A prolapsed uterus is a condition where the uterus descends into the vagina due to weakened pelvic floor muscles and damaged connective tissue. This can range from mild cases where the uterus droops slightly, to severe cases where the entire uterus protrudes out of the vaginal opening.
For women who want to get pregnant, a prolapsed uterus can raise concerns about whether conception and carrying a pregnancy to term will be possible. The good news is that in many cases, getting pregnant with a prolapsed uterus is certainly possible, especially when the prolapse is mild. However, precautions need to be taken to have a healthy pregnancy and delivery.
What is Uterine Prolapse?
The uterus is normally held in place by various ligaments and muscles of the pelvic floor. Uterine prolapse occurs when these supportive structures weaken and no longer provide enough support, allowing the uterus to sink down into the vagina.
There are different types of uterine prolapse:
- Cystocele: The bladder bulges into the front vaginal wall. This is the most common type of pelvic organ prolapse.
- Rectocele: The rectum bulges into the back vaginal wall.
- Uterine prolapse: The uterus itself descends into the vagina. This is categorized into mild, moderate, and severe prolapse depending on how far it descends.
- Vaginal vault prolapse: The top of the vagina loses support after a hysterectomy.
Uterine prolapse often happens along with cystocele, rectocele, or both. The main symptom is a feeling of pelvic pressure or something protruding from the vagina. Other symptoms can include lower back pain, painful intercourse, urinary issues, and difficulty with bowel movements.
What Causes Uterine Prolapse?
There are several factors that can contribute to uterine prolapse:
- Pregnancy and childbirth: The strain of carrying a pregnancy and vaginal delivery can overstretch and damage the pelvic floor. This is the top cause of prolapse in younger women.
- Menopause: Loss of estrogen leads to weaker pelvic tissues. This affects older women most often.
- Hysterectomy: Removing the uterus eliminates its support, increasing prolapse risk.
- Obesity: Extra weight and pressure on the pelvis strains supportive tissues.
- Smoking: Chronic coughing can weaken pelvic muscles.
- Heavy lifting: Regular heavy lifting adds pressure to pelvic structures.
- Connective tissue disorders: Conditions like Ehlers-Danlos syndrome impair tissue strength.
- Prior pelvic surgery: Cutting pelvic ligaments during surgery can cause prolapse later on.
- Family history: Genetics can make women prone to prolapse.
Can You Get Pregnant if You Have a Prolapsed Uterus?
The good news is yes, you can absolutely still get pregnant with a prolapsed uterus in many cases. However, the ease of getting pregnant and risks during pregnancy and delivery depend on the severity of the prolapse.
Mild Uterine Prolapse
With mild uterine prolapse where the uterus droops only slightly into the vagina, getting pregnant is often not too difficult. The prolapsed uterus does not directly block the fallopian tubes or interfere with conception.
One study found that women with untreated mild pelvic organ prolapse had similar fertility rates as the general population. However, they did have slightly elevated risks of infertility, miscarriage, and preterm birth compared to women without prolapse.
Overall, mild prolapse generally does not require surgery or drastic measures before getting pregnant. Trying to conceive naturally for 6-12 months is reasonable. If pregnancy does not happen after that time, further evaluation and treatment can be considered before resorting to invasive options like IVF.
Moderate Uterine Prolapse
When the uterus prolapses partway into the vagina, it can sometimes obstruct the cervix or make intercourse difficult. However, pregnancy is still possible in many cases.
One study looked at 61 women with moderate pelvic organ prolapse who got pregnant without any prior prolapse surgery. About half conceived naturally while the other half used fertility treatments like intrauterine insemination. They found an overall pregnancy rate of 77% which is quite favorable.
However, women with untreated moderate prolapse do have higher risks of issues like infertility, preterm delivery, and malpresentation during pregnancy compared to mild cases. Trying to conceive naturally for 3-6 months is reasonable, but earlier surgical intervention may be beneficial before resorting to extensive fertility treatments.
Severe Uterine Prolapse
With severe prolapse where the entire uterus protrudes out of the vaginal opening, getting pregnant can be much more challenging. The protruding uterus can obstruct the cervix and make intercourse extremely difficult or impossible.
In severe cases, surgery is usually recommended before attempting pregnancy. Trying to conceive before surgery often results in frustration and failure. Studies have found pregnancy rates close to zero in women with severe pelvic organ prolapse that was not surgically corrected first.
The good news is that today there are excellent surgical options that can reconstruct the anatomy and support the uterus, making pregnancy possible again for many women.
Surgical Options to Repair Prolapse Before Pregnancy
For moderate to severe uterine prolapse, surgery is often needed to repair the anatomy and provide support before pregnancy can successfully occur. There are two main approaches:
Vaginal Surgery
Many types of vaginal surgery can be performed to lift up and resuspend a prolapsed uterus or rebuild the pelvic floor:
- Sacrospinous ligament fixation: Stitches attach the cervix or vaginal vault to the sacrospinous ligament.
- Uterosacral ligament suspension: The ligaments are strengthened to lift the uterus.
- Anterior/posterior repair: Stitches repair the bladder or rectum.
- Mesh augmentation: Mesh reinforces weakened vaginal tissue.
The benefits of vaginal surgery include shorter recovery times and no abdominal incisions. However, the first vaginal delivery after prolapse surgery poses risks of recurrence. Still, 60-80% of women successfully deliver vaginally after vaginal prolapse repairs.
Abdominal Surgery
Abdominal procedures like Sacro hysteropexy can also be used to treat uterine prolapse:
- The uterus is lifted back into place and stitched to the sacrum to hold it up.
- Mesh or sutures can also attach the uterus to the ligaments for support.
Abdominal surgery has a longer recovery but may provide more durable results than vaginal surgery alone. Most studies show around a 70-80% vaginal delivery success rate after abdominal prolapse repairs.
When choosing surgery, the patient’s desire for pregnancy is a major factor. Younger women wanting children will benefit most from uterine-sparing procedures that reconstruct anatomy and allow for pregnancy.
Can You Deliver Vaginally After Prolapse Surgery?
Many women who become pregnant after prolapse surgery wonder if they will be able to deliver vaginally or if cesarean section is necessary.
The short answer is that in many cases, vaginal delivery is possible after surgical correction of pelvic organ prolapse. However, the risk of recurrence is lifelong, and precautions must be taken.
According to ACOG, 60-80% of women can successfully deliver vaginally after either transvaginal or abdominal prolapse repair procedures. However, 20-40% will experience some recurrence of prolapse symptoms after delivery.
Factors that increase the chances of successful vaginal delivery after prolapse surgery include:
- Mild to moderate prolapse (not severe)
- No mesh used in prior repairs
- Sacrospinous ligament fixation or uterosacral ligament suspension procedures
- No prior recurrence of prolapse after surgery
- Avoiding any unneeded episiotomies during delivery
- Use of a pessary during pregnancy to support repaired anatomy
- Careful monitoring of prolapse symptoms throughout pregnancy
- Allowing 6 months after surgery before conceiving to maximize healing
- Pelvic floor physical therapy during and after pregnancy
Even with these optimizing factors, prolapse recurrence risk can never be eliminated fully. But with careful management, most women can deliver vaginally after prolapse surgery. Close monitoring by an experienced maternal-fetal medicine specialist and possible use of a pessary during delivery are recommended.
What Are the Risks of Getting Pregnant with a Prolapsed Uterus?
For women wishing to get pregnant with uterine prolapse, either untreated or after surgical correction, some increased risks need to be considered:
Issues with Conception and Early Pregnancy
- Reduced fertility: Moderate to severe prolapse can impact fertility, requiring surgery or fertility treatments.
- Increased miscarriage risk: Prolapse is linked to higher miscarriage rates.
- Malpresentation: The uterus may not align properly for implantation.
Risks During Pregnancy
- Preterm labor and birth: Prolapse increases risks for early delivery.
- Fetal malpresentation: The baby may not get into optimal birthing position.
- Placental complications: Issues like placenta previa and abruption occur more often.
- Pessary discomfort: Pessaries may require adjustment or removal during pregnancy.
Risks During Labor and Delivery
- Obstructed labor: The prolapsed uterus may block the birth canal.
- Uterine rupture: Prior uterine surgery raises rupture risks.
- Excessive bleeding: Abnormal placentation and poor uterine contraction can cause hemorrhage.
- Need for operative delivery: Forceps, vacuum or cesarean delivery may be required.
- Recurrent prolapse: Prolapse often worsens after delivery.
Optimizing Pregnancy Outcomes with a Prolapsed Uterus
While risks may be increased, there are many ways to optimize pregnancy outcomes with a prolapsed uterus:
- Achieve full surgical repair of prolapse before pregnancy when needed
- Use a vaginal pessary during pregnancy to support the uterus
- Screen for cervical incompetence and consider preventive cerclage
- Monitor for malpresentation later in pregnancy and try techniques to turn the baby
- Have a birthing plan in place accounting for prolapse issues
- Consider elective cesarean for severe prolapse or high-risk situations
- Use preventive incision closure techniques to reduce prolapse worsening
- Follow up quickly after delivery for evaluation and management of recurrent prolapse
The key is close monitoring and care from specialists in maternal-fetal medicine and pelvic reconstruction throughout pregnancy and postpartum.
Vaginal Pessaries for Prolapse Support During Pregnancy
Vaginal pessaries are one of the most helpful tools for supporting pelvic organ prolapse during pregnancy. A pessary is a removable silicone device inserted into the vagina to hold up the uterus and bladder.
Benefits of pessary use during pregnancy include:
- Provides mechanical support to lift the uterus
- Helps prevent worsening prolapse symptoms
- Can reduce urinary leakage and discomfort
- Allows a vaginal delivery in some cases
- Avoids risks of additional prolapse surgery during pregnancy
- Is removable if complications develop
Studies have found up to a 78% success rate for vaginal delivery with a pessary in place after prior prolapse surgery. If prolapse symptoms worsen, the pessary can be removed during pregnancy and replaced after delivery.
Pessaries require ongoing monitoring and maintenance during pregnancy. Some women cannot tolerate them. But when successful, they can be a simple way to support normal vaginal delivery.
Physical Therapy for Prolapse During and After Pregnancy
Pelvic floor physical therapy is an important component of prolapse prevention and treatment before, during, and after pregnancy. Benefits include:
- Strengthens pelvic floor muscles to better support organs
- Improves symptoms like incontinence and discomfort
- Reduces pressure on pelvic organs
- Promotes healing after delivery
- Helps prevent recurrent prolapse after surgery
- Allows safe return to exercise after pregnancy
With a prolapsed uterus, a prenatal physical therapy program should focus on:
- Kegel exercises to improve pelvic floor contraction
- Biofeedback training to isolate proper muscles
- Postural training to reduce pressure on pelvic organs
- Manual techniques to improve pelvic alignment and muscle function
After delivery, pelvic floor rehabilitation helps strengthen overstretched tissues. Continued therapy and exercise helps support the pelvis long-term.
Physical therapy offers a drug-free and nonsurgical option to help manage prolapse during and after pregnancy. It is an important piece of the treatment plan.
Caring for Prolapse After Pregnancy and Delivery
After giving birth vaginally with uterine prolapse, it is common for prolapse symptoms to worsen temporarily. Using these tips can help manage prolapse after pregnancy:
- Ice packs can help reduce swelling and discomfort.
- Sitz baths keep the perineal area clean to prevent infection.
- Pain relievers ease postpartum soreness.
- Always push prolapsed tissues back in place gently.