pregnancy, with occasional spotting of blood. Both ring and Hodge types of pessary had been tried without success, Vaginal examination revealed a considerable degree of prolapse: the anterior cul-de-sac measuring 1 v! inches (3.25 cm.) and the posterior 4% inches (10.5 cm). There was much localized edema and ulceration but no evidence of urinary infection. The patient was admitted to the hospital and the prolapse reduced leaving a flavine pack inside the vagina for 48 hours. When the edema had subsided, a special pessary (Fig. 1) was inserted. She was allowed to become ambulant and discharged within 5 days. During the next 4 weeks, the pregnancy was uncomplicated and the pessary was retained without discomfort (Fig. 2). She was no longer incontment of urine and her bowel function was quite normal. No further uterovaginal prolapse occurred. Labor commenced at term and the prssary was removed following spontaneous rupture of the membranes. The first stage of labor lasted
Communications
in brief
575
no backache, and no vaginal discharge. Sexual intercourse was entirely satisfactory and the bowel function was normal. On examination the cemix was healthy and the uterus seemed to br well supported. Three years later this patient had no disability and there was no evidence, of recurrence of prolapse. The pessary consists of an upper circular ring 70 mm. in diameter attached by three struts to a lower oval ring 30 x 35 mm. The tuo anterior struts arr recessed to permit the upper ring to lodge over the symphysis pubis. Thr posterior strut is straight and measures 115 mm. in length. The device was manufactured from Acrylic resin by a technical dental pro<‘(+\ to the precise specification rrquired by this particular patient.
Fig. 2. Drawing nancy.
of
pessary
in place
during
preg-
3% hours and the large anterior lip of the cervix was present until delivery of a normal male infant weighing 6 pounds, 12 ounces. One week following delivery the cervix appeared closed and healthy. The uterus was involuted and retroverted with a very large cystocele present together with a considerable degree of descent of the vaginal vault amounting to Stage II prolapse. The pessary was therefore replaced. One month after delivery the cervix was still healthy but could be drawn 5 cm. outside the vulva. The anterior and posterior cul-de-sacs were of equal length. A plastic ring pessary was inserted in place of the special device. Two months following delivery the patient was again admitted to the hospital. Through a Pfannenstiel incision bilateral tubal ligation together with a Gilliam-type ventrosuspension was performed and the appendix was also removed. The patient was then placed in lithotomy when it was ascertained that the cervix could by then only be pulled down to the introitus. Finally, anterior rolporrhaphy and posterior colpoperineorrhaphy were carried out. Mrs. E. R. was discharged on the thirteenth day without incident. One month later she had no compIaints, there was no stress incontinence,
The pcssary enabled the patient to hc, (‘IItire+ active from the thirty-fourth week of l”cgnancy. Whcrcas other kinds of pcssary M’CI~’ uncomfortable and could not be retained, this device was at no time expelled and the cervix \+as unable to descend through the ring. hlorvoxw, the patient was not aware of its prescnct~ and found it easy, while at stool, to steady the lowt*r ring digitally. Thrrc was no furtht’r urinary incontincncc and the pessary was retained for one month post partum without symptoms or at>psis. The device can bc made to any \pc,citic.ation rcquirrd by individual cases in any dental laboratory. A (XC of uterine prolapse associatcsti with pregnancy and a normal live dplivrr): i- ~IWsented. A nrw type of plastic cradle haviug advantages over thr more common vaginal pessaries is described. The operative measures takrn to finally improve this patient’s conditicln arc’ also
mentioned.
I am indebtrd to Surgeon Captain f D) D. Goodridgr, Royal Navy, for professional dental advice, to his demonstrator dental technician Mr. K. Clarke for making the pessary at thr Naval Hospital in Malta. and to John Richard5 for Fig. 2. REFERENCES
1.
Mufarriz.
and Keettel, W. C.: .4%rM. J. 73: 899, 1957. Marcus, M. B., and Brant, M. I.: West. J. Surg. 66: 90, 1958.
OBST.
2.
I.
K.,
& GYNEC.
Communications
in brief
Uterine prolapse Case report and pessary DESMOND
BLUETT,
M.R.C.S., London,
in pregnancy: description of
M.B.,
M.R.C.O.G. England
CA s E s o F uterine prolapse associated with pregnancy are uncommon, and the incidence is probably about one case in 10,000 deliveries. Most publications originate from the American literature, and 194 collected cases were reported by Marcus and Brant.2 The condition is not usually evident before the thirty-fourth week of gestation, and simple elongation and hypertrophy of the cervix must be distinguished from actual prolapse in pregnancy. Treatment in most cases consists of prolonged rest in bed and the use of various forms of pessary. Subsequent measures following delivery range from surgical repair to abdominal or vaginal hysterect0my.l Mrs. E. R., a 26-year-old, gravida 4, para 3 patient, had experienced no previous difficulty in labor and her largest baby had weighed 8 pounds, 4 ounces. when first
Fig.
She gave examined
1. Photograph
no history of prolapse, at the twenty-second
of
pessary
used
for
and week
prolapse.
in her fourth pregnancy, no evidence of prolapse was recorded. Her weight at that time was 107 pounds, blood pressure 115/85 mm. Hg, with a hemoglobin of 10.4 Gm. per cent and negative serologic test. At 32 weeks’ gestation the prrsentation was cephalic and the fetal heart audible. There was an associated iron deficiency When examined by a specialist for the anemia. first time at 36 weeks, the fetus was found to occupy the right occipitoanterior position and the head was engaged. It was noted that the cervix uteri was elongated and eroded, lying 10 cm. outside the vulva. The patient admitted to stress incontinence during the entire pregnancy, with occasional spotting of blood. Both ring and Hodge types of pessary had been tried without success, Vaginal examination revealed a considerable degree of prolapse: the anterior cul-de-sac measuring 1 v! inches (3.25 cm.) and the posterior 4% inches (10.5 cm). There was much localized edema and ulceration but no evidence of urinary infection. The patient was admitted to the hospital and the prolapse reduced leaving a flavine pack inside the vagina for 48 hours. When the edema had subsided, a special pessary (Fig. 1) was inserted. She was allowed to become ambulant and discharged within 5 days. During the next 4 weeks, the pregnancy was uncomplicated and the pessary was retained without discomfort (Fig. 2). She was no longer incontment of urine and her bowel function was quite normal. No further uterovaginal prolapse occurred. Labor commenced at term and the prssary was removed following spontaneous rupture of the membranes. The first stage of labor lasted
Communications
in brief
575
no backache, and no vaginal discharge. Sexual intercourse was entirely satisfactory and the bowel function was normal. On examination the cemix was healthy and the uterus seemed to br well supported. Three years later this patient had no disability and there was no evidence, of recurrence of prolapse. The pessary consists of an upper circular ring 70 mm. in diameter attached by three struts to a lower oval ring 30 x 35 mm. The tuo anterior struts arr recessed to permit the upper ring to lodge over the symphysis pubis. Thr posterior strut is straight and measures 115 mm. in length. The device was manufactured from Acrylic resin by a technical dental pro<‘(+\ to the precise specification rrquired by this particular patient.
Fig. 2. Drawing nancy.
of
pessary
in place
during
preg-
3% hours and the large anterior lip of the cervix was present until delivery of a normal male infant weighing 6 pounds, 12 ounces. One week following delivery the cervix appeared closed and healthy. The uterus was involuted and retroverted with a very large cystocele present together with a considerable degree of descent of the vaginal vault amounting to Stage II prolapse. The pessary was therefore replaced. One month after delivery the cervix was still healthy but could be drawn 5 cm. outside the vulva. The anterior and posterior cul-de-sacs were of equal length. A plastic ring pessary was inserted in place of the special device. Two months following delivery the patient was again admitted to the hospital. Through a Pfannenstiel incision bilateral tubal ligation together with a Gilliam-type ventrosuspension was performed and the appendix was also removed. The patient was then placed in lithotomy when it was ascertained that the cervix could by then only be pulled down to the introitus. Finally, anterior rolporrhaphy and posterior colpoperineorrhaphy were carried out. Mrs. E. R. was discharged on the thirteenth day without incident. One month later she had no compIaints, there was no stress incontinence,
The pcssary enabled the patient to hc, (‘IItire+ active from the thirty-fourth week of l”cgnancy. Whcrcas other kinds of pcssary M’CI~’ uncomfortable and could not be retained, this device was at no time expelled and the cervix \+as unable to descend through the ring. hlorvoxw, the patient was not aware of its prescnct~ and found it easy, while at stool, to steady the lowt*r ring digitally. Thrrc was no furtht’r urinary incontincncc and the pessary was retained for one month post partum without symptoms or at>psis. The device can bc made to any \pc,citic.ation rcquirrd by individual cases in any dental laboratory. A (XC of uterine prolapse associatcsti with pregnancy and a normal live dplivrr): i- ~IWsented. A nrw type of plastic cradle haviug advantages over thr more common vaginal pessaries is described. The operative measures takrn to finally improve this patient’s conditicln arc’ also
mentioned.
I am indebtrd to Surgeon Captain f D) D. Goodridgr, Royal Navy, for professional dental advice, to his demonstrator dental technician Mr. K. Clarke for making the pessary at thr Naval Hospital in Malta. and to John Richard5 for Fig. 2. REFERENCES
1.
Mufarriz.
and Keettel, W. C.: .4%rM. J. 73: 899, 1957. Marcus, M. B., and Brant, M. I.: West. J. Surg. 66: 90, 1958.
OBST.
2.
I.
K.,
& GYNEC.