The document discusses uterine prolapse during pregnancy. It notes that uterine prolapse occurring for the first time during pregnancy is rare, about 1 in 10,000-15,000 deliveries. Risk factors for uterine prolapse include multiparity, congenital elongation of the cervix, trauma, neurological disorders, and pelvic floor muscle weakness. During pregnancy, prolapse can aggravate anatomical changes and increase risks of complications like abortion, preterm labor, and infection. Management involves techniques like pessary, bed rest, surgery to tighten the introitus, and sometimes termination is needed if repositioning is not possible. During labor, manual techniques and operative delivery may be needed.

2. I n t r o d u c t i o n
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 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.

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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.

4. E t i o l o g y
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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5. E f f e c t s O n P r o l a p s e
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.
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6. 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.
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7. P r o l a p s e & I n f e r t i l i t y
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• Difficulty in intercourse.
• Altered and distorted cervical
anatomy
• Hostile cervical mucus for sperm
entry
• Chronic P.I.D.
• Oedematous & Hypertrophied
cervix

8. E f f e c t s o n p r e g n a n c y
Increased chances of …
• Discomfort & Pelvic pain
• Bleeding
• Abortion
• Preterm labour
• Cervical infection leads to fibrosis
• Chorioamnionitis
• Constipation
• Retention of urine may require catheterization
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9. D u r i n g L a b o u r
Increased chances of …
• Early rupture of membrane
• Cervical dystocia
Secondary arrest around 5 – 6 cm , for
which C.S. is preferred.
• Prolonged labour due to non dilatation of
cervix & obstruction due to sagging cystocele
& rectocele.
• Operative interference
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10. D u r i n g P u e r p e r i u m
• Sub involution
• Uterine sepsis
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11. M a n a g e m e n t
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12. Divided into…
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1. During Pregnancy
2. during labour
3. during Post Partum
period

13. D u r i n g P r e g n a n c y
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.
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14. P e s s a r y
• Various pessaries are available.
• Most suitable ring pessary of proper sized
should be used.
• Before reposition of pessary , must be
cleaned with antiseptic solution.
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15. 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. 15

16. W h e n t h e pelvic f l o o r is
t o o m uch lax…
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• 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.

17. • 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.
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18. A n A l t e r n a t i v e o p t i o n
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All the conventional modalities of Rx
- Bed rest
- Tampons
- Pessary
Causes discomfort , pain , infection ,
dysuria and prolonged bed rest.

19. I n t r o i t a l T i g h t e n i n g
• 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.
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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 .

21. A d v a n t a g e s
• Daycare procedure
• Very simple & safe
• Under local anesth with total duration of 3
– 5 minutes.
• Analgesic & Antibiotic cream for
local application.
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22. D u r i n g L a b o u r
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• 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.

23. • 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.
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24. D u r i n g P u e r p e r i u m
• 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.
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25. • 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
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26. T a k e Home M e s s a g e
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
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27. Müllerian duct anomaly classification
 The American Fertility Society (AFS)
classified muellerian anomalies according to
the major uterine anatomic types. The AFS
classes of muellerian anomalies are:
 Hypoplasia/agenesis
 Unicornuate
 Didelphys
 Bicornuate
 Septate
 Arcuate

28. Classification into 4 groups:
1. Agenesis of uterus/vagina
2-Unilateral development :Unicornate
uterus
3. Lateral Fusion defects (obstructive or
non-obstructive).
4-Defects in Vertical Fusion (obstructive or
non-obstructive)

29. Uterine Anomalies
Absence of Uterus Fusion anomalies

31. Why is this important?
 Majority have no problem conceiving, but
have higher rates of:
– 1. Spontaneous Abortion
– 2. Premature Delivery
– 3. Infertility
– 4. Abnormal Fetal Lie
– 5. Dystocia at delivery
– 6. Dysmenorrhea, endometriosis
– 7. Cervical incompetence

32. Thank you