Download The management of urogynaecological problems in pregnancy and

DOI: 10.1111/j.1744-4667.2012.00111.x
2012;14:153–158
Review
The Obstetrician & Gynaecologist
http://onlinetog.org
The management of urogynaecological problems in
pregnancy and the early postpartum period
Fida Asali
MSc MRCOG,
a
Ismaiel Mahfouz
MSc MRCOG,
b
Christian Phillips
DM MRCOG
c,
*
a
Assistant Professor in Obstetrics and Gynaecology/Consultant Obstetrician and Gynaecologist, Faculty of Medicine, The Hashemite University, PO
Box 150459, Zarqa 13115, Jordan
b
Consultant Obstetrician and Gynaecologist, Jordan Healthcare Centre, Amman, Jordan
c
Consultant Obstetrician and Gynaecologist, Hampshire Hospitals NHS Foundation Trust, Basingstoke and North Hampshire Hospital,
Aldermaston Road, Basingstoke, Hants RG24 9NA, UK
*Correspondence: Christian Phillips. Email: [email protected]
Key content
Lower urinary tract infection is associated with increased maternal
and fetal morbidity.
There is an association between pelvic organ prolapse and
increasing parity and vaginal deliveries.
Lower urinary tract dysfunction and pelvic organ prolapse are
common during pregnancy and the postpartum period, but often
resolve.
Special consideration is needed regarding the management of
lower urinary tract dysfunction and pelvic organ prolapse during
pregnancy and the postpartum period, with an emphasis on
conservative management.
To understand the epidemiology and management of lower
urinary tract dysfunction in pregnancy.
To be aware of the epidemiology and management of pelvic organ
prolapse in pregnancy.
Ethical issues
Should pregnant women be prescribed antimuscarinic drugs when
adverse effects on the fetus have been shown in animal studies?
Should women who have not completed their families be offered
surgery for pelvic organ prolapse?
Should elective caesarean section be offered to women who have
had previous successful incontinence surgery?
Learning objectives
To know how to manage lower urinary tract infection in
pregnancy.
Keywords overactive bladder symptoms / pelvic organ prolapse /
urinary tract infection / urinary incontinence
Please cite this paper as: Asali F, Mahfouz I, Phillips C. The management of urogynaecological problems in pregnancy and the early postpartum period. The
Obstetrician & Gynaecologist 2012;14:153–158.
Introduction
significant potential morbidity for both mother and baby,
including:3
Various urogynaecological problems can occur during
pregnancy and the postpartum period. This review
addresses the effects and management of the more
common ones, which include lower urinary tract infection
and dysfunction, and pelvic organ prolapse.
Lower urinary tract infection
Urinary tract infection (UTI) is the most common medical
complication of pregnancy.1 The incidence of asymptomatic
bacteruria during pregnancy is 2–5%1 and if not treated, up
to 20% of women will develop a lower UTI. The overall
incidence of UTI in pregnancy is 8%.2 The increased
susceptibility to UTI is thought to be due to various
physiological changes, which include changes in bladder
volume, decreased bladder tone and ureteric dilatation,
all of which lead to the development of urinary stasis.3
Urinary tract infection during pregnancy can cause
ª 2012 Royal College of Obstetricians and Gynaecologists
chorioamnionitis
endometritis
fetal growth restriction
stillbirth
preterm labour and delivery
increased perinatal mortality
mental retardation
developmental delay.
In light of this, early recognition and treatment can reduce
maternal and fetal morbidity. A Cochrane review4 has shown
that antibiotic treatment is effective at curing UTI, but there
are insufficient data with which to recommend any specific
treatment regimen or duration.
The risk of recurrent UTI in pregnancy is around 4–5%.
Long-term, low-dose antimicrobial cover and single-dose
antimicrobial cover in intercourse-related UTI may be
considered as prophylactic measures.5
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Urogynaecological management in pregnancy and early postpartum period
Lower urinary tract dysfunction
Epidemiology
Urinary incontinence is defined as the complaint of any
involuntary leakage of urine.6 During pregnancy the
prevalence varies between 32% and 64% and is higher in
parous than in nulliparous women.7 The prevalence is low in
the first trimester but rises rapidly during the second and
third trimesters.8 In a 6-year longitudinal study, MacArthur
et al.9 showed that the prevalence of persistent urinary
incontinence postpartum was 24%.
Stress urinary incontinence (SUI) is the involuntary
leakage of urine on exertion, sneezing or coughing.6 It is
common during pregnancy, but it generally resolves in the
postpartum period.10
Overactive bladder syndrome (OAB) is defined as urgency
with or without urge incontinence, usually with frequency and
nocturia.6 The incidence of OAB symptoms in pregnancy is up
to 18%11 and symptoms appear to increase with greater
gestation but decrease rapidly after childbirth. While dry OAB
(without urinary incontinence) has no negative effect on
quality of life, wet OAB (with urinary incontinence)
compromises quality of life both during and after pregnancy.11
Brown et al.12 showed that stress and mixed urinary
incontinence are more common during pregnancy than urge
urinary incontinence alone, the incidence of which is 5.9%. A
population study showed that urinary incontinence is
associated with increasing age, first pregnancy and
increasing parity.13
Pathophysiology and aetiology
The exact pathophysiology of lower urinary tract dysfunction
during pregnancy is not clear. It has been suggested that high
levels of relaxin, an increased glomerular filtration rate,
increased urinary bladder neck mobility, the gravid uterus and
altered connective tissue composition may all play a role.14
Vaginal delivery has been thought to cause postpartum SUI15.
There is an association between parity, delivery and the
development of SUI15. Several reports show an increased risk
of SUI following vaginal delivery compared with caesarean
section;15 however, caesarean section appears to be only
partially protective against the development of SUI 6 years
after delivery.9 The development of SUI after vaginal delivery is
thought to be a consequence of muscular and neuromuscular
injuries of the pelvic floor as well as damage to the suburethral
fascia.16 Damage to the levator ani has been well documented
following vaginal delivery and is thought to be associated with
the subsequent development of lower urinary tract symptoms.17
While urodynamic studies are commonly used in the
investigation of lower urinary tract symptoms in nonpregnant women, there are differences in the study
parameters between the pregnant and non-pregnant
population. Pregnancy is associated with lower first sensation
154
and strong desire to void, and a decrease in the maximum
cystometric capacity. In light of this, urodynamic studies are
not considered reliable at assessing bladder function in
pregnancy, and are of more interest in the research setting.18
Management of stress urinary incontinence
Management in pregnancy and the early postpartum period
is mainly conservative and includes lifestyle interventions,
physical therapies and the use of anti-incontinence devices,
pads and catheters: these are considered to have a low risk of
adverse effects and do not affect subsequent treatments.
There is evidence that pelvic floor muscle training during a
first pregnancy reduces the likelihood of postnatal urinary
incontinence. The National Institute for Health and Clinical
Excellence guideline on the management of urinary
incontinence in women19 recommends that pelvic floor
muscle training is offered to women in their first pregnancy
as a preventive strategy. Furthermore, the 4th International
Consultation on Incontinence7 showed that continent
pregnant nulliparous women who participated in intensive
supervised pelvic floor muscle training were less likely to
experience urinary incontinence in late pregnancy and the
early postpartum period. Pelvic floor muscle training should
also be offered as first-line therapy to women with persistent
urinary incontinence 3 months after delivery.20
Poor response to pelvic floor muscle training in the early
postpartum period may be caused by neurogenic injury,
which may resolve over time. Allen et al.21 showed that there
is evidence of nerve damage in over 80% of women after
vaginal delivery. This may take several months to recover and
may interfere with women’s ability to isolate and contract the
pelvic floor muscles in the early postpartum period.
Continence pessaries are used in the management of SUI and
can be considered as an alternative to other conservative
treatment.22 They are believed to increase urethral resistance by
augmenting urethral closure during episodes of increased intraabdominal pressure.23 Their effectiveness in non-pregnant
women has been described in several studies, most of which had
small samples with short-term follow-up.24 While there are no
reports on their effectiveness in the management of SUI in
pregnant women, they are used both during pregnancy and in
the postpartum period. They may be offered to women who do
not respond well to pelvic floor muscle training.
Pregnancy, childbirth and continence surgery
Once they have exhausted conservative treatments, some
women may want further intervention for treating their SUI.
The role of surgery for SUI in women who wish further
pregnancies is a difficult and ethically challenging dilemma.
In those women who have not yet completed their family
there are several factors that should be considered. The first is
the effect of pregnancy and childbirth on previous continence
surgery. There are data to suggest that, after a continence
ª 2012 Royal College of Obstetricians and Gynaecologists
Asali et al.
procedure, delivery by caesarean section may have a
protective effect25,26. It has been shown that the rate of
postpartum continence in women who have had previous
bladder neck suspension or midurethral sling is higher after
caesarean section than after vaginal delivery.25,26 There is
emerging evidence, however, (although only in the form of
case reports) that vaginal delivery may not increase the risk of
recurrence of SUI when compared with caesarean section.27
Secondly, women should also be counselled about the
success rates of primary, secondary and tertiary procedures
for incontinence. Data taken from women in the nonpregnant population suggest a significant reduction in
success rates with an increasing number of procedures. The
efficacy of colposuspension is 81% after the first procedure,
25% after the second and 0% after three colposuspensions.28
The results are similar for midurethral tapes in women with a
previous failed continence procedure.29
Women should be counselled that pregnancy and delivery
may have a deleterious effect on the outcome of previous
surgery and that elective caesarean section may be only partially
protective. MacArthur et al.9 found that delivery exclusively by
caesarean section was associated with less persistent urinary
incontinence compared with those delivered by caesarean
section in addition to vaginal delivery; however, the prevalence
of persistent symptoms is still high (14%).
Periurethral bladder neck injection with bulking agents is a
useful option for short-term symptomatic relief of SUI30 and
would be a suitable option for women who are yet to
complete their families, as this does not appear to affect
subsequent surgery such as a retropubic sling. Groenen
et al.31 proposed a management strategy for women with SUI
who still want to conceive or for women who want to become
pregnant after previous incontinence surgery (see Box 1).
However, any decision about surgery should be made in
conjunction with the woman after careful consideration of
the pros and cons of surgical intervention.
Box 1. A proposed management strategy for women
with stress urinary incontinence who want to conceive
or who want to become pregnant after previous
incontinence surgery
Advise women to try to complete their family before incontinence
surgery.
If a woman becomes pregnant after incontinence surgery,
institute conservative treatment.
If the woman is continent after previous incontinence surgery,
caesarean section should be considered; however, if the
continence procedure has not been successful, vaginal delivery
may be suggested.
If incontinence recurs or persists postpartum, await spontaneous
recovery for at least 6 months to 1 year.
A repeat midurethral sling procedure, if necessary, is the most
likely to be safe and effective.
ª 2012 Royal College of Obstetricians and Gynaecologists
Management of overactive bladder symptoms
There appears to be little evidence available on the treatment
of OAB symptoms in pregnancy; neither are there any studies
that assess the effect of bladder and pelvic floor muscle
training. The mainstay of treatment is conservative and
includes lifestyle modifications, fluid manipulation, avoiding
caffeine, bladder and pelvic floor muscle training, and
alternative therapies such as acupuncture. The use of
antimuscarinics during pregnancy and breastfeeding is
recommended only when the medication is of clear benefit
to the mother. A MEDLINE search did not reveal any studies
on the use of antimuscarinics during pregnancy. However,
the US Food and Drug Administration have listed
antimuscarinics as either:
category B drugs: animal reproduction studies have failed
to demonstrate a risk to the fetus and there are no
adequate and well-controlled studies in pregnant women
OR animal studies have shown an adverse effect, but
adequate and well-controlled studies in pregnant women
have failed to demonstrate a risk to the fetus in any
trimester
OR:
category C drugs: animal reproduction studies have shown
an adverse effect on the fetus and there are no adequate
and well-controlled studies in humans, but potential
benefits may warrant use of the drug in pregnant women
despite potential risks.
Pelvic organ prolapse
Background
The severity of pelvic organ prolapse (POP) as measured
by the Pelvic Organ Prolapse Quantification (POP-Q)
staging system appears to increase during pregnancy in
nulliparous women. However, the stage does not change
significantly postpartum. The POP-Q stage may be higher
in women delivered vaginally than in women delivered
by caesarean section, with the most frequent site of
prolapse being the anterior compartment.32 Prospective
quantification of POP showed that postpartum 52% of
nulliparous women had stage 2 prolapse, 37% had
developed a prolapse in a new compartment and 15%
had developed a more severe degree of prolapse compared
with antenatal examinations.33
Pathophysiology and aetiology
Mant et al.34 showed that age, parity and weight were
significantly associated with increased risk of developing
prolapse, but parity was shown to have the strongest
relationship. The pelvic organs are supported by three
mechanisms:
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Urogynaecological management in pregnancy and early postpartum period
the pelvic floor musculature and its intact nerve supply
the integrity of the connective tissue of the suspensory
ligaments and endopelvic fascia
the posterior angulation of the vagina.
Damage to any of these during pregnancy or parturition
can predispose to POP later in life.35 Hormonal changes
during pregnancy are thought to alter the quality of
connective tissue. Progesterone relaxes smooth muscle and
relaxin plays a role in connective tissue remodelling, allowing
tissue stretching, which may be irreversible if tissues are
stretched beyond their physiological limits. This can be seen
in vitro by measuring the biomechanical properties of
collagen within connective tissues, which have been shown
to be altered in pregnancy.36
Direct myogenic injury as well as denervation of the nerves
supplying the muscles of the pelvic floor occurs during
pregnancy, especially during vaginal delivery.37 Evidence of
this can also be seen clinically on ultrasound of the pelvic
musculature in the postpartum period. This has shown
avulsion of the levator ani from their attachments in onethird of women after vaginal birth.38 Furthermore, women
with levator avulsion defects were found to be twice as likely
to show POP than women without.39
Management of pelvic organ prolapse during
pregnancy and postpartum
As parity and childbirth are important factors in the
causation of POP, women should be advised to complete
their families before considering surgical treatment.
The mainstay of treatment for symptomatic POP during
pregnancy and the postpartum period is conservative. There
is little evidence in the literature on the management of
prolapse in pregnancy and the majority of treatment
rationales have been extrapolated from the results of
studies on conservative management of SUI. The aim of
treatment is to improve symptoms. Conservative treatment
includes lifestyle interventions such as:
stopping smoking
reducing exacerbating predisposing factors, including
heavy lifting and chronic coughing
treating constipation
pelvic floor muscle training
using vaginal pessaries.
Vaginal rings and pessaries can be offered as a conservative
treatment option for women with symptomatic POP during
pregnancy and in the postpartum. The aim is to manage POP
by mechanically supporting the pelvic viscera. They can be
changed without risk to mother or fetus. Modern pessaries
are made from a variety of materials, including rubber,
plastic and silicone. While there are no studies about the use
of rings and pessaries during pregnancy and the postpartum,
156
there is good evidence that they provide symptomatic relief
and may prevent worsening of POP in the non-pregnant
population; this evidence has been adopted for use in
pregnancy.40
If women have surgery for POP and they then fall
pregnant, it is important to advise them about the effect of
any future pregnancy and delivery on their previous surgery.
Because of the paucity of data on this subject, the advice
given to women is anecdotal. However, it seems logical to
advise women who have had POP surgery to have supervised
pelvic floor muscle training as soon as possible in pregnancy.
Mode of delivery is contentious. A discussion about the risks
of vaginal delivery and caesarean section is essential and
should include the risks of pregnancy and delivery on the
potential development of further prolapse. A clinician will
usually offer elective caesarean section to women with
previous successfully repaired POP, should they become
pregnant and if their prolapse does not deteriorate during
pregnancy, because of the uncertainty of the effect of vaginal
delivery on the development of de novo prolapse. This is,
again, a difficult decision and should be made in conjunction
with the woman once she has carefully considered the
implications of surgery.
Fertility-preserving pelvic organ prolapse surgery
A minority of women with symptomatic prolapse may wish
to have surgery but retain their fertility: these women
should initially be offered conservative management. If
conservative measures fail, surgery can then be considered.
The aims of surgery are to improve symptoms and restore
anatomy and function while preserving future fertility.
A variety of uterine-preserving surgical operations for
symptomatic POP have been described, using a vaginal,
abdominal or laparoscopic approach. Uterosacral
suspension/plication, sacrospinous uterosacral fixation and
sacrohysteropexy – either open or laparoscopic – are among
the most common procedures. There are limited data
regarding the effects of surgery on fertility, delivery and the
durability of these procedures after pregnancy and delivery. A
review41 shows that laparoscopic or open hysteropexy seems
to be a safe procedure, with cure rates ranging from 91–100%
at 3 month to 5 year follow-up. However, reports on
pregnancy and delivery following hysteropexy are mostly in
the form of case reports and series. Two case series of around
60 women42,43 in total reported four cases of term deliveries,
all by caesarean section, and one early pregnancy loss. There
are no reports of vaginal delivery after hysteropexy.
Summary
Lower urinary tract symptoms are common during
pregnancy and the postpartum period.
ª 2012 Royal College of Obstetricians and Gynaecologists
Asali et al.
Effective diagnosis and treatment of UTI during pregnancy
reduces the risks of maternal and fetal complications,
including prematurity and increased maternal morbidity
and perinatal mortality.
Urinary incontinence is common during pregnancy:
treatment is usually conservative.
Women who are yet to complete their families or who
have undergone a previous continence procedure and are
contemplating pregnancy should be counselled regarding
the effects of pregnancy and childbirth on the durability of
the procedure. Caesarean delivery may be protective.
The effect of pregnancy and childbirth on previous POP
surgery is not known, although it is believed to increase the
risk of recurrence.
Women presenting with symptomatic POP who have not
completed their family should be encouraged to try
conservative treatments until their family is complete.
Careful consideration should be made regarding surgery
for prolapse or incontinence prior to pregnancy and
careful counselling is needed regarding the subsequent
mode of delivery and the likelihood of recurrence.
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ª 2012 Royal College of Obstetricians and Gynaecologists