Claassens, H.J.H.

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28 Februarie 1959 S.A. TYDSKRIF VIR GE EESKUNDE 175PROLAPSE OF THE UTERUS I PREG A CYH. J. H. CLAASSE s, M.B., Ch.B., M.Med. (0. & G.) (CAPE To ), M.R. .O.G. (LOND.)Late Registrar, Division of Obstetrics and Gynaecology, University of Cape Town and Grcote Schuur Ho pital Cape TownUterine and vaginal prolapse in pregnancy are comparativelyrare. Only 192 cases have been described up to the presenttime, besides I complete and 2 incomplete case records. Inmost of these cases the reports were brief and the degree ofseverity of the condition was not properly asses ed. Further-more no comprehensive appraisal of the condition fromthe onset of pregnancy to the stage of postpartum involutionhas been published.In pregnancy gross hypertrophy of the cervix may occur.This is also found in prolapse and it may be difficult todifferentiate one condition from the other. The custom ofdescribing prolapse in 3 degrees should be adhered to indescribing the condition in the pregnant state. Most recordsdescribe cases of the first degree, some of the second, andcase descriptions of procidentia in the literature are rarealthough Keettel 3 states that procidentia occurs up to the7th month of pregnancy.Prolapse does not seem to affect fertility adversely (Conant1),despite statements by authors like Stabler.2 According toKeette1,3 Kibel4 and Vigilante and .Bellinger5 the incidenceof the condition is one in 10,000-15,000 pregnancies, being4-5 times more common in multiparous than primiparouswomen. In most of the reported cases pregnancy occurred inpatients already suffering from prolapse. While it is held thatprevious pregnancies were responsible for the state of pro-lapse, the degree of multiparity does not seem to have anybearing upon its incidence, nor do previous forceps deliveries.Stabler and other consider any sudden strain during preg-nancy, e.g. defaecation, a precipitating cause of venous stasisand thus of acute oedema of the cervix with extrusion in a fewhours. It is, however, possible that there may be other un-explained factors.Prolapse cannot occur during pregnancy unless there isrelaxation and tearing of the structures which support theuterus, together with softening and elongation of ligamentsand tissues such as the lateral cervical, pubocervical anduterosacral ligaments, the fascia of the pelvic floor, vaginaland perineal tissues, and possibly the round ligaments.Marked cervical changes follow secondarily on impairedvenous return and exposure. These changes, which are dueto hypertrophy and engorgement, a tendency for erosionsto develop, and infection, cause gross enlargement of cer icaltissues. These changes, moreover, may occur very quickly,even within a few hours or days.The condition of descensus with "its annoying and evenmcapacitative consequences can be expected to occur up toapproximately the 12th week, when pregnancy has advancedfar enough to lift the uterus out of the pelvis and the cervixinto the vagina, but there are rather frequent exceptions.It usually lasts ntil the stage of labour, which is usuallyeasy. There is a tendency for the condition of prolapse torecur after labour, when it is often worse than before.The onset of prolapse is often sudden. Most writers feelthat sudden strain is the precipitating factor but we do notconfirm this. In no recorded case was the onset a sociatedwith shock; medical aid was often not even sought for vary-ing periods of time until the prolapse had become incapacitat-ing or too painful (case I). Prolap e often recurs repeatedlduring the first 12 weeks of pregnancy and it may becomeirreducible. The fundu i ometune lower than e pected,but it is difficult to judge thi before the 12th week, and thecervical protrusion with purple di colouration may be seenat the vulva.Prolapse of the uterus in pregnancy can be divided into4 clinical types, in order of frequency:1. Cases with an early onset. These u ually occur in asso-ciation with pre-existing prolapse. In these cases remissionis u ually maintained after the utem i lifted out of the pet i .2. Cases in which prolapse may persist throughout preg-nancy. This is a rare group.3. Cases which occur late in pregnancy.4. Ca es in which the uterus is pu hed down e.g. in theone case of ectopic pregnancy which developed a prolap e atthe 16th week and which was only discovered at the 36thweek, described by Morgan and Keevel.8OBSTETRICAL COMPUCATIO SFew conditions have so many possible obstetrical complica-tions as prolapse of the uterus in pregnancy:1. Infertility, which seems to occur only when prolapseis so marked that coitus is difficult, so that seminal poolingis impossible, or where chronic cervicitis exists. One patient,a religious objector to operation, had 4 successive pregnancieswith a seeo'nd-degree prolapse existing throughout.2. An increased abortion risk, estimated at 15 %by Gaetoneand Labriola,7 thought to be due to cervical sta i and in-Jection or temperature changes.3. Urinary difficulty with severe infection (case 1).4. Irreducibility or incarceration of the uterus possiblywith urinary retention (case 2).5. Premature delivery.6. Cervical dystocia, which according to Stande~ oftenari es in prolapse occurring in late pregnancy, or when thepr01ap e was neglected, or when it is persistently present.7. Puerperal infection, which was the cause of 8 of the 9reported maternal deaths.8. The high rate offoetal mortality which is described-up to22 %in Keettel's series. 39. The danger of inanition which may result from po iblyprolonged bed rest.10. Unexpected postpartum prolapse (case 3).It must be emphasized that most of these complicatingfactors may be avoided by early adequate treatment before andduring pregnancy.REVIEW OF LITERATUREKeettel 3 in 1941 analysed the 170 cases described to that date.Complete records existed in 140 cases; of these 124 werecollected by Franke in 1892 (quoted by KeetteI3). In Keettel'series treatment ranged from radical during the early day, toconservative in later times.In 1911 Findlay9 advised therapeutic abortion and vaginalrepair if the patient was incapacitated and if bed rest failedto control the condition, while Harris in 1912, quoted by176 S.A. MEDICAL JOURNAL 28 February 1959Keettel,3 advocated Porro-Caesarean section. Keettel re-commended symptomatic conservative treatment with spon-taneous delivery and he advised DUhrssen's incisions ifnecessary or low forceps application; and in 1941 StanderSrecommended therapeutic abortion for incarceration. Themethods of delivery in Keettel's collected cases were spon-taneous in 35 % of cases, forceps deliveries in 23 %, DUhrssen'sincisions in 30%, version and extraction in 4%, craniotomy in8 %, and Porro-Caesarean section in 1%. There was a foetaldeath rate of 22 % (due to operative interventiofl, prolongedlabour and prematurity), frequent prematurity, and 14 cases ofsevere maternal sepsis wi th 8 deaths (before 1911 there were6 such deaths with a 5 % mortality rate and during the period1911-1940 there was a mortality rate of 14%). One othermaternal death was due to uterine perforation. The mortalityrate for the whole series was 6·3 %.Subsequently 22 other cases were recorded, of which IO fulldescriptions could be traced and analysed. All had spon-taneous deliveries. The only death recorded was that of afoetus with a prolapsed and non-pulsating cord. In 1 case withan incarcerated uterus delivery took place nearly at term. In 2cases prolapse existed before pregnancy. In one of these,prolapse occurred in the 6th week of gestation (she had ahistory of prolapse during a previous pregnancy) and, in theother, prolapse occurred in the 28th week. In 6, prolapseoccurred between the 32nd and 38th weeks of gestation.All ten cases were treated conservatively with bed rest andpessaries where necessary; 3 recovered completely.Klawans and Kantor10 make a strong plea for a rational andstandardized approach throughout pregnancy. They added4 case records in their valuable paper. In 2 cases a severedegree of prolapse existed before pregnancy and, in both,pessaries were used up to the 14th week. According to mostwriters prolapse after this stage is uncommon and yet itoccurred repeatedly in both cases. Pessaries were then usedthroughout pregnancy and during labour until the cervixhad dilated to almost 7 cm., i.e. virtually to its full extent.The pessaries were replaced immediately after labour tosupport the ligaments during involution. No infection wasnoticed before, during or after labour. Stabler and Conantdisagree with the use of pessaries because of the danger ofinfection. Stabler preferred complete rest ·in bed for the first3 months. After this period an occasional day in bed everyweek was sufficient. Vigilante and Bellinger report on apatient who had an abortion in the 22nd week during aprevious pregnancy, and for whom a pessary could not befitted then or now. She was confined to bed thoughout thepregnancy and she gave birth to a mature infant withoutintervention. Stabler suggests that it is possible to amputatea cervix successfully during pregnancy; the parts heal· sur-prisingly rapidly and cleanly after simple colporrhaphy. Hedoes not recommend the full Manchester repair and con-siders that to do less would be useless.TREATMENTWherever indicated the condition of prolapse in pregnancymust be treated, even in young women, because the results infurther pregnancies and deliveries under adequate supervisionare quite satisfactory. Episiotomy may be necessary to avoidsudden rupture of the anterior or posterior vaginal wall(Stabler). In pregnancy it is important to correct the prolapseas soon as possible for fear of incarceration or abortion; if thecondition has an acute onset, rest in bed with its foot-endraised will invariably reduce the oedema and the uterus canthen be replaced into the abdomen after a day or two. Reduc-tion under anaesthesia may be attempted if rest in bed failsto reduce the prolapse; such failure may however be anindication for therapeutic abortion in view of the dangers offoetal mortality, infection and dystocia. A subsequent repairoperation should be performed if necessary. In some patientsthe condition persists or recurs, even after the 14th week.Good results have then been obtained both by using pessaries,usually of the Hodge type, under adequate supervision(which is less likely to disrupt the patient's everyday life),and by repeated or prolonged rest in bed (which is safer fromthe point of view of possible infection). During labour watch-ful conservatism should be employed; in many instances thecervix will dilate outside the body, when Dlihrssen's incisionsand possibly the use of low forceps should suffice. The useof a pessary after returning the uterus to the abdomen afterlabour may be of great value, but it should not be allowed tobe trapped by the involuting birth canal. Colpoplastic repairmay be indicated after full involution, regardless of age andof whether the uterus is in the abdomen or not. In some olderpatients simultaneous hysterectomy may be considered. Somepatients, particularly those with an unexpected spontaneousonset ofprolapse, may recover completely after full involution.Fig. 1. Case 1.28 Februarie 1959 S.A. TYDSKRIF VIR GE EESKUNDE 177CASE REPORTSCase IA 24-year-old Coloured female was admitted on 14 February1954 at the 28th week of ge talion. She had one full-time nomlaldelivery in 1952 with a bad tear which was stitched by her doctor.Soon after the present conception she noticed a protru ion at theintroitus which gradually grew bigger and at 16 week her doctorinserted a pessary, which failed to improve matters (Fig. I). For3 months she experienced great difficulty with micturition. Shehad to push up the prolapse to initiate and complete the act,and she also complained of frequency and dysuria.The patient was a healthy young woman with the fundus at 24weeks. The cervix and part of the uterus were prolap ed outsidethe vagina; there was no cervical ulceration. The perineum wasdeficient. The urine contained numerou pu cells.The patient was confined to bed and the prolapse repeatedlyreduced. After 3 weeks she was allowed up. The blood-urea levelhad been 31 mg. % and the severe urinary infection re pondedonly to chJoromycetin therapy. Six weeks after admission shewas sent to a convalescent home for 4 weeks, from where shewas readmitted at 38 weeks. At 41 weeks she was delivered of a7 lb. 12 oz. infant after a normal18-hour labour. The puerperiumwas uneventful.Five months after delivery she was readmitted complainingof 'something coming down', dyspareunia and stress incontinence.On examination a large cystocele, prolapse of the second degree,a large annular cervical erosion and a deficient perineum werefound. A Manchester repair with buttressing of the bladderbase was performed successfully. The histological examinationof the cervix indicated chronic cervicitis. She was not seen again.Case 2A 28-year-old Coloured female presented on 24 October 1956with sudden inability to urinate. She had had 3 normal fUll-termdeliveries and was then 12 weeks pregnant. On examinationher bladder was found to be distended to the umbilicus, thecongested cervix protuded just beyond the vulva, and the pro-lapsed uterus was incarcerate(j. Catheterization was performedwith some difficulty. The patient was then instructed to lie face-down with the foot of the bed raised and within a few hours theuterus lifted to the normal position. She was allowen up aftera few days and discharged after a week. She also was not seenagain.Case 3A 28-year-old Coloured female, who had had a normal full-termdelivery previously, was admitted on 5 March 1954, 5 hoursafter a normal full-time delivery, complaining of 'somethingwhich dropped out after the delivery'. Examination revealed aprolapsed postpartum uterus (Fig. 2). Both the patient and themid\vife stated that the prolapse occurred after delivery of theplacenta. The uterine prolapse was reduced and the patientdischarged. Two months later she was quite well and there wasno sign of any genital prolapse.SUMMARY1. The rare condition of prolapse of the cervix and uterusin pregnancy is described, with a review of the literature.o previous comprehensive report in the literature could betraced.2. Three case records are presented. The first is the recordof a typical case; the second case presented with urinaryFig. 2. Case 3.obstruction, and the third with postpartum prolap e, whichhas not been described before.SAMEVATIl 'G1. Die seldsame toestand van prolaps van die cervix enuterus met swangerskap word beskryf-vir die eer te keersover va gestel kon word. 'n Oor ig van die literatuur oor dieonderwerp word verskaf.2. Drie gevallestudies word aangeteken; die eerste i 'ntipiese geval, die tweede toon versperring van die urinewee,en die derde is 'n ge al met postpartum prolaps wat, soverbekend, nog nie vantevore beskryf is rue.My thanks are due to Prof. lames T. Louw for his advice andconstructive criticism, and to Dr. . H. G. Cloete, MedicalSuperintendent of the Groote Schuur Hospital, for permissionto publish.REFERENCES1. Conant, M. D. et al. (l957): Amer. J. ObsteL Gynec., 73, 914.2. Stabler, F. (1955): British Gynaecological Practice, p. 311. London: Heine-mann.3. Keettel, W. C. (1941): Amer. J. Obstet. Gynec., 42, 121.4. Kibel, 1. (t944): Ibid., 47, 703.5. Vigilante, M. and Bellinger, F. R. (I956): Ohstet. and Gynec., 8,284.6. Morgan, R. G. and Keeve~ . C. (1945): Brit. Med. l., 2, 649.7. Gaetone, J. and Labriola, F. (1956): Ohstet. and Gynec., 8, 278.8. Stander, H. J. (I94t): Text-book of Obstetrics, pp. 653 and 881. Londonand New York: Appleton Century.9. Findlay. P. (1911): J. Amer. Med. Assoc., 57, 2131.10. Klawans. A. H. and Kantor, A. E. (1949): Ibid., 57,939.BRUCELLOSIS I KRUGERSDORP, WITH A REVIEW OF THE PROBLEM 1SOUTHER AFRICAJOHN SAVILLE LEWIS, M.B., Ch.B., D.P.H. (CAPE To ,), Medical Officer ofHeallh, Port Elizabeth*'Brucellosis is a disease of mi takes. If we do not think of itwe miss it, or we may think of it and test for it, yet findnothing. It eludes us. evertheless, as a cause of pyrexia of* Formerly Medical Officer of Health, Kruger dorp.undetermined origin it i important, an ob cure headache,la situde, abdominal pain or arthriti may be due to itssmouldering activity.'lDr. Wallis's apt de cription of a baffling disease i illustrated

Prolapse of the uterus in pregnancy

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Prolapse of the uterus in pregnancy

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