Repeated pregnancy in a woman with uterine prolapse from a rural area in Nepal.
Article Type: Case study
Subject: Pregnancy (Development and progression)
Pregnancy (Care and treatment)
Pregnancy (Case studies)
Uterus (Prolapse)
Uterus (Care and treatment)
Uterus (Case studies)
Author: Pantha, Sandesh
Pub Date: 05/01/2011
Publication: Name: Reproductive Health Matters Publisher: Elsevier Science Publishers Audience: General Format: Magazine/Journal Subject: Family and marriage; Health; Women's issues/gender studies Copyright: COPYRIGHT 2011 Reproductive Health Matters ISSN: 0968-8080
Issue: Date: May, 2011 Source Volume: 19 Source Issue: 37
Geographic: Geographic Scope: Nepal Geographic Code: 9NEPA Nepal
Accession Number: 259077087
Full Text: Abstract: Pelvic organ prolapse is common in rural women in Nepal. Pregnancy in a woman with pelvic organ prolapse is uncommon and rarely continues beyond the second trimester If it proceeds after that, the uterus usually ascends with progression of pregnancy and becomes abdominal, leaving little trace of prolapse. Pregnancy continuing to term with uterine prolapse is very rare. The case reported here is of a pregnant woman from a remote district in Nepal who had nine pregnancies and at 38 weeks of pregnancy presented at the district hospital with severe uterine prolapse, a large cervical ulcer and the baby's foot protruding from the cervix. Air transport was the only means of reaching the nearest hospital with emergency obstetric care, 200km away. The baby was delivered stillborn at the airport by the auxiliary nurse-midwife who accompanied her Her husband was counselled for and had a vasectomy. The woman was fitted with a ring pessary but could not afford to go to the nearest town for surgery for the prolapse. People in remote areas of Nepal often seek medical advice very late. This and the lack of education, low utilisation of family planning services, and lack of skilled birth attendance and safe delivery centres at local level contribute to high maternal morbidity and mortality.

Keywords: maternal morbidity, uterine prolapse, stillbirth, emergency obstetric care, Nepal

Resume

Le prolapsus est frequent chez les Nepalaises rurales. La grossesse chez une femme avec prolapsus est inhahituelle et se poursuit rarement apres le deuxieme trimestre. Si elle continue au-dela, l'uterus s'eleve avec la progression de la grossesse et devient abdominal, laissant peu de traces du prolapsus. Il est tres rare qu'une grossesse arrive a terme en cas de prolapsus genital. Le cas decrit ici concerne une femme enceinte dans un district isole qui a eu neuf grossesses et s'est presentee a 38 semaines a l'hopital du district avec un prolapsus genital severe, un large ulcere genital et le pied du bebe depassant du col de l'uterus. Un transport aerien etait le seul moyen d'atteindre l'hopital le plus proche dispensant des soins obstetricaux d'urgence, a 200 kilometres de la. La sage-femme infirmiere auxiliaire qui accompagnait la mere a accouche le bebe mort-ne a l'aeroport. Le mari a ete vu en consultation et a subi une vasectomie. On a pose un pessaire a la femme, mais elle n'avait pas les moyens de se rendre a la ville la plus proche pour s'y faire operer du prolapsus. Les habitants des zones isolees du Nepal consultent souvent tres tard les medecins. Ce phenomene ainsi que le manque d'instruction, le faible recours aux services de planification familiale, le manque d'assistance qualifiee a l'accouchement et l'absence de centres de maternite sans risque au niveau local contribuent a un taux eleve de morbidite et mortalite maternelles.

Resumen

En Nepal, el prolapso dei organo pelvico es comun en mujeres rurales. El embarazo en una mujer con prolapso del organo pelvico no es comun y rara vez continua mas alla del segundo trimestre. Si continua, el utero generalmente asciende con la evolucion dei embarazo y se vuelve abdominal, dejando poco rastro del prolapso. Muy rara vez el embarazo continua a termino cuando hay prolapso uterino. Aqui se presenta el caso de una mujer embarazada, de un distrito remoto, quien tuvo nueve embarazos y a las 38 semanas dei embarazo acudio ai hospital distrital con prolapso uterino severo, una ulcera cervical grande y el pie del bebe salido dei cervix. Transporte aereo fue el unico medio de llegar al hospital mas cercano, a 200 km de distancia, para recibir cuidados obstetricos de emergencia. La enfermera auxiliar-partera profesional que la acompanaba la ayudo en un parto de mortinato en el aeropuerto. El esposo de la mujer tuvo una vasectomia tras recibir consejeria ai respecto. A la mujer le colocaron un pesario vaginal, pero ella no tenia los recursos financieros para ir ai pueblo mas cercano y someterse a una cirugia para el prolapso. Las personas en zonas remotas de Nepal a menudo buscan asesoria medica muy tarde. Esto aunado a la falta de educacion, el uso infrecuente de servicios de planificacion familiar y la falta de asistencia de parto calificada y centros de parto seguros a nivel local, contribuyen a las altas tasas de morbilidad y mortalidad maternas.

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Pelvic organ prolapse is common in women in rural areas in Nepal. (1) Early marriage, early pregnancy, (2) unassisted home delivery, lack of health facilities, unwillingness to seek health care during pregnancy and childbirth due to various religious and social taboos, are the major contributory factors. (1) In addition, improper hygiene, unbalanced and non-nutritious diet and lack of proper rest during the puerperium make the condition worse. (1) Although the median age at marriage for women in Nepal is 18 years, uneducated women are often married by the age of 16. (3) Soon after marriage, they conceive, and most of them do not attend a health facility for regular antenatal care or delivery. (4,5)

Pregnancy with uterine prolapse is rare. (6,7) Even if pregnancy occurs, the increase in the size of the developing fetus pushes the prolapsed uterus back into the abdominal cavity. While there have been a few reported cases of complete or partial uterovaginal prolapse in the second trimester of pregnancy, (8) it is rarely seen after the fourth month of gestation. (6) Fewer than 250 cases of pregnancy with uterine prolapse have been reported. Those reported were mostly up to the early third trimester. (7) I have found none which continued to full terra reported in the literature.

While working as a medical officer in the Jumla district hospital in a rural area of Nepal, I attended a woman whose case is reported here, who presented at terra pregnancy with uterovaginal prolapse in which the baby's foot was protruding, along with a huge pressure sore in the anterior lip of the cervix.

Situation at presentation

The woman was 36 years old, from a remote area in Jumla District. She came to the district hospital in November 2008 at 38 weeks of gestation in labour pain, which had started 28 hours back. Two hours after it commenced, her membranes ruptured. One leg of the baby then came out. They waited at home for 12 more hours. As labour did not progress further, she was carried to the district hospital; a distance of 14 hours walk. History revealed that she had not had regular antenatal check-ups. She had also not taken iron supplementation or had tetanus immunisation during pregnancy.

She was of moderate build and at arrival, her vitals were stable. Fetal heart beat was absent. Contractions were mild but regular. On inspection of the vagina there was a huge uterovaginal prolapse with decubitus ulcer on the cervix measuring 7 x 1 centimetres and a prolapsed foot (Figure 1).

Obstetric history

Married at 14 years of age, she was only 15 when she delivered her first child. She had had nine previous pregnancies, of which the first five resulted in four live births and one miscarriage (Table 1). After the fifth pregnancy, a uterine prolapse appeared six days post-partum. Initially it was reducible but after three years it became irreducible. She became pregnant four more times with uterine prolapse before the pregnancy reported here, all of which ended in miscarriage in the first trimester or adverse fetal outcome, either stillbirth or neonatal death. She and her husband had not adopted any family planning method. Despite having these problems, she had never sought any medical help.

[FIGURE 1 OMITTED]

Management

As it was late at night when she arrived, all laboratory facilities in the hospital were closed till the morning. We could not even find out her blood group. We continued with conservative management and supported her with intravenous fluids and antibiotics. We decided not to undertake any intervention at that point bur to wait and refer her to the nearest centre with comprehensive obstetric care facilities--Bheri Zonal Hospital at Nepalgunj, which is about 200 km south of the district. The only means of transport there is by air, and for that too we had to wait, as the flights would only commence again in the morning.

Next morning, we sent her to the airport with an auxiliary nurse-midwife, who was asked to stay with her until she boarded the plane. In the interim, with the nurse-midwife's assistance, she delivered a stillborn baby of 3.2 kg in the airport while waiting to board the plane. She was brought back to the hospital and admitted for treatment of the decubitus ulcer.

She underwent dressing daily for 10 days and was discharged on the tenth day. She was treated with antibiotic, metronidazole and a combination of amoxicillin with clavulenic acid, in the hospital. Before discharge, her husband was counselled for sterilisation and vasectomy was performed.

Discussion

This is an extremely rare case. In her obstetric history, there were multiple pregnancies, complications of labour, lack of delivery by a skilled attendant, lack of adequate rest during the puerperium, and lack of nutritious food, all major contributing causes of uterine prolapse. (1,4,5,8) Had she had adequate rest, antenatal care and delivery at a health centre, maternal morbidity and mortality could have been reduced and the chance of a good fetal outcome increased. (7)

Jumla is one of the most remote areas of Nepal and is lagging far behind in education and living standards compared to other districts. In Jumla, while 85% of pregnant women attend one antenatal visit, only 45% attend four rimes, as recommended by the World Health Organization. In addition, only 7.5% of births are attended by a skilled birth attendant. (9)

Early marriage and early childbearing are the leading causes of uterine prolapse in our society. (3-6) Patriarchal norms pressure women to have male children, and go through repeated pregnancies to do so. This results in multiple pregnancies without sufficient child spacing. (10)

I remained at the district hospital Jumla until April 2010. The woman had not received any further treatment for the uterine prolapse except for a ring pessary up to that rime. Although I personally invited her to attend the district hospital during a uterine prolapse surgery camp, there were no such camps between November 2008 and March 2010. There is no record of whether she attended one after that. She could not afford to go to the nearest town for surgery for the prolapse.

People in remote areas of Nepal tend to seek medical advice at a very late stage, which is one of the leading reasons for higher morbidity and mortality. Lack of education, low utilisation of family planning services, and lack of skilled birth attendants and safe delivery centres at grassroots level have also contributed to this problem. A multisectoral approach by the Government and non-governmental organisations will be essential to ensure availability and use of safe delivery and family planning services.

References

(1.) Sah DK, Doshi NR, Das CR. Vaginal hysterectomy for pelvic organ prolapse in Nepal. Kathmandu University Medical Journal 2010;8(2):281-84.

(2.) Bonetti TR, Erpelding A, Pathak LR, et al. Listening to "felt needs": investigating genital prolapse in Western Nepal. Reproductive Health Matters 2004;12(23):166-75.

(3.) Choe MK, Thapa S, Mishra V. Early marriage and early motherhood in Nepal. Biological Science 2005;37:143-62.

(4.) Fraser AM, Rockert JEB, Ward RH. Association of young maternal age with adverse reproductive outcomes. New England Journal of Medicine 1995;332(17):1113-17.

(5.) Mawajedh SM, Al-Qutob RJ, Farag AM. Prevalence and risk factors of genital

prolapse. Saudi Medical Journal 2003;24(2):161-65.

(6.) Daskalakis G, Lymberopoulos E, Anastasakis E, et al. Uterine prolapse complicating pregnancy, Archives of Gynecology & Obstetrics 2007;276:391-92.

(7.) Brown HL. Cervical prolapse complicating pregnancy. National Medical Association 1997;89:346-48.

(8.) Piver MS, Sepzia J. Uterine prolapse during pregnancy. Obstetrics and Gynaecology 1968;32(6):765-69.

(9.) Rawal LB, Tiwari SK, Devkota BS, et al. Women's educational status and maternal and child health care practices in Jumla district of West Nepal. Nepal Health Research Council 2004;2(21:19-22.

(10.) Karki YB. Sex preference and value of sons and daughters in Nepal. Studies in Family Planning 1988;19(3):169-78.

Sandesh Pantha

First-year resident, MD General Practice; National Academy of Medical Sciences, Kathmandu, Nepal. E-mail: sanducmc@yahoo.com
Table 1. Obstetric history of the patient

Year     Age   Outcome          Remarks

1988     15    Liveborn boy     Normal vaginal delivery
                                at home

1990     17    Liveborn boy     Normal vaginal delivery
                                at home

1991     18    Liveborn girl    Normal vaginal delivery
                                at home

1992     19    1st trimester    Heavy bleeding from
               miscarriage      vagina for 10 days

1996     23    Liveborn girl    Prolapse appeared on
                                6th day post-partum
2001     28    1st trimester    Husband was in India
               miscarriage      during this time

2003     30    2nd trimester
               miscarriage

2005     32    2nd trimester
               miscarriage

2007     34    1st trimester
               miscarriage

2008     36    Stillbirth       Husband had a vasectomy
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