Effects of Uterine Prolapse on Cervix: Childbirth Trauma

copy of an article which states childbirth trauma to be a primary cause:

Cervical Prolapse During Pregnancy
from Journal of the American Board of Family Practice

Discussion
The main support of the uterus and vaginal vault is the Mackenrodt ligament, also known as the cardinal ligament.[9] It forms a firm attachment from the supravaginal cervix to the tough obturator fascia on the side wall of the pelvis. Failure of these supportive ligaments leads to prolapse of the uterus and vaginal vault. Three factors lead to failure of the supportive ligaments and fasciae:[9] childbirth trauma, congenital and developmental weakness, and the influence of menopause. Childbirth trauma is likely the cause of most reported cases of cervical prolapse complicating pregnancy. The gradual decrease in parity in the United States within the last several decades probably accounts for the recent low incidence of such occurrences.[10] Cervical prolapse in nulliparous pregnant patients is likely to be secondary to congenital or developmental weakness of supportive fascia.[3] Uterine prolapse in nonpregnant women is most common, however, in those who are past their child-bearing years, particularly during and after menopause. In addition, obesity, large pelvic inlet, and a history of difficult deliveries or large babies can predispose an otherwise supported uterus to fall through the introitus.[1]

Prolapse of the cervix during pregnancy might not be entirely secondary to simple uterine prolapse. Hypertrophic elongation of the cervix is also likely to contribute.[6] As the pregnancy progresses through the fourth and fifth months, the uterus ascends out of the pelvis and the protruding cervix and prolapsed vaginal wall typically recede.

The association of cervical prolapse with pregnancy and abdominoplasty has not been well studied because of the rarity of such an occurrence. It is known that flaccidity of abdominal musculoaponeurotic tissues increases with subsequent pregnancies.[11] Expert opinion suggests that abdominal relaxation and pelvic relaxation coexist, and by surgically repairing the former with abdominoplasty, the pelvic outlet could become the weakest area and the point through which increased abdominal pressure will transmit.[12] Increased age and multiparity can further weaken the pelvic floor and predispose to cervical prolapse.

The treatment of cervical prolapse during pregnancy has ranged considerably, particularly in earlier times. Chinese native doctors saturated the protruding cervix with kerosene oil and set fire to it.[13] In 1911 Findley[13] recommended interruption of the pregnancy followed by plastic repair. Pessary placement was recommended as early as 1901.[14] From 1920 to 1945 the most common method of delivery was with forceps after Dührssen incisions. In 1968, however, Piver and Spezia[8] reported a spontaneous delivery rate of 84.8%, a considerable improvement from Keettel's reported 34.7%.[4] Management options have not varied much in recent years. The key to successful treatment is early recognition with conservative management. Slight Trendelenburg position with bed rest and replacement of the uterus after resolution of edema will often protect the cervix from trauma and desiccation and decrease the incidence of preterm labor.[1] Keeping the cervix moist is of great importance. Prophylactic antibiotics are not indicated.[1] Placement of a well-fitting Smith-Hodge or doughnut pessary will often allow the patient to continue with the pregnancy without difficulty.[7] Most patients will have spontaneous vaginal deliveries. If a pessary is used during pregnancy, it should be reinserted immediately postpartum to support the fascia and ligaments during involution.[8]

In summary, cervical prolapse predisposes the pregnant patient to many complications she would otherwise not face. The family physician who practices obstetrics should feel comfortable diagnosing and managing pregnancies complicated by cervical prolapse. With early recognition and appropriate conservative intervention, most dangers can be avoided. Obstetric backup should be available should serious complications arise.

Reprint Address
Address reprint requests to Keith Frey, MD, Mayo Thunderbird Family Medicine Center, 13737 North 92nd St, Scottsdale, AZ 85260.

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