Medicurio

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Puerperium is defined as the time from the delivery of the placenta through the first few weeks after the delivery. This period is usually considered to be 6 weeks in duration. By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery have resolved and the body has reverted to the nonpregnant state.

Puerperium, the period of adjustment after childbirth during which the mother’s reproductive system returns to its normal prepregnant state. It generally lasts six to eight weeks and ends with the first ovulation and the return of normal menstruation.

Puerperal changes begin almost immediately after delivery, triggered by a sharp drop in the levels of estrogen and progesterone produced by the placenta during pregnancy. The uterus shrinks back to its normal size and resumes its prebirth position by the sixth week. During this process, called involution, the excess muscle mass of the pregnant uterus is reduced, and the lining of the uterus (endometrium) is reestablished, usually by the third week. While the uterus returns to its normal condition, the breasts begin lactation. Colostrum, a high-protein form of milk, is produced by the second day after the birth and is gradually converted to normal breast milk, which has less protein and more fat, by the middle of the second week.

The chief medical problems associated with the puerperium include usually mild, transient depression, resulting from emotional letdown and discomfort associated with puerperal changes; clotting disorders, caused by blood stasis and prevented by an early return to normal activity; bleeding from a retained placenta; and puerperal fever, a major cause of maternal death until the 19th century. A combination of improved sanitary measures and modern antibiotics has now greatly reduced the mortality associated with puerperal fever.

Routine Postpartum Care

The immediate postpartum period most often occurs in the hospital setting, where the majority of women remain for approximately 2 days after a vaginal delivery and 3-4 days after a cesarean delivery. During this time, women are recovering from their delivery and are beginning to care for the newborn. This period is used to make sure the mother is stable and to educate her in the care of her baby (especially the first-time mother). While still in the hospital, the mother is monitored for blood loss, signs of infection, abnormal blood pressure, contraction of the uterus, and ability to void.  There is also attention to Rh compatibility, maternal immunization statuses and breastfeeding.

Vaginal delivery

After a vaginal delivery, most women experience swelling of the perineum and consequent pain. This is intensified if the woman has had an episiotomy or a laceration. Routine care of this area includes ice applied to the perineum to reduce the swelling and to help with pain relief. Conventional treatment is to use ice for the first 24 hours after delivery and then switch to warm sitz baths. However, little evidence supports this method over other methods of postpartum perineum treatment. Pain medications are helpful both systemically as nonsteroidal anti-inflammatory drugs (NSAIDs) or narcotics and as local anesthetic spray to the perineum.

Hemorrhoids are another postpartum issue likely to affect women who have vaginal deliveries. Symptomatic relief is the best treatment during this immediate postpartum period because hemorrhoids often resolve as the perineum recovers. This can be achieved by the use of corticosteroid creams, witch hazel compresses, and local anesthetics in addition to a bowel regimen that avoids constipation.

Tampon use can be resumed when the patient is comfortable inserting the tampon and can maintain it without discomfort. This often takes longer for the woman who has had an episiotomy or a laceration than for one who has not. The vagina and perineum should first be fully healed, which takes several weeks. Tampons must be changed frequently to prevent infection.

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Cesarean delivery

The woman who has had a cesarean delivery understandably will experience post-op pain at the abdominal incision. This, too, can be treated with heat or ice to the incision site, abdominal binder support, and use of systemic pain medication. Activities of daily living should be resumed as tolerated but without unnecessary delay.

Sexual intercourse

Sexual intercourse may resume when bright red bleeding ceases, the vagina and vulva are healed, and the woman is physically comfortable and emotionally ready. Physical readiness varies greatly among women but may take several weeks. Birth control is important to protect against pregnancy because the first ovulation is very unpredictable.

Patient education

Substantial education takes place during the hospital stay, especially for the first-time mother. The mother (and often the father) is taught routine care of the baby, including feeding, diapering, and bathing, as well as what can be expected from the baby in terms of sleep, urination, bowel movements, and eating.

Discharge instructions

The new mother should be given discharge instructions and expectations/precautions to consider once leaving the hospital. The most important information is who and where to call if she has problems or questions. She also needs details about resuming her normal activity. Instructions vary, depending on whether the mother has had a vaginal or a cesarean delivery and any comorbidities that may have been part of her care.

A systemic review of ovulation and menses in nonlactating women found that although most women begin ovulation at least 6 weeks postpartum, with mean day of first ovulation occurring 45-94 days postpartum, a limited number ovulate sooner. Two studies reporting earliest day of first ovulation reported it occurring on days 25 and 27 postpartum, emphasizing the need for early postpartum contraception discussion and method initiation to decrease the risk of pregnancy soon after delivery.

Many options are available, as follows:

• Natural methods can be used in highly motivated couples, to include the use of monitoring the basal body temperature and the quality and quantity of the cervical mucus to determine what phase of the menstrual cycle the woman is in and if it is safe to have intercourse.
• Barrier methods of contraception, such as condoms, are widely available, as are vaginal spermicides. Condoms are available over-the-counter, while diaphragms and cervical caps must be fitted.
• Hormonal methods of contraception are numerous. Combined estrogen-progestin agents are taken daily by mouth or monthly by injection. Progestin-only agents are available for daily intake or by long-acting injections that are effective for 12 weeks.
• Intrauterine devices can be placed immediately post partum (after delivery of the placenta) or after uterine involution occurs typically 4-6 weeks after delivery. Immediate postpartum insertion is associated with an increased risk of expulsion, approximately 24%. Immediate insertion is contraindicated in those with any postpartum infection including peripartum chorioamnionitis, endometritis or puerperal sepsis.
• Permanent methods of birth control (ie, tubal ligation, vasectomy) are options for those who are certain they do not desire more children.

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Liver disease that occurs during pregnancy can present a challenge for healthcare providers. Certain liver diseases are uniquely associated with pregnancy, whereas others are unrelated. The liver diseases unique to pregnancy include hyperemesis gravidarum, acute fatty liver of pregnancy (AFLP), intrahepatic cholestasis of pregnancy (ICP), and hemolysis and elevated liver enzymes and low platelets (HELLP) syndrome. Liver disease such as acute viral hepatitis can occur in pregnancy, and pregnancy may occur in a patient with underlying chronic liver disease, including patients with cirrhosis and portal hypertension, and patients who have undergone liver transplantation.

In the initial evaluation of a pregnant patient with abnormal liver tests, the American College of Gastroenterology (ACG) recommends these women undergo the same standard workup as that of nonpregnant individuals. With regard to imaging studies and/or endoscopy in pregnant women, the ACG has the following recommendations :

• Ultrasonography is safe and the preferred imaging modality for the assessment of abnormal liver studies suggestive of biliary tract disease.
• Magnetic resonance imaging (MRI) with gadolinium can be used in the second and third trimester.
• Computed tomography (CT) scans carry a risk of teratogenesis and childhood hematologic malignancies but may be used judiciously with minimized radiation protocols (2-5 rads).
• Endoscopy is safe in pregnancy but should be deferred until the second trimester if possible.
• Meperidine and propofol can be used for endoscopic sedation.

Laboratory Value	Expected Trend in Pregnancy
Albumin	Decrease
Alkaline phosphatase	Increase
ALT	No expected change/slight decrease
AST	No expected change/slight decrease
Bilirubin	No expected change/slight decrease
Bile acid	No expected change
GGT	No expected change/slight decrease
Platelets	No expected change
Prothrombin time	No expected change

Modality	Pregnancy Considerations	Lactation Considerations	Other Issues
Ultrasound	Acceptable modality	Acceptable modality	No available data on contrasted ultrasound in pregnancy and lactation
CT	Risk of ionizing radiation exposure to fetus during pregnancy	Acceptable modality	Greatest risk of radiation exposure is at 8 to 15 weeks of gestation
Oral and iodinated contrast not teratogenic
Less than 1% of iodinated contrast is excreted in breast milk
MRI	Acceptable modality when performed without contrast	Acceptable modality with and without contrast	Gadolinium is associated with teratogenicity; crosses the placenta and is found in amniotic fluid and fetal circulation. Less than 0.04% is excreted into breast milk
Liver biopsy	Can be performed in pregnancy	Acceptable modality	Limited data on preterm births seen when performed during pregnancy
Transjugular liver biopsy confers radiation exposure
Transient elastography	Not approved by the FDA for use in pregnancy	Not contraindicated in lactation	–
Endoscopy	Upper endoscopy is acceptable in pregnancy and typically recommended to occur in the second trimester	Acceptable modality with consideration of compatibility of sedating medications with lactation	Ensure proper informed consent with discussion about fetal risks
Consideration of compatibility of sedating medications with pregnancy		Ensure adequate oxygenation and hemodynamic stability during procedure
Ensure left lateral decubitus position to avoid IVC compression

Liver Diseases That Are Unique to Pregnancy

Hyperemesis Gravidarum

Hyperemesis gravidarum (HG) is seen earlier than other liver diseases that are unique to pregnancy, typically presenting in the first trimester and resolving by the twentieth week of gestation. Occurring in about 0.3% to 2% of pregnancies, HG presents as intractable nausea and vomiting with subsequent dehydration, weight loss, electrolyte imbalance, and nutritional deficiency. Liver involvement is seen in 50% to 60% of patients with HG. Biochemical changes include elevations in aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels, which are typically mildly elevated but have been observed to rise to as high as 1,000 in some patients with HG. Jaundice is rare, occurring more commonly in severe cases of HG. The etiology of elevated liver enzymes in HG is unclear but has been proposed to involve liver cell injury due to multiple factors, including dehydration, starvation, and placental‐derived cytokines, including tumor necrosis factor alpha. It is noted that liver enzyme levels return to normal levels after resolution of HG, and thus there are no long‐term sequelae of HG on liver‐related health.

HG treatment involves administration of intravenous fluid, antiemetic therapy, and vitamin and mineral supplementation. Thiamine and folic acid supplementation are particularly emphasized, and metoclopramide, promethazine, and ondansetron are anti‐emetic therapies that are considered as compatible with pregnancy. Dietary modification should focus on consumption of small, frequent, low‐fat meals with high carbohydrate content. Enteral or parenteral nutrition can be cautiously considered in severe HG cases.

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Hypertensive Disorders of Pregnancy

Hypertensive disorders of pregnancy that involve the liver include preeclampsia/eclampsia and the HELLP syndrome. Preeclampsia is seen in about 3% to 5% of pregnancies, and it is defined by the presence of new onset hypertension with a systolic blood pressure of ≥140 mm Hg and a diastolic blood pressure of ≥90 mm Hg measured on at least two occasions that are 4 to 6 hours apart and proteinuria of greater than 300 mg/day. Eclampsia occurs in about 1.4% of pregnancies; it is defined by the development of generalized seizures during preeclampsia. HELLP syndrome occurs in 0.2% to 0.6% of pregnancies and complicates 10% to 20% of cases of preelampsia/eclampsia. Whereas preeclampsia is typically described as occurring after the twentieth week of gestation, HELLP syndrome is predominantly considered as occurring in the third trimester between weeks 28 and 36 of gestation. In 30% of cases, HELLP syndrome presents in the early postpartum period.

HELLP syndrome has been viewed as representing one presentation on a spectrum of clinical manifestations of preeclampsia/eclampsia. Other manifestations of preeclampsia can involve hypertension in the absence of proteinuria, and in this clinical scenario, the presence of end‐organ injury in the setting of gestational hypertension can help to define preeclampsia. Due to the dilemma of distinguishing HELLP syndrome along the spectrum of preeclampsia/eclampsia, two diagnostic criteria for HELLP syndrome have been established. The Tennessee Classification categorizes HELLP syndrome as complete HELLP syndrome or partial HELLP syndrome, and the Mississippi Triple Class System divides HELLP syndrome into three classesBoth of these classification systems define subtypes of HELLP based on the severity of observed thrombocytopenia, liver enzyme elevations, and hemolysis.

HELLP Class	Mississippi Classification	Tennessee Classification
Class 1 (severe)	AST or ALT ≥70 IU/L	AST ≥70 IU/L
LDH ≥600 IU/L	LDH ≥600 IU/L or bilirubin ≥1.2 mg/dL
Platelet count ≤50 × 109/L
Class 2 (moderate)	AST or ALT ≥70 IU/L	N/A
LDH ≥600 IU/L
Platelet count 50‐100 × 109/L
Class 3 (mild)	AST or ALT ≥40 IU/L	N/A
LDH ≥600 IU/L
Platelet count 100‐150 × 109/L
Partial HELLP syndrome	Presence of severe preeclampsia plus one of the following: ELLP, EL, HEL, LP

Acute Fatty Liver of Pregnancy

Acute fatty liver of pregnancy (AFLP) is a rare disorder that occurs in about 1:7,000 to 1:15,000 pregnancies. Typically occurring in the third trimester, it involves maternal microvesicular fat deposition in the liver that leads to hepatic decompensation with potential for hepatic failure. Maternal mortality is 10% to 15%, and fetal mortality is up to 20%.

It is thought that AFLP is caused by inherited deficiencies of enzymes that are involved in the mitochondrial metabolism of fetal fatty acids. Impairment in fatty acid oxidation in the fetus and placenta can lead to increases in the levels of intermediate products of metabolism that accumulate in the placenta and maternal blood, leading to maternal hepatotoxicity. The most investigated fatty acid oxidation defect that is thought to contribute to AFLP is a deficiency in long chain 3‐hydroxyacyl‐coenzyme A‐dehydrogenase (LCHAD), which is a part of the mitochondrial trifunctional protein (MTP). G1528C and E474Q mutations of MTP are thought to be the cause of LCHAD deficiency and development of AFLP.

Class	Feature*
Clinical features	Vomiting
	Abdominal pain
	Polydispsia/polyuria
	Encephalopathy
Laboratory features	Elevated bilirubin (>14 μmol/L)
	Hypoglycemia (<4 mmol/L)
	Elevated urea (>340 μmol/L)
	Leukocytosis (>11 × 109/L)
	Elevated transaminases (>42 IU/L)
	Elevated ammonia (>47 μmol/L)
	Elevated creatinine (>150 μmol/L)
	Coagulopathy (prothrombin time >14 seconds or activated partial thromboplastin time >34 seconds)
Radiographic features	Ascites or bright‐appearing liver on ultrasound
Histologic features	Microvesicular steatosis on liver biopsy

Intrahepatic Cholestasis of Pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is the most common pregnancy‐related liver disease. Typically presenting in the second or third trimester of pregnancy, the prevalence of ICP is 0.1% to 2%. Epidemiologic data have indicated that it occurs with higher prevalence in South American and Scandinavian countries, and additional risk factors for it include advanced maternal age, multiparity, and a previous history of cholestasis with oral contraceptive use. The classic symptom of ICP is pruritus, but epigastric pain, fatigue, anorexia, and jaundice have also been observed. The typical laboratory finding in ICP is an elevation in bile acid levels. AST and ALT levels range from normal levels to 10 times to 20 times normal.

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Pregnancy leads to physiologic changes in renal and systemic hemodynamics that cause important alterations in acid-base, electrolyte, and kidney function.

Understanding these changes is essential when evaluating pregnant women with kidney disease.

Disorders that cause acute kidney injury in early or late pregnancy generally fall into very different categories. It must also be remembered that pregnancies in women with underlying chronic kidney disease who require dialysis during pregnancy or who have previously undergone kidney transplantation pose unique sets of issues.

Ideally, women with kidney disease or systemic diseases that would put them at risk during pregnancy should receive preconception counseling from physicians knowledgeable about the current literature related to pregnancy. The team of physicians who care for these patients is often led by an experienced specialist in high-risk, maternal-fetal obstetrics working with a nephrologist and/or others. Successful maternal and fetal outcomes for women with preexisting kidney disease, and those with onset of kidney disease during pregnancy, require a close working relationship among all physicians involved in the care of these patients.

Overview of Acute Kidney Injury in Pregnancy

Acute kidney injury (AKI) is not common in pregnancy, and kidney injury requiring dialysis is very rare in pregnancy. Data from Canada reported an  incidence of pregnancy-related AKI of 2.68 per 10,000 deliveries. AKI requiring dialysis in pregnancy or postpartum occur in 1 per 10,000 pregnant women, but it is associated with increased mortality.It is therefore important that clinicians who are asked to care for patients with this unusual complication be aware that while an acute reduction in GFR may result from any of the causes seen in the non-gravid state, a number of disorders are specific to pregnancy.

Pregnancy-specific kidney disorders generally can be organized into those occurring in early pregnancy and those occurring in late pregnancy. Disorders arising in early pregnancy include the following:

• Prerenal azotemia
• Acute tubular necrosis
• Renal cortical necrosis
• Pyelonephritis
• Thrombotic thrombocytopenic purpura

Disorders arising in late pregnancy, almost all of which are usually specific to pregnancy, include the following:

• Preeclampsia
• Acute fatty liver of pregnancy
• Hemolytic-uremic syndrome

The following conditions should also be considered in evaluating acute kidney injury in pregnancy:

• Obstructive uropathy
• Nephrolithiasis
• Antiphospholipid syndrome

Obstructive uropathy should be considered in the setting of moderate or severe dilatation of the collecting system in women with oliguria or anuria. The most likely causes are the gravid uterus, polyhydramnios, kidney stones, and enlarged uterine fibroids. Obstructive uropathy usually resolves with delivery, although ureteral stenting may be required preterm.

In pregnancy, 1,25 di-hydroxycholecaliferol (vitamin D) levels are elevated due to increased production by the kidneys and placenta, resulting in hypercalciuria. This results in an increased risk of nephrolithiasis along with an increased risk of urinary tract infection. Ultrasonography is the primary diagnostic imaging modality used, and ureteral stenting may be necessary if the stones cannot be passed.

Women with anticardiolipin antibodies and the lupus anticoagulant are at risk of fetal loss and worsening renal function. All pregnant women with lupus should be screened for antiphospholipid antibodies and anti-Ro/SSA and anti-La/SSB antibodies. Treatment with low-dose aspirin or heparin should be considered but depends on the antibody levels, the risk of pre-eclampsia,and any previous obstetric history of early fetal loss and/or thrombosis.

Kidney Injury in Early Pregnancy

While prerenal azotemia can be caused by any cause of volume depletion during pregnancy, one of the more important causes is hyperemesis gravidarum. Hyperemesis gravidarum can be diagnosed by the history of persistent vomiting and is typically associated with metabolic alkalosis. Treatment consists of antiemetic therapy and volume replacement with intravenous normal saline and often potassium. Less commonly, hemorrhage associated with spontaneous abortion can also result in prerenal azotemia.

Acute tubular necrosis (ATN) in the first trimester is most likely to be caused by hemorrhage from spontaneous abortion or shock secondary to septic abortion. Septic abortion is most commonly due to gram-negative sepsis, primarily Escherichia coli, although in some cases, Clostridium perfringens is responsible, which can cause myonecrosis of the uterus and myoglobinuria. ATN due to these conditions is often more severe and more likely to require temporary dialysis until renal function recovers. ATN can also be caused by other causes seen in the non-gravid state, or by severe volume depletion from hyperemesis gravidarum.

The diagnosis of ATN should be suspected in the setting of septic abortion, and the diagnosis can be confirmed by urinalysis showing granular casts and urinary indices with an elevated fractional excretion of sodium. Treatment includes fluid resuscitation and pressors for hypotension; antibiotics; and, if necessary, dialysis.

Renal cortical necrosis (RCN) is a rare cause of severe AKI.  RCN is more likely to be a cause of AKI in developing countries but even there, the incidence is falling. ^[9]  Post-abortal sepsis is a common cause of RCN in developing countries, while abruptio placentae is responsible for RCN in 50%-60% of cases in pregnancy in developed countries. Other obstetric causes of RCN include puerperal sepsis, eclampsia, obstetric hemorrhage, intrauterine death, and thrombotic microangiopathy of pregnancy. Primary disseminated intravascular coagulation in the setting of severe renal ischemia is the most likely initiating event.

Postpartum Kidney Injury

Currently, most cases of AKI occur in the postpartum rather than the postabortal period, reflecting a decline in septic abortions and improvements in prenatal care.  Postpartum AKI, TTP, and HUS represent overlapping syndromes that have in common severe hypertension, microangiopathic hemolytic anemia, thrombocytopenia, and AKI.

Patients with postpartum AKI usually present days to weeks following a normal delivery, with severe hypertension, hemolytic anemia, thrombocytopenia, and kidney failure. This disorder may also be related to retained placental fragments. HUS may be difficult to differentiate from severe preeclampsia or HELLP syndrome and may require postpartum kidney biopsy for diagnosis.

Kidney biopsy in HUS demonstrates glomerular thrombi and fibrin deposition, and fibrinoid necrosis of arterioles. When HUS is suspected, treatment should be initiated with plasma exchange or plasmapheresis. The value of corticosteroid therapy for HUS remains unclear.

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Pregnancy and underlying kidney disease

In general, patients with chronic kidney disease (CKD) have reduced fertility. Only about 1.5% of women on long-term dialysis become pregnant. However, fertility improves significantly following kidney transplantation.

Historically, pregnancy has been regarded as posing very high risk to women with underlying kidney disease. However, the risk depends on the degree of kidney disease, the underlying disorder, and associated complications such as hypertension and proteinuria. It can therefore be difficult to predict the outcome in an individual patient.

Management of Kidney Disease in Pregnancy

Pregnant patients with kidney disease are often under the care of a maternal-fetal specialist who has advanced training in high-risk obstetrics. These patients receive frequent obstetric follow-up that includes careful blood pressure monitoring, renal function testing, and 24-hour urine protein collections. Consultation with a nephrologist often occurs, particularly for patients with more advanced disease and those with progressive renal failure.

Almost all patients with significant kidney disease and/or hypertension in late pregnancy, or when the likelihood of fetal viability is very high, are delivered and then can be managed as non-gravid patients. If progressive renal failure occurs either in early pregnancy or before fetal viability can be assured, however, dialysis may need to be considered.

Significant changes in dialysis care are required when managing a pregnant woman on hemodialysis. Nephrological management involves the intensification of dialysis dose, management of electrolytes, volume status, anemia, and bone care. Obstetric care concentrated on optimization and surveillance of fetal well-being and growth.

Dialysis should be initiated when the serum creatinine level is 3.5-5.0 mg/dL or the GFR is below 20 mL/min. Fetal outcome is improved with longer, more frequent hemodialysis sessions, which usually involves 20 hours of dialysis per week. Daily dialysis is more likely to prevent hypotension and significant metabolic shifts.

Dialysis should aim to keep BUN levels below 50 mg/dL, because controlling uremia may avoid polyhydramnios, control hypertension, and improve the mother’s nutritional status. Peritoneal dialysis with smaller volumes and frequent exchanges can also be done to achieve these same goals.

Anemia should be treated with erythropoietin-stimulating agents and careful attention to iron therapy. Nutritional support that allows weight gains of 0.3 to 0.5 kg/wk should be maintained in the second and third trimesters.

Pregnancy in patients receiving dialysis

Although fertility is significantly impaired in women with end-stage renal disease, pregnancy may still occur. Most women on dialysis are anovulatory, with either irregular or no menses, which can result in significant delays in the diagnosis of pregnancy in those who do conceive. In addition, the spontaneous abortion rate for pregnant women who require dialysis is approximately 50%. For pregnancies that continue, however, the fetal survival rate is as high as 71%.

Pregnancy in women with kidney transplants

Pregnancy in women following kidney transplantation has become commonplace. Transplantation restores fertility, and although most women with kidney transplants can deliver successfully, there is a higher risk of miscarriage, therapeutic abortion, stillbirth, ectopic pregnancy, preterm birth, low birthweight babies, and neonatal death.

Recommendations regarding health status for pregnancy in kidney transplant recipients include the following :

• Good general health for 2 years post-transplantation, with serum creatinine levels below 2.0 mg/dL (preferably < 1.5 mg/dL)
• No recent acute rejection or ongoing rejection
• Normotension, or hypertension controlled with minimal antihypertensive agents
• No or minimal proteinuria
• No evidence of pelvicaliceal dilatation on renal ultrasonogram

Recommended immunosuppression in kidney transplant recipients includes the following:

• Prednisone – Less than 15 mg per day (mg/d)
• Azathioprine – 2 mg/kg/d or less
• Calcineurin inhibitor–based therapy at appropriate therapeutic levels
• Breast-feeding on cyclosporine is not recommended; tacrolimus may be taken during breast-feeding, though monitoring of infant levels is recommended.
• Mycophenolate mofetil and sirolimus should be discontinued for 6 weeks prior to conception
• If necessary, methylprednisolone is the preferred agent for treatment of rejection should it occur during pregnancy

The following are complication risks in kidney transplant recipients:

• Immunosuppressive agents increase the risk of hypertension during pregnancy
• Preeclampsia occurs in approximately one third of kidney transplant recipients
• Almost 50% of pregnancies in these women end in preterm delivery due to hypertension
• Blood levels of calcineurin inhibitors need to be frequently monitored due to changes in volumes of distribution of extracellular volume
• There is an increased risk of cytomegalovirus, toxoplasmosis, and herpes infections, which raise concern for the fetus

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Life has lots of transitions — from infant to toddler, and youth to adult. For some, another transition is considering when to start a family.

Later in life, your transition may be to end fertility when you’re done growing your family.

If your next life transition involves birth control, you have some important choices to make. Depending on your stage of life, you may be considering either temporary or permanent birth control. Visit with your health care clinician or an OBGYN specialist about the best options for you.

Temporary Birth Control

Your options include:

• Rhythm method — This involves not using birth control and avoiding sex during fertile times of the month.
• Hormonal methods — Includes the pill, vaginal ring or a hormone patch. They mimic natural hormones in a woman’s body. They prevent ovulation and change the uterus and cervix so fertilization is much less likely to happen.
• Barrier methods — Condoms, a diaphragm, sponge or cervical cap. The barriers stop sperm from reaching the egg.
• Injectable methods — Progestin is injected every three months. Since the hormone dosage is less than other options, some patients prefer it. This method prevents conception similarly to other hormonal methods.

You may prefer a long-acting reversible contraceptive (LARC). These methods can last for three to 10 years. LARCs include:

• Intrauterine devices — A T-shaped device is inserted into the uterus. The devices keep sperm from reaching the egg. There are two types of IUDs, hormonal and non-hormonal. Copper, non-hormone containing IUDs last approximately 10 years and hormone containing IUDSs last 3 to 5 years.
• Hormonal implants — A match-stick sized plastic rod is implanted under the skin of the patient’s upper arm. The rod releases a special contraceptive hormone. This delivery system has hormonal results similar to hormonal and injectable methods.

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Permanent Birth Control

Your health care clinician can give you important information about your options for permanent birth control — also known as sterilization. The National Institutes of Health describes three approaches:

• Tubal ligation — During this surgery, the clinician cuts, ties or seals your fallopian tubes. This blocks the egg’s path from your ovaries to the uterus. It also stops sperm from reaching the egg.
• Sterilization implant — This is a nonsurgical way to block your fallopian tubes. A clinician inserts a thin tube through the vagina and into the uterus. A soft, flexible implant is placed in each fallopian tube. During the following three months scar tissue forms around the implants. This scar tissue blocks the fallopian tubes so sperm can’t reach the egg. Temporary birth control is used while the fallopian tube tissue changes.
• Vasectomy — This is an option for permanent male birth control. A surgeon cuts, closes or blocks the vas deferens. This is the duct that carries sperm from the testes to the ejaculatory ducts. Once the duct is blocked, sperm can’t leave the testis. This procedure may not be fully effective for up to three months. Temporary birth control is used during the three months after the procedure.

When considering permanent birth control options, check with your health care clinician. Some health care facilities have policies that limit the permanent birth control options they offer. Tubal ligation and vasectomy may not be available to you.

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A multiple pregnancy is when you are pregnant with twins, triplets or more. Three babies or more is called a ‘higher order’ pregnancy, and it’s rare – occurring in just 1 in 50 multiple pregnancies. Find out more about the different types of multiple pregnancy here.

How do multiple pregnancies occur?

Multiple pregnancies occur when more than one embryo implants in your uterus (womb). This can happen if you release more than one egg during the menstrual cycle and each egg is fertilised by a sperm. Sometimes, a fertilised egg spontaneously splits into 2, resulting in identical embryos.

Multiple pregnancies are more common than they used to be, mainly because of the increasing use of in vitro fertilisation (IVF).

Fertility drugs often cause more than one egg to be released from the ovaries. IVF can result in a multiple pregnancy if more than one fertilised embryo is transferred to the uterus and develops. Sometimes, one of these eggs may split into twins after it is transferred.

Women aged 35 and older are more likely to release more than one egg during ovulation, so they are more likely to have a multiple pregnancy. You are also more likely to have a multiple pregnancy if you have a history of twins in your family.

Diagnosis of multiple pregnancy

Signs you may be expecting multiple babies include:

• You gain weight rapidly at the start of the pregnancy.
• You have severe morning sickness.
• More than one heartbeat is picked up during a prenatal examination.
• The uterus is larger than expected.

A multiple pregnancy is confirmed by an ultrasound scan, usually in the first trimester (the first 12 weeks). The ultrasound will confirm the type of multiple pregnancy, whether there is one placenta or 2, and how many amniotic sacs there are. These are all important factors for later in the pregnancy and it’s important to identify them as early as possible.

If you are carrying multiple babies, you will have to see your doctor more often than women who are expecting one baby. While most multiple pregnancies progress smoothly, there’s a higher chance of the babies being born prematurely, having a low birth weight, or for you to have other complications with your pregnancy.

Types of multiple pregnancy

The most common type of multiples are:

Fraternal twins

Two separate eggs are fertilised and implant in the uterus. The babies are siblings who share the same uterus — they may look similar or different, and may either be the same gender (2 girls or 2 boys) or of different genders. A pregnancy with fraternal twins is statistically the lowest risk of all multiple pregnancies since each baby has its own placenta and amniotic sac. You will sometimes hear fraternal twins referred to as ‘dizygotic’ twins, referring to 2 zygotes (fertilised eggs).

Identical twins

Identical twins are formed when a single fertilised egg is split in half. Each half (embryo) is genetically identical, so the babies share the same DNA. That means the babies will share many characteristics. However, because their appearance is influenced by the environment as well as by genes, sometimes identical twins can look quite different. Identical twins may share the same placenta and amniotic sac, or they may have their own placenta and amniotic sac. You will sometimes hear identical twins referred to as ‘monozygotic’, referring to one zygote (fertilised egg).

Triplets and ‘higher order multiples’ (HOMs)

Triplets, quadruplets, quintuplets, sextuplets or more can be a combination both of identical and fraternal multiples. For example, triplets can be either fraternal (trizygotic), forming from 3 individual eggs that are fertilised and implanted in the uterus; or they can be identical, when one egg divides into 3 embryos; or they can be a combination of both.

If you are having 3 babies or more, you will need a lot of support throughout your pregnancy.

Are identical twins or triplets always the same sex?

Because identical twins or triplets share genetic material, they are always the same sex. The sex of a baby is determined by the particular sperm cell that fertilizes the egg at conception. There are two kinds of sperm cells — those carrying an X chromosome or Y chromosome. The mother’s egg carries an X chromosome. If a sperm cell carrying an X chromosome fertilizes the egg, it will make a XX combination (female). If the sperm cell is carrying a Y chromosome, you end up with an XY pairing (male).

Identical multiples start as one egg and then split, so whatever chromosome combination is present at fertilization is the sex of all multiples.

What increases the chance of a multiple pregnancy?

There are several factors that can increase the risk of a multiple birth. You might be at a higher risk of getting pregnant with more than one baby at a time if you:

• Are older (women in their 30s are at a higher risk of multiples because the body starts to release multiple eggs at one time when you get older).
• Are a twin yourself or have twins in your family.
• Are using fertility drugs.

You might also be at a higher risk of a multiple pregnancy if you are taller than average or have a higher body weight.

Another risk factor for a multiple pregnancy is genetic. There is an increased possibility of a multiple pregnancy if you are a multiple yourself, or if multiples run in your family. This heredity trait is generally passed down through the maternal (mother’s) side of the family.

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The use of fertility drugs can be another reason you might have a multiple birth. Treatments for infertility can increase your risk of a multiple pregnancy because procedures, like in vitro fertilization (IVF), often involve transferring more than one fertilized egg into your womb. Your provider usually transfers more than one egg at a time to increase the odds of a successful pregnancy.

What are the signs of a multiple pregnancy?

The only way to know if you’re pregnant with more than one baby during your pregnancy is through an ultrasound exam with your healthcare provider. During this test, your provider can look at images of the inside of your uterus and confirm how many babies are in there.

You might experience more intense symptoms during a multiple pregnancy than with a single pregnancy. These can include:

• Severe nausea and vomiting (morning sickness).
• Rapid weight gain in the first trimester of pregnancy.
• Sore or very tender breasts.
• High human chorionic gonadotrophin (hCG) levels — this hormone is made during pregnancy and is what a pregnancy test picks up.
• High amounts of the protein alpha-fetoprotein in your blood.

Apart from an ultrasound, your provider might suspect multiples if there’s more than one heartbeat detected during a fetal Doppler scan.

What complications are linked to multiple births?

Anyone can experience complications during pregnancy — regardless of how many babies you’re carrying. However, most healthcare providers consider multiple pregnancies higher risk than single pregnancies. This doesn’t mean that every woman who carries more than one baby during a pregnancy is going to have problems. If you’re pregnant with multiples, your provider will want to watch you for possible complications that can happen when you carry more than one baby at once. Your provider will talk to you about each risk factor and frequently check with you to make sure you aren’t experiencing anything concerning.

Possible complications include:

• Premature labor and birth: The most common complication of multiple births is premature labor. If you’re pregnant for multiples, you are more likely to go into premature labor (before 37 weeks) than a woman carrying only one baby. The goal for many moms of multiples is to complete 37 weeks. This is considered term in a twin pregnancy and reaching this week of gestation increases the chance the babies will be born healthy and at a good weight. Babies that are born prematurely are at risk of another complication of multiple births — low birth weight.
• Preeclampsia or gestational hypertension (high blood pressure): High blood pressure is called hypertension. During pregnancy, your healthcare provider will watch your blood pressure carefully to make sure you don’t develop gestational hypertension (high blood pressure during pregnancy). This can lead to a dangerous condition called preeclampsia. Complications related to high blood pressure happen at twice the rate in women carrying multiples compared to women pregnant with only one baby. This complication also tends to happen earlier in pregnancy and be more severe in multiple pregnancies than single pregnancies.
• Gestational diabetes: You can develop diabetes during pregnancy. This happens because of the increased amount of hormones from the placenta. The size of the placenta can also be a factor in this condition. If you have two placentas, there’s an increased resistance to insulin.
• Placenta abruption: This condition happens when the placenta detaches (separates) from the wall of your uterus before delivery. This is an emergency situation. Placenta abruption is more common in women who are carrying multiples.
• Fetal growth restriction: This condition can also be called intrauterine growth restriction (IUGR) or small for gestational age (SGA). This condition happens when one or more of your babies is not growing at the proper rate. This condition might cause the babies to be born prematurely or at a low birth-weight. Nearly half of pregnancies with more than one baby have this problem.

Fraternal twins always have two placentas. The risks of pregnancies with fraternal twins are similar to those of pregnancies with only one baby. However, the number of possible risks are increased when compared to pregnancies with one baby.

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Pregnancy begins with a fertilized egg. Normally, the fertilized egg attaches to the lining of the uterus. An ectopic pregnancy occurs when a fertilized egg implants and grows outside the main cavity of the uterus.

An ectopic pregnancy most often occurs in a fallopian tube, which carries eggs from the ovaries to the uterus. This type of ectopic pregnancy is called a tubal pregnancy. Sometimes, an ectopic pregnancy occurs in other areas of the body, such as the ovary, abdominal cavity or the lower part of the uterus (cervix), which connects to the vagina.

An ectopic pregnancy can’t proceed normally. The fertilized egg can’t survive, and the growing tissue may cause life-threatening bleeding, if left untreated.

From fertilization to delivery, pregnancy requires a number of steps in a woman’s body. One of these steps is when a fertilized egg travels to the uterus to attach itself. In the case of an ectopic pregnancy, the fertilized egg doesn’t attach to the uterus. Instead, it may attach to the fallopian tube, abdominal cavity, or cervix.

While a pregnancy test may reveal a woman is pregnant, a fertilized egg can’t properly grow anywhere other than the uterus. According to the American Academy of Family Physicians (AAFP), ectopic pregnancies occur in about 1 out of every 50 pregnancies (20 out of 1,000).

An untreated ectopic pregnancy can be a medical emergency. Prompt treatment reduces your risk of complications from the ectopic pregnancy, increases your chances for future, healthy pregnancies, and reduces future health complications.

causes

A tubal pregnancy — the most common type of ectopic pregnancy — happens when a fertilized egg gets stuck on its way to the uterus, often because the fallopian tube is damaged by inflammation or is misshapen. Hormonal imbalances or abnormal development of the fertilized egg also might play a role.

The cause of an ectopic pregnancy isn’t always clear. In some cases, the following conditions have been linked with an ectopic pregnancy:

• inflammation and scarring of the fallopian tubes from a previous medical condition, infection, or surgery
• hormonal factors
• genetic abnormalities
• birth defects
• medical conditions that affect the shape and condition of the fallopian tubes and reproductive organs

Your doctor may be able to give you more specific information about your condition.

symptoms

Nausea and breast soreness are common symptoms in both ectopic and uterine pregnancies. The following symptoms are more common in an ectopic pregnancy and can indicate a medical emergency:

• sharp waves of pain in the abdomen, pelvis, shoulder, or neck
• severe pain that occurs on one side of the abdomen
• light to heavy vaginal spotting or bleeding
• dizziness or fainting
• rectal pressure

You should contact your doctor or seek immediate treatment if you know that you’re pregnant and have any of these symptoms.

You may not notice any symptoms at first. However, some women who have an ectopic pregnancy have the usual early signs or symptoms of pregnancy — a missed period, breast tenderness and nausea.

If you take a pregnancy test, the result will be positive. Still, an ectopic pregnancy can’t continue as normal.

As the fertilized egg grows in the improper place, signs and symptoms become more noticeable.

Early warning of ectopic pregnancy

Often, the first warning signs of an ectopic pregnancy are light vaginal bleeding and pelvic pain.

If blood leaks from the fallopian tube, you may feel shoulder pain or an urge to have a bowel movement. Your specific symptoms depend on where the blood collects and which nerves are irritated.

Emergency symptoms

If the fertilized egg continues to grow in the fallopian tube, it can cause the tube to rupture. Heavy bleeding inside the abdomen is likely. Symptoms of this life-threatening event include extreme lightheadedness, fainting and shock.

When to see a doctor

Seek emergency medical help if you have any signs or symptoms of an ectopic pregnancy, including:

• Severe abdominal or pelvic pain accompanied by vaginal bleeding
• Extreme lightheadedness or fainting
• Shoulder pain

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Diagnosis

If you suspect you may have an ectopic pregnancy, see your doctor immediately. Ectopic pregnancies can’t be diagnosed from a physical exam. However, your doctor may still perform one to rule out other factors.

Another step to diagnosis is a transvaginal ultrasound. This involves inserting a special wand-like instrument into your vagina so that your doctor can see if a gestational sac is in the uterus.

Your doctor may also use a blood test to determine your levels of hCG and progesterone. These are hormones that are present during pregnancy. If these hormone levels start to decrease or stay the same over the course of a few days and a gestational sac isn’t present in an ultrasound, the pregnancy is likely ectopic.

If you’re having severe symptoms, such as significant pain or bleeding, there may not be enough time to complete all these steps. The fallopian tube could rupture in extreme cases, causing severe internal bleeding. Your doctor will then perform an emergency surgery to provide immediate treatment.

A pelvic exam can help your doctor identify areas of pain, tenderness, or a mass in the fallopian tube or ovary. However, your doctor can’t diagnose an ectopic pregnancy by examining you. You’ll need blood tests and an ultrasound.

Pregnancy test

Your doctor will order the human chorionic gonadotropin (HCG) blood test to confirm that you’re pregnant. Levels of this hormone increase during pregnancy. This blood test may be repeated every few days until ultrasound testing can confirm or rule out an ectopic pregnancy — usually about five to six weeks after conception.

Ultrasound

A transvaginal ultrasound allows your doctor to see the exact location of your pregnancy. For this test, a wandlike device is placed into your vagina. It uses sound waves to create images of your uterus, ovaries and fallopian tubes, and sends the pictures to a nearby monitor.

Abdominal ultrasound, in which an ultrasound wand is moved over your belly, may be used to confirm your pregnancy or evaluate for internal bleeding.

Other blood tests

A complete blood count will be done to check for anemia or other signs of blood loss. If you’re diagnosed with an ectopic pregnancy, your doctor may also order tests to check your blood type in case you need a transfusion.

risk factors

All sexually active women are at some risk for an ectopic pregnancy. Risk factors increase with any of the following:

• maternal age of 35 years or older
• history of pelvic surgery, abdominal surgery, or multiple abortions
• history of pelvic inflammatory disease (PID)
• history of endometriosis
• conception occurred despite tubal ligation or intrauterine device (IUD)
• conception aided by fertility drugs or procedures
• smoking
• history of ectopic pregnancy
• history of sexually transmitted diseases (STDs), such as gonorrhea or chlamydia
• having structural abnormalities in the fallopian tubes that make it hard for the egg to travel

If you have any of the above risk factors, talk to your doctor. You can work with your doctor or a fertility specialist to minimize the risks for future ectopic pregnancies.

Complications

An ectopic pregnancy can cause your fallopian tube to burst open. Without treatment, the ruptured tube can lead to life-threatening bleeding.

Treatment

A fertilized egg can’t develop normally outside the uterus. To prevent life-threatening complications, the ectopic tissue needs to be removed. Depending on your symptoms and when the ectopic pregnancy is discovered, this may be done using medication, laparoscopic surgery or abdominal surgery.

Medication

An early ectopic pregnancy without unstable bleeding is most often treated with a medication called methotrexate, which stops cell growth and dissolves existing cells. The medication is given by injection. It’s very important that the diagnosis of ectopic pregnancy is certain before receiving this treatment.

After the injection, your doctor will order another HCG test to determine how well treatment is working, and if you need more medication.

Laparoscopic procedures

Salpingostomy and salpingectomy are two laparoscopic surgeries used to treat some ectopic pregnancies. In these procedure, a small incision is made in the abdomen, near or in the navel. Next, your doctor uses a thin tube equipped with a camera lens and light (laparoscope) to view the tubal area.

In a salpingostomy, the ectopic pregnancy is removed and the tube left to heal on its own. In a salpingectomy, the ectopic pregnancy and the tube are both removed.

Which procedure you have depends on the amount of bleeding and damage and whether the tube has ruptured. Also a factor is whether your other fallopian tube is normal or shows signs of prior damage.

Emergency surgery

If the ectopic pregnancy is causing heavy bleeding, you might need emergency surgery. This can be done laparoscopically or through an abdominal incision (laparotomy). In some cases, the fallopian tube can be saved. Typically, however, a ruptured tube must be removed.

Home care

Your doctor will give you specific instructions regarding the care of your incisions after surgery. The chief goals are to keep your incisions clean and dry while they heal. Check them daily for infection signs, which could include:

• bleeding that won’t stop
• excessive bleeding
• foul-smelling drainage from the site
• hot to the touch
• redness
• swelling

You can expect some light vaginal bleeding and small blood clots after surgery. This can occur up to six weeks after your procedure. Other self-care measures you can take include:

• don’t lift anything heavier than 10 pounds
• drink plenty of fluids to prevent constipation
• pelvic rest, which means refraining from sexual intercourse, tampon use, and douching
• rest as much as possible the first week postsurgery, and then increase activity in the next weeks as tolerated

Always notify your doctor if your pain increases or you feel something is out of the ordinary.

Prevention

Prediction and prevention aren’t possible in every case. You may be able to reduce your risk through good reproductive health maintenance. Have your partner wear a condom during sex and limit your number of sexual partners. This reduces your risk for STDs, which can cause PID, a condition that can cause inflammation in the fallopian tubes.

Maintain regular visits with your doctor, including regular gynecological exams and regular STD screenings. Taking steps to improve your personal health, such as quitting smoking, is also a good preventive strategy.

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Uterine fibroids are noncancerous growths of the uterus that often appear during childbearing years. Also called leiomyomas (lie-o-my-O-muhs) or myomas, uterine fibroids aren’t associated with an increased risk of uterine cancer and almost never develop into cancer.

Fibroids range in size from seedlings, undetectable by the human eye, to bulky masses that can distort and enlarge the uterus. You can have a single fibroid or multiple ones. In extreme cases, multiple fibroids can expand the uterus so much that it reaches the rib cage and can add weight.

Many women have uterine fibroids sometime during their lives. But you might not know you have uterine fibroids because they often cause no symptoms. Your doctor may discover fibroids incidentally during a pelvic exam or prenatal ultrasound.

Fibroids are abnormal growths that develop in or on a woman’s uterus. Sometimes these tumors become quite large and cause severe abdominal pain and heavy periods. In other cases, they cause no signs or symptoms at all. The growths are typically benign, or noncancerous. The cause of fibroids is unknown.

Fibroids are also known by the following names:

• leiomyomas
• myomas
• uterine myomas
• fibromas

According to the Office on Women’s Health, up to 80 percentTrusted Source of women have them by the age of 50. However, most women don’t have any symptoms and may never know they have fibroids.

types

The type of fibroid a woman develops depends on its location in or on the uterus.

Intramural fibroids

Intramural fibroids are the most common type of fibroid. These types appear within the muscular wall of the uterus. Intramural fibroids may grow larger and can stretch your womb.

Subserosal fibroids

Subserosal fibroids form on the outside of your uterus, which is called the serosa. They may grow large enough to make your womb appear bigger on one side.

Pedunculated fibroids

Subserosal tumors can develop a stem, a slender base that supports the tumor. When they do, they’re known as pedunculated fibroids.

Submucosal fibroids

These types of tumors develop in the middle muscle layer, or myometrium, of your uterus. Submucosal tumors aren’t as common as the other types.

causes

Doctors don’t know the cause of uterine fibroids, but research and clinical experience point to these factors:

• Genetic changes. Many fibroids contain changes in genes that differ from those in normal uterine muscle cells.
• Hormones. Estrogen and progesterone, two hormones that stimulate development of the uterine lining during each menstrual cycle in preparation for pregnancy, appear to promote the growth of fibroids. Fibroids contain more estrogen and progesterone receptors than normal uterine muscle cells do. Fibroids tend to shrink after menopause due to a decrease in hormone production.
• Other growth factors. Substances that help the body maintain tissues, such as insulin-like growth factor, may affect fibroid growth.
• Extracellular matrix (ECM). ECM is the material that makes cells stick together, like mortar between bricks. ECM is increased in fibroids and makes them fibrous. ECM also stores growth factors and causes biologic changes in the cells themselves.

• Pregnancy Pregnancy increases the production of estrogen and progesterone in your body. Fibroids may develop and grow rapidly while you’re pregnant.

Doctors believe that uterine fibroids develop from a stem cell in the smooth muscular tissue of the uterus (myometrium). A single cell divides repeatedly, eventually creating a firm, rubbery mass distinct from nearby tissue.

The growth patterns of uterine fibroids vary — they may grow slowly or rapidly, or they may remain the same size. Some fibroids go through growth spurts, and some may shrink on their own.

Many fibroids that have been present during pregnancy shrink or disappear after pregnancy, as the uterus goes back to a normal size.

Symptoms

Your symptoms will depend on the number of tumors you have as well as their location and size. For instance, submucosal fibroids may cause heavy menstrual bleeding and trouble conceiving.

If your tumor is very small or you’re going through menopause, you may not have any symptoms. Fibroids may shrink during and after menopause. This is because women undergoing menopause are experiencing a drop in their levels of estrogen and progesterone, hormones that stimulate fibroid growth.

Symptoms of fibroids may include:

• heavy bleeding between or during your periods that includes blood clots
• pain in the pelvis or lower back
• increased menstrual cramping
• increased urination
• pain during intercourse
• menstruation that lasts longer than usual
• pressure or fullness in your lower abdomen
• swelling or enlargement of the abdomen

Many women who have fibroids don’t have any symptoms. In those that do, symptoms can be influenced by the location, size and number of fibroids.

In women who have symptoms, the most common signs and symptoms of uterine fibroids include:

• Heavy menstrual bleeding
• Menstrual periods lasting more than a week
• Pelvic pressure or pain
• Frequent urination
• Difficulty emptying the bladder
• Constipation
• Backache or leg pains

Rarely, a fibroid can cause acute pain when it outgrows its blood supply, and begins to die.

Fibroids are generally classified by their location. Intramural fibroids grow within the muscular uterine wall. Submucosal fibroids bulge into the uterine cavity. Subserosal fibroids project to the outside of the uterus.

When to see a doctor

See your doctor if you have:

• Pelvic pain that doesn’t go away
• Overly heavy, prolonged or painful periods
• Spotting or bleeding between periods
• Difficulty emptying your bladder
• Unexplained low red blood cell count (anemia)

Seek prompt medical care if you have severe vaginal bleeding or sharp pelvic pain that comes on suddenly.

Diagnosis

Uterine fibroids are frequently found incidentally during a routine pelvic exam. Your doctor may feel irregularities in the shape of your uterus, suggesting the presence of fibroids.

If you have symptoms of uterine fibroids, your doctor may order these tests:

• Ultrasound. If confirmation is needed, your doctor may order an ultrasound. It uses sound waves to get a picture of your uterus to confirm the diagnosis and to map and measure fibroids. A doctor or technician moves the ultrasound device (transducer) over your abdomen (transabdominal) or places it inside your vagina (transvaginal) to get images of your uterus.
• Lab tests. If you have abnormal menstrual bleeding, your doctor may order other tests to investigate potential causes. These might include a complete blood count (CBC) to determine if you have anemia because of chronic blood loss and other blood tests to rule out bleeding disorders or thyroid problems.

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Other imaging tests

If traditional ultrasound doesn’t provide enough information, your doctor may order other imaging studies, such as:

• Magnetic resonance imaging (MRI). This imaging test can show in more detail the size and location of fibroids, identify different types of tumors and help determine appropriate treatment options. An MRI is most often used in women with a larger uterus or in women approaching menopause (perimenopause).
• Hysterosonography. Hysterosonography (his-tur-o-suh-NOG-ruh-fee), also called a saline infusion sonogram, uses sterile saline to expand the uterine cavity, making it easier to get images of submucosal fibroids and the lining of the uterus in women attempting pregnancy or who have heavy menstrual bleeding.
• Hysterosalpingography. Hysterosalpingography (his-tur-o-sal-ping-GOG-ruh-fee) uses a dye to highlight the uterine cavity and fallopian tubes on X-ray images. Your doctor may recommend it if infertility is a concern. This test can help your doctor determine if your fallopian tubes are open or are blocked and can show some submucosal fibroids.
• Hysteroscopy. For this, your doctor inserts a small, lighted telescope called a hysteroscope through your cervix into your uterus. Your doctor then injects saline into your uterus, expanding the uterine cavity and allowing your doctor to examine the walls of your uterus and the openings of your fallopian tubes.

Risk factors

There are few known risk factors for uterine fibroids, other than being a woman of reproductive age. Factors that can have an impact on fibroid development include:

• Race. Although any woman of reproductive age can develop fibroids, black women are more likely to have fibroids than are women of other racial groups. In addition, black women have fibroids at younger ages, and they’re also likely to have more or larger fibroids, along with more-severe symptoms.
• Heredity. If your mother or sister had fibroids, you’re at increased risk of developing them.
• Other factors. Onset of menstruation at an early age; obesity; a vitamin D deficiency; having a diet higher in red meat and lower in green vegetables, fruit and dairy; and drinking alcohol, including beer, appear to increase your risk of developing fibroids.

Complications

Although uterine fibroids usually aren’t dangerous, they can cause discomfort and may lead to complications such as a drop in red blood cells (anemia), which causes fatigue, from heavy blood loss. Rarely, a transfusion is needed due to blood loss.

Pregnancy and fibroids

Fibroids usually don’t interfere with getting pregnant. However, it’s possible that fibroids — especially submucosal fibroids — could cause infertility or pregnancy loss.

Fibroids may also raise the risk of certain pregnancy complications, such as placental abruption, fetal growth restriction and preterm delivery.

Treatment

There’s no single best approach to uterine fibroid treatment — many treatment options exist. If you have symptoms, talk with your doctor about options for symptom relief.

Watchful waiting

Many women with uterine fibroids experience no signs or symptoms, or only mildly annoying signs and symptoms that they can live with. If that’s the case for you, watchful waiting could be the best option.

Fibroids aren’t cancerous. They rarely interfere with pregnancy. They usually grow slowly — or not at all — and tend to shrink after menopause, when levels of reproductive hormones drop.

Medications

Medications for uterine fibroids target hormones that regulate your menstrual cycle, treating symptoms such as heavy menstrual bleeding and pelvic pressure. They don’t eliminate fibroids, but may shrink them. Medications include:

• Gonadotropin-releasing hormone (GnRH) agonists. Medications called GnRH agonists treat fibroids by blocking the production of estrogen and progesterone, putting you into a temporary menopause-like state. As a result, menstruation stops, fibroids shrink and anemia often improves. GnRH agonists include leuprolide (Lupron, Eligard, others), goserelin (Zoladex) and triptorelin (Trelstar, Triptodur Kit). Many women have significant hot flashes while using GnRH agonists. GnRH agonists typically are used for no more than three to six months because symptoms return when the medication is stopped and long-term use can cause loss of bone. Your doctor may prescribe a GnRH agonist to shrink the size of your fibroids before a planned surgery or to help transition you to menopause.
• Progestin-releasing intrauterine device (IUD). A progestin-releasing IUD can relieve heavy bleeding caused by fibroids. A progestin-releasing IUD provides symptom relief only and doesn’t shrink fibroids or make them disappear. It also prevents pregnancy.
• Tranexamic acid (Lysteda, Cyklokapron). This nonhormonal medication is taken to ease heavy menstrual periods. It’s taken only on heavy bleeding days.
• Other medications. Your doctor might recommend other medications. For example, oral contraceptives can help control menstrual bleeding, but they don’t reduce fibroid size. Nonsteroidal anti-inflammatory drugs (NSAIDs), which are not hormonal medications, may be effective in relieving pain related to fibroids, but they don’t reduce bleeding caused by fibroids. Your doctor may also suggest that you take vitamins and iron if you have heavy menstrual bleeding and anemia.

Noninvasive procedure

MRI-guided focused ultrasound surgery (FUS) is:

• A noninvasive treatment option for uterine fibroids that preserves your uterus, requires no incision and is done on an outpatient basis.
• Performed while you’re inside an MRI scanner equipped with a high-energy ultrasound transducer for treatment. The images give your doctor the precise location of the uterine fibroids. When the location of the fibroid is targeted, the ultrasound transducer focuses sound waves (sonications) into the fibroid to heat and destroy small areas of fibroid tissue.
• Newer technology, so researchers are learning more about the long-term safety and effectiveness. But so far data collected show that FUS for uterine fibroids is safe and effective.

Minimally invasive procedures

Certain procedures can destroy uterine fibroids without actually removing them through surgery. They include:

• Uterine artery embolization. Small particles (embolic agents) are injected into the arteries supplying the uterus, cutting off blood flow to fibroids, causing them to shrink and die. This technique can be effective in shrinking fibroids and relieving the symptoms they cause. Complications may occur if the blood supply to your ovaries or other organs is compromised. However, research shows that complications are similar to surgical fibroid treatments and the risk of transfusion is substantially reduced.
• Radiofrequency ablation. In this procedure, radiofrequency energy destroys uterine fibroids and shrinks the blood vessels that feed them. This can be done during a laparoscopic or transcervical procedure. A similar procedure called cryomyolysis freezes the fibroids. With laparoscopic radiofrequency ablation, also called Lap-RFA, your doctor makes two small incisions in the abdomen to insert a slim viewing instrument (laparoscope) with a camera at the tip. Using the laparoscopic camera and a laparoscopic ultrasound tool, your doctor locates fibroids to be treated. After locating a fibroid, your doctor uses a specialized device to deploy several small needles into the fibroid. The needles heat up the fibroid tissue, destroying it. The destroyed fibroid immediately changes consistency, for instance from being hard like a golf ball to being soft like a marshmallow. During the next three to 12 months, the fibroid continues to shrink, improving symptoms. Because there’s no cutting of uterine tissue, doctors consider Lap-RFA a less invasive alternative to hysterectomy and myomectomy. Most women who have the procedure get back to regular activities after 5 to 7 days of recovery. The transcervical — or through the cervix — approach to radiofrequency ablation also uses ultrasound guidance to locate fibroids.
• Laparoscopic or robotic myomectomy. In a myomectomy, your surgeon removes the fibroids, leaving the uterus in place. If the fibroids are few in number, you and your doctor may opt for a laparoscopic or robotic procedure, which uses slender instruments inserted through small incisions in your abdomen to remove the fibroids from your uterus. Larger fibroids can be removed through smaller incisions by breaking them into pieces (morcellation), which can be done inside a surgical bag, or by extending one incision to remove the fibroids. Your doctor views your abdominal area on a monitor using a small camera attached to one of the instruments. Robotic myomectomy gives your surgeon a magnified, 3D view of your uterus, offering more precision, flexibility and dexterity than is possible using some other techniques.
• Hysteroscopic myomectomy. This procedure may be an option if the fibroids are contained inside the uterus (submucosal). Your surgeon accesses and removes fibroids using instruments inserted through your vagina and cervix into your uterus.
• Endometrial ablation. This treatment, performed with a specialized instrument inserted into your uterus, uses heat, microwave energy, hot water or electric current to destroy the lining of your uterus, either ending menstruation or reducing your menstrual flow. Typically, endometrial ablation is effective in stopping abnormal bleeding. Submucosal fibroids can be removed at the time of hysteroscopy for endometrial ablation, but this doesn’t affect fibroids outside the interior lining of the uterus. Women aren’t likely to get pregnant following endometrial ablation, but birth control is needed to prevent a pregnancy from developing in a fallopian tube (ectopic pregnancy).

With any procedure that doesn’t remove the uterus, there’s a risk that new fibroids could grow and cause symptoms.

Traditional surgical procedures

Options for traditional surgical procedures include:

• Abdominal myomectomy. If you have multiple fibroids, very large fibroids or very deep fibroids, your doctor may use an open abdominal surgical procedure to remove the fibroids. Many women who are told that hysterectomy is their only option can have an abdominal myomectomy instead. However, scarring after surgery can affect future fertility.
• Hysterectomy. This surgery — the removal of the uterus — remains the only proven permanent solution for uterine fibroids. But hysterectomy is major surgery. Hysterectomy ends your ability to bear children. If you also elect to have your ovaries removed, the surgery brings on menopause and the question of whether you’ll take hormone replacement therapy. Most women with uterine fibroids may be able to choose to keep their ovaries.

Morcellation during fibroid removal

Morcellation — a process of breaking fibroids into smaller pieces — may increase the risk of spreading cancer if a previously undiagnosed cancerous mass undergoes morcellation during myomectomy. There are several ways to reduce that risk, such as evaluating risk factors before surgery, morcellating the fibroid in a bag or expanding an incision to avoid morcellation.

All myomectomies carry the risk of cutting into an undiagnosed cancer, but younger, premenopausal women generally have a lower risk of undiagnosed cancer than do older women.

Also, complications during open surgery are more common than the chance of spreading an undiagnosed cancer in a fibroid during a minimally invasive procedure. If your doctor is planning to use morcellation, discuss your individual risks before treatment.

The Food and Drug Administration (FDA) advises against the use of a device to morcellate the tissue (power morcellator) for most women having fibroids removed through myomectomy or hysterectomy. In particular, the FDA recommends that women who are approaching menopause or who have reached menopause avoid power morcellation. Older women in or entering menopause may have a higher cancer risk, and women who are no longer concerned about preserving their fertility have additional treatment options for fibroids.

If you’re trying to get pregnant or might want to have children

Hysterectomy and endometrial ablation won’t allow you to have a future pregnancy. Also, uterine artery embolization and radiofrequency ablation may not be the best options if you’re trying to optimize future fertility.

Have a full discussion of the risks and benefits of these procedures with your doctor if you want to preserve the ability to become pregnant. Before deciding on a treatment plan for fibroids, a complete fertility evaluation is recommended if you’re actively trying to get pregnant.

If fibroid treatment is needed — and you want to preserve your fertility — myomectomy is generally the treatment of choice. However, all treatments have risks and benefits. Discuss these with your doctor.

Risk of developing new fibroids

For all procedures except hysterectomy, seedlings — tiny tumors that your doctor doesn’t detect during surgery — could eventually grow and cause symptoms that warrant treatment. This is often termed the recurrence rate. New fibroids, which may or may not require treatment, also can develop.

Also, some procedures — such as laparoscopic or robotic myomectomy, radiofrequency ablation, or MRI-guided focused ultrasound surgery (FUS) — may only treat some of the fibroids present at the time of treatment.

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Pelvic floor prolapse is the herniation of the pelvic organs through the perineum. Depending on the pelvic organ involved, pelvic prolapse further categorizes into:

1. Anterior compartment containing urinary bladder(cystocele)
2. Middle compartment containing uterine or vaginal prolapse (uterus or vagina)
3. Posterior compartment containing either the small bowel loops (enterocele) or rectum (rectocele).

Pelvic prolapse is very common among multiparous women over 50 (affects approximately 50% of women over age 50). Symptoms include fecal or urinary incontinence, uterine prolapse, constipation, or incomplete defecation. Pelvic prolapse can negatively impact the patient’s body image and sexuality. Pelvic prolapse treatments range from non-surgical approaches like Kegel exercise and pessary to various surgical procedures. 

Definition/Description

Pelvic organ prolapse is the descent of a pelvic organ into or outside of the vaginal canal or anus. It mainly results from pelvic floor dysfunction.

There are several types:

• Cystocele: prolapse of the bladder into the vagina
• Urethrocele: prolapse of the urethra
• Uterine prolapse
• Vaginal vault prolapse: prolapse of the vagina
• Enterocele: small bowel prolapse
• Rectocele: rectum prolapse

Etiology

Pelvic organ prolapse has a multifactorial etiology. It is likely caused by a combination of physiological, anatomical, reproductive, genetic and lifestyle factors that interact and contribute to dysfunction of the pelvic floor. 

Symptoms

A variety of symptoms may be present including:

• Vaginal bulging
• Feeling of pelvic pressure or heaviness
• Pelvic pain
• Urinary or fecal incontinence or obstruction
• Altered daily activities, sexual function and quality of life
• Risk Factors

causes

The factors causing pelvic organ prolapse are different between patients. Risk factors include the following:

Primary Pelvic Organ Prolapse

• Pregnancy and labour
• Obesity/BMI
• Respiratory problems involving a chronic, long-term cough
• Cancer of the pelvic organs
• Hysterectomy (surgical removal of the uterus)
• Genetics (possibly) due to weaker connective tissues
• History of vaginal delivery increases the risk 5.56 times
• Hypertension and Diabetes Mellitus combined increase the risk by 1.9 times
• Increased birth weight
• Age
• Parity (i.e. the number of times a woman has given birth to a fetus with a gestational age of greater than or equal to 24 weeks, alive or stillborn)

Pelvic Organ Prolapse Recurrence (after native tissue repair)

• Preoperative stage 3 or 4 pelvic organ prolapse (i.e. a more severe prolapse)

Diagnosis

Diagnosis of pelvic organ prolapse begins with your medical history and a physical exam of your pelvic organs. This can help your health care provider determine the type of prolapse, such as bladder, rectum or uterine.

Some tests might also be needed. Ask your health care provider to explain why each test is being done. Tests for pelvic organ prolapse might include:

• Bladder function tests. Some tests are as simple as finding out whether your bladder leaks when it’s put back into place at the time of your physical exam. Other tests might measure how well your bladder empties. Seeing these results can help you and your doctor determine the most appropriate type of management for prolapse.
• Pelvic floor strength tests. Your doctor will test the strength of your pelvic floor and sphincter muscles at the time of your physical examination. This tests the strength of muscles and ligaments that support the vaginal walls, uterus, rectum, urethra and bladder.
• Magnetic resonance imaging (MRI). An MRI will use a magnetic field and radio waves to create detailed images of your pelvis. This is useful only in complex cases.
• Ultrasound. This imaging method will use high-frequency sound waves to produce images of your kidneys, bladder and the muscles around your anus. An ultrasound is useful only in complex cases.

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Treatment/Management

As prolapse treatment options expand to include more conservative choices, greater awareness and education is needed among women and professionals about these as a first line treatment and preventive measure (alongside a multi-professional team approach).

Women presenting with prolapse symptoms need to be

• listened to by the health care team,
• offered information about treatment choices
• supported to make a decision that is right for them.

A qualitative research developed a conceptual model that explores the experience of living with a POP, and the model indicated that: the physical losses of POP are linked to loss of identity; women conceptualized POP as part of womanhood, and a vicious cycle of taboo, silence, and misunderstanding about POP and its treatment. And further, POP is not taken seriously in healthcare.

Treatment for pelvic organ prolapse usually involves either conservative management (for mild prolapse or women who are not good surgical candidates) or surgery. Conservative treatments include pelvic floor muscle training and the use of devices (pessaries).

Physiotherapy

Physical therapists play a major role in the nonsurgical management of POP. Along with pessary support, pelvic-floor muscle training (PFMT) is cited in highly credible reviews as a main nonsurgical option for women with POP.

For all the information re retraining these muscles see the physiotherapy section of Pelvic Floor Dysfunction and Kegel’s Exercises

In a study by Panman et al in 2016, examining the two-year effects of pelvic floor muscle retraining, it was demonstrated that in women aged 55 and greater with symptomatic mild pelvic organ prolapse, pelvic floor muscle retraining results in a significant decrease in pelvic floor symptoms when compared to watchful waiting (note: statistically significant but below the minimal clinically important difference). Additionally, it was found that pelvic floor muscle retraining was more effective in women who experienced increased pelvic floor symptom distress at baseline. Conversely, the same study found no difference in sexual functioning, quality of life, function of the pelvic floor muscles or degree of prolapse.

A randomised control trial compared the effect of intravaginal vibratory stimulation (IVVS) with intravaginal electrical stimulation (IVES) in women with pelvic floor dysfunctions, unable to voluntarily contract the pelvic floor muscles. The results showed improvement with both techniques, with IVVS superior to IVES in improving pelvic floor muscle strength.

Pelvic floor muscle retraining included: (Kegel exercises diagram in illustration)

• Explanation and description of the pelvic floor
• Instruction regarding how to contract and relax pelvic floor muscles
  • If unable to perform this task, use feedback through digital palpation
  • If insufficient control demonstrated, use myofeedback or electrical stimulation

• General exercise program provided, subsequently modified for individual needs
• Taught correct technique for contracting pelvic floor muscles before and during increases in abdominal pressure
• Received information about washroom habits and lifestyle
• If pelvic floor muscles were overactive, focus was on relaxation rather than contraction
• Face-to-face contact with physiotherapist as well as encouragement to maintain practice at home 3-5 times per week, 2-3 times per day

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The uterus (womb) is a muscular structure that’s held in place by pelvic muscles and ligaments. If these muscles or ligaments stretch or become weak, they’re no longer able to support the uterus, causing prolapse.

Uterine prolapse occurs when the uterus sags or slips from its normal position and into the vagina (birth canal).

Uterine prolapse may be incomplete or complete. An incomplete prolapse occurs when the uterus is only partly sagging into the vagina. A complete prolapse occurs when the uterus falls so far down that some tissue protrudes outside of the vagina.

Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and weaken and no longer provide enough support for the uterus. As a result, the uterus slips down into or protrudes out of the vagina.

Uterine prolapse can occur in women of any age. But it often affects postmenopausal women who’ve had one or more vaginal deliveries.

Mild uterine prolapse usually doesn’t require treatment. But if uterine prolapse makes you uncomfortable or disrupts your normal life, you might benefit from treatment.

• Muscle weakness or relaxation may allow your uterus to sag or come completely out of your body in various stages:
  • First degree: The cervix drops into the vagina.
  • Second degree: The cervix drops to the level just inside the opening of the vagina.
  • Third degree: The cervix is outside the vagina.
  • Fourth degree: The entire uterus is outside the vagina. This condition is also called procidentia. This is caused by weakness in all of the supporting muscles.
• Other conditions are usually associated with prolapsed uterus. They weaken the muscles that hold the uterus in place:
  • Cystocele: A herniation (or bulging) of the upper front vaginal wall where a part of the bladder bulges into the vagina. It’s also called a prolapsed bladder. This may lead to urinary frequency, urgency, retention, and incontinence (loss of urine).
  • Enterocele: The herniation of the upper rear vaginal wall where a small bowel portion bulges into the vagina. Standing leads to a pulling sensation and backache that is relieved when you lie down.
  • Rectocele: The herniation of the lower rear vaginal wall where the rectum bulges into the vagina. This makes bowel movements difficult, to the point that you may need to push on the inside of your vagina to empty your bowel.

Causes

Uterine prolapse results from the weakening of pelvic muscles and supportive tissues. Causes of weakened pelvic muscles and tissues include:

• Pregnancy
• Difficult labor and delivery or trauma during childbirth
• Delivery of a large baby
• Being overweight or obese
• Lower estrogen level after menopause
• Chronic constipation or straining with bowel movements
• Chronic cough or bronchitis
• Repeated heavy lifting

Symptoms

Women who have a minor uterine prolapse may not have any symptoms. Moderate to severe prolapse may cause symptoms, such as:

• the feeling that you’re sitting on a ball
• vaginal bleeding
• increased discharge
• problems with sexual intercourse
• the uterus or cervix protruding out of the vagina
• a pulling or heavy feeling in the pelvis
• constipation or difficulty passing stool
• recurring bladder infections or difficulty emptying your bladder

If you develop these symptoms, you should see your doctor and get treatment right away. Without proper attention, the condition can impair your bowel, bladder, and sexual function.

Mild uterine prolapse generally doesn’t cause signs or symptoms. Signs and symptoms of moderate to severe uterine prolapse include:

• Sensation of heaviness or pulling in your pelvis
• Tissue protruding from your vagina
• Urinary problems, such as urine leakage (incontinence) or urine retention
• Trouble having a bowel movement
• Feeling as if you’re sitting on a small ball or as if something is falling out of your vagina
• Sexual concerns, such as a sensation of looseness in the tone of your vaginal tissue

Often, symptoms are less bothersome in the morning and worsen as the day goes on.

When to see a doctor

See your doctor to discuss your options if signs and symptoms of uterine prolapse become bothersome and disrupt your normal activities

Risk factors

Factors that can increase your risk of uterine prolapse include:

• One or more pregnancies and vaginal births
• Giving birth to a large baby
• Increasing age
• Obesity
• Prior pelvic surgery
• Chronic constipation or frequent straining during bowel movements
• Family history of weakness in connective tissue
• Being Hispanic or white

Complications

Uterine prolapse is often associated with prolapse of other pelvic organs. You might experience:

• Anterior prolapse (cystocele). Weakness of connective tissue separating the bladder and vagina may cause the bladder to bulge into the vagina. Anterior prolapse is also called prolapsed bladder.
• Posterior vaginal prolapse (rectocele). Weakness of connective tissue separating the rectum and vagina may cause the rectum to bulge into the vagina. You might have difficulty having bowel movements.

Severe uterine prolapse can displace part of the vaginal lining, causing it to protrude outside the body. Vaginal tissue that rubs against clothing can lead to vaginal sores (ulcers.) Rarely, the sores can become infected

diagnosis

Your doctor can diagnose uterine prolapse by evaluating your symptoms and performing a pelvic exam. During this exam, your doctor will insert a device called a speculum that allows them to see inside of the vagina and examine the vaginal canal and uterus. You may be lying down, or your doctor may ask you to stand during this exam.

Your doctor may ask you to bear down as if you’re having a bowel movement to determine the degree of prolapse.

Your health care provider can diagnose uterine prolapse with a medical history and physical examination of the pelvis.

• The doctor may need to examine you in standing position and while you are lying down and ask you to cough or strain to increase the pressure in your abdomen.
• Specific conditions, such as ureteral obstruction due to complete prolapse, may need an intravenous pyelogram (IVP) or renal sonography. Dye is injected into your vein, and a series of X-rays are taken to view its progress through your bladder.
• Ultrasound may be used to rule out other pelvic problems. In this test, a wand is passed over your abdomen or inserted into your vagina to create images with sound waves.
• Pelvic magnetic resonance imaging (MRI) is sometimes done if you have more than one prolapsed organ or to help plan surgery.

Prevention

To reduce your risk of uterine prolapse, try to:

• Perform Kegel exercises regularly. These exercises can strengthen your pelvic floor muscles — especially important after you have a baby.
• Treat and prevent constipation. Drink plenty of fluids and eat high-fiber foods, such as fruits, vegetables, beans and whole-grain cereals.
• Avoid heavy lifting and lift correctly. When lifting, use your legs instead of your waist or back.
• Control coughing. Get treatment for a chronic cough or bronchitis, and don’t smoke.
• Avoid weight gain. Talk with your doctor to determine your ideal weight and get advice on weight-loss strategies, if you need them.

treatment

Treatment isn’t always necessary for this condition. If the prolapse is severe, talk with your doctor about which treatment option is appropriate for you.

Nonsurgical treatments include:

• losing weight to take stress off pelvic structures
• avoiding heavy lifting
• doing Kegel exercises, which are pelvic floor exercises that help strengthen the vaginal muscles
• wearing a pessary, which is a device inserted into the vagina that fits under the cervix and helps push up and stabilize the uterus and cervix

The use of vaginal estrogen has been well-studied and shows improvement in vaginal tissue regeneration and strength. While using vaginal estrogen to help augment other treatment options may be helpful, on its own it doesn’t reverse the presence of a prolapse.

Surgical treatments include uterine suspension or hysterectomy. During uterine suspension, your surgeon places the uterus back into its original position by reattaching pelvic ligaments or using surgical materials. During a hysterectomy, your surgeon removes the uterus from the body through the abdomen or the vagina.

Surgery is often effective, but it’s not recommended for women who plan on having children. Pregnancy and childbirth can put an immense strain on pelvic muscles, which can undo surgical repairs of the uterus.

Treatment of uterine prolapse is largely dependent on the extent to which a patient is experiencing symptoms. Treatments include surgical and non-surgical options, the choice of which will depend on general health, the severity of the condition and plans for a future pregnancy.

Proper diagnosis and management of uterine prolapse can majorly impact a patient’s quality of life and can have long-term physical and mental health effects. Healthcare practitioners should thoroughly counsel patients with uterine prolapse so they can make informed decisions and choose the treatment that is right for them.

Options include:

• Pelvic floor exercises
• Vaginal pessary
• Vaginal surgery.

1. Pelvic floor muscle training:

• Typically taught to patients in association with a physiotherapist. They have been shown to result in subjective improvement in symptoms by patients as well as objective improvement in the The Pelvic Organ Prolapse Quantification (POP-Q) system score by examiners.

2. Vaginal pessaries:

• Objects often made of silicone that are inserted into the vagina to provide support for the prolapsed pelvic organs.
• Vaginal pessaries can be an effective way of reducing the symptoms of a prolapse, but they will not be appropriate for everyone. Together with pelvic floor exercises, they may provide a non-surgical solution to manage a uterine prolapse.
• Vaginal pessaries provide a solution in 84% of cases of advanced pelvic organ prolapse with mild adverse events in 31% of cases. 
• Patients must be fitted for a pessary and commonly try several pessaries before finding the appropriate one. The examiner should be able to sweep a single finger between the pessary and vaginal walls. The patient should be able to walk, bend, and urinate comfortably without shifting the pessary. Complications of pessary placement include vaginal irritation/ulceration, discharge, pain, bleeding, and odor.
• Regular reassessments of pessary fit should be performed to ensure that the pessary is not rubbing against the walls of the vagina, as this can lead to irritation of the vaginal mucosa and predispose patients to infection. Patients with dementia or poor follow up are not good candidates for pessary placement as they require frequent cleaning and regular reassessment of position to prevent complications.

Surgical management

• Decision should be made after a detailed discussion with the patient regarding the desire for future vaginal intercourse, effects on body image, cultural views, alternative treatments, and potential complications.
• In moderate to severe cases, the prolapse may have to be surgically repaired. In laparoscopic surgery, instruments are inserted through the navel. The uterus is pulled back into its correct position and reattached to its supporting ligaments. The operation can also be performed with an abdominal incision.
• Surgery may fail and the prolapse can recur if the original cause of the prolapse, such as obesity, coughing or straining, is not addressed.

Physiotherapy

Physical therapists play a major role in the nonsurgical management of Uterine prolapse. Along with pessary support, pelvic-floor muscle training (PFMT) is cited in highly credible reviews as a main nonsurgical option for women with Uterine prolapse.

For all the information re retraining these muscles see the physiotherapy section of Pelvic Floor Dysfunction and Kegel’s Exercises

In a study by Panman et al in 2016, examining the two-year effects of pelvic floor muscle retraining, it was demonstrated that in women aged 55 and greater with symptomatic mild pelvic organ prolapse, pelvic floor muscle retraining results in a significant decrease in pelvic floor symptoms when compared to watchful waiting (note: statistically significant but below the minimal clinically important difference). Additionally, it was found that pelvic floor muscle retraining was more effective in women who experienced increased pelvic floor symptom distress at baseline. Conversely, the same study found no difference in sexual functioning, quality of life, function of the pelvic floor muscles or degree of prolapse.

A randomised control trial compared the effect of intravaginal vibratory stimulation (IVVS) with intravaginal electrical stimulation (IVES) in women with pelvic floor dysfunctions, unable to voluntarily contract the pelvic floor muscles. The results showed improvement with both techniques, with IVVS superior to IVES in improving pelvic floor muscle strength.

Pelvic floor muscle retraining included: (Kegel exercises diagram in illustration)

• Explanation and description of the pelvic floor
• Instruction regarding how to contract and relax pelvic floor muscles
  • If unable to perform this task, use feedback through digital palpation
  • If insufficient control demonstrated, use myofeedback or electrical stimulation

• General exercise program provided, subsequently modified for individual needs
• Taught correct technique for contracting pelvic floor muscles before and during increases in abdominal pressure
• Received information about washroom habits and lifestyle
• If pelvic floor muscles were overactive, focus was on relaxation rather than contraction
• Face-to-face contact with physiotherapist as well as encouragement to maintain practice at home 3-5 times per week, 2-3 times per day 

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Normal puberty begins between eight and 14 years of age in girls and between nine and 14 years of age in boys. Pubic hair distribution is used to stage puberty, along with breast size and contour in girls and testicular volume in boys. Some children experience constitutional sexual precocity, but precocity is likely to be pathologic if it occurs in very young children, if there is contrasexual development or if the sequence of normal pubertal milestones is disrupted. Delayed puberty may be constitutional, but pathologic causes should be considered. The etiology of a pubertal disorder can often be determined with the use of a focused medical history, a directed physical examination and appropriate diagnostic tests. Treatment for disorders of puberty is determined by the underlying cause.

Puberty is a process leading to physical and sexual maturation that involves the development of secondary sexual characteristics as well as growth, changes in body composition and psychosocial maturation.

Girls: key physical changes in puberty

If you have a daughter, these are the main external physical changes in puberty that you can expect.

Around 10-11 years

• Breasts will start developing. This is the first visible sign that puberty is starting. It’s normal for the left and right breasts to grow at different speeds. It’s also common for the breasts to be a bit tender as they develop. If your child wants a bra, a soft crop top or sports bra can be a good first choice.
• Your daughter will have a growth spurt, and she’ll get taller. Some parts of her body – like her head, face and hands – might grow faster than her limbs and torso. This might leave her looking out of proportion for a while. On average girls grow 5-20 cm. They usually stop growing at around 16-17 years.
• Your daughter’s body shape will change. For example, her hips will widen.
• Your daughter’s external genitals (vulva) and pubic hair will start to grow. Her pubic hair will get darker and thicker over time.

Around 12-14 years (about two years after breast development starts)

• Hair will start growing under your daughter’s arms.
• Your daughter will get a clear or whitish discharge from her vagina for several months before her periods start. If the discharge bothers your daughter, you could suggest she uses a panty liner. If your daughter says she has itching, pain or a bad or strong odour, check with a GP.
• Periods will start. This is when the lining of the uterus (womb), including blood, is shed every month. Your daughter might get pain before and during her period, like headaches or stomach cramps. Her periods might be irregular at first.

Boys: key physical changes in puberty

If you have a son, these are the main external physical changes in puberty that you can expect.

Around 11-13 years

• The external genitals (penis, testes and scrotum) will start to grow. It’s normal for one testis to grow faster than the other. You can reassure your son that men’s testes usually aren’t the same size.
• Pubic hair will start to grow. It will get darker and thicker over time.

Around 12-14 years

• Your son will have a growth spurt. He’ll get taller and his chest and shoulders will get broader. Some parts of his body – like his head, face and hands – might grow faster than his limbs and torso. This might leave him looking out of proportion for a while. On average boys grow 10-30 cm. They usually stop growing at around 18-20 years.
• It’s common for boys to have minor breast development. If your son is worried by this, you can let him know it’s normal and usually goes away by itself. If it doesn’t go away or if your son’s breasts seem to be growing a lot, he could speak to his GP.

Around 13-15 years

• Hair will start growing on other parts of your son’s body – under his arms, on his face and on the rest of his body. His leg and arm hair will thicken. Some young men will grow more body hair into their early 20s.
• Your son will start producing more testosterone, which stimulates the testes to produce sperm.
• Your son will start getting erections and ejaculating (releasing sperm). During this period, erections often happen for no reason at all. Just let your son know that this is normal and that people don’t usually notice. Ejaculation during sleep is often called a ‘wet dream’.

Around 14-15 years
The larynx (‘Adam’s apple’ or voice box) will become more obvious. Your son’s larynx will get larger and his voice will ‘break’, eventually becoming deeper. Some boys’ voices move from high to low and back again, even in one sentence. This will stop in time.

Other physical changes in puberty: inside and out

Brain
Changes in the teenage brain affect your child’s behaviour and social skills. Your child will begin to develop improved self-control and skills in planning, problem-solving and decision-making. This process will continue into your child’s mid-20s.

Bones, organs and body systems
Many of your child’s organs will get bigger and stronger. Lung performance improves, limbs grow, and bones increase in thickness and volume.

Clumsiness
Because children grow so fast during puberty, their centres of gravity change and their brains might take a while to adjust. This might affect your child’s balance. You might see a bit more clumsiness for a while, and your child might be more likely to be injured.

Physical strength
Muscles increase in strength and size during this period. Your child’s hand-eye coordination will get better over time, along with motor skills like ball-catching and throwing.

Weight
Your child will gain weight and need more healthy food. Teenagers’ stomachs and intestines increase in size, and they need more energy, proteins and minerals. Foods with plenty of calcium and iron are important for bone growth and blood circulation.

Sleep patterns
Sleep patterns change, and many children start to stay awake later at night and sleep until later in the day. Also, the brain re-sets the body clock during puberty. Children going through puberty need more sleep than they did just before puberty started.

Sweat
A new type of sweat gland in the armpit and genital area develops during puberty. Skin bacteria feed on the sweat this gland produces, which can lead to body odour. Hygiene is important.

Skin and hair
Glands in the skin on the face, shoulders and back start to become more active during puberty, producing more oil. This can lead to skin conditions like acne. If you’re concerned about your child’s skin, first check whether the pimples or acne are worrying your child too. If they are, consider speaking with your GP.

Children might find their hair gets oilier, and they need to wash it more. This is normal.

Teeth
Children will get their second molars at around 13 years. Third molars – ‘wisdom teeth’ – might appear between 14 and 25 years. These teeth can appear in singles, pairs, as a full set of four wisdom teeth – or not at all. Healthy teeth and gums are vital to your teenage child’s health, so teenage dental care is important.

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Puberty and children with additional needs

Children with additional needs are likely to go through the physical changes of puberty in the same way as other children.

Some children might have delayed physical development because of chronic health problems, which might cause a delay in the onset of puberty. How your child manages puberty emotionally might also be affected by additional needs. A health professional can answer any questions you might have about this.

Pubertal Milestones in Girls

Tanner stage	Breasts*	Standard	Pubic hair*	Standard	Growth	Other
1	Prepubertal, elevation of papilla only		Prepubertal, villus hair only	—	Basal: about 5.0 to 6.0 cm (2.0 to 2.4 in) per year	Adrenarche Ovarian growth
2	Breast bud appears under enlarged areola (11.2 years)		Sparse growth of slightly pigmented hair along the labia (11.9 years)		Accelerated: about 7.0 to 8.0 cm (2.8 to 3.2 in) per year	Clitoral enlargement Labia pigmentation Uterus enlargement
3	Breast tissue grows beyond areola without contour separation (12.4 years)		Hair is coarser, curled and pigmented; spreads across the pubes (12.7 years)		Peak velocity: about 8.0 cm (3.2 in) per year (12.5 years)	Axillary hair (13.1 years) Acne (13.2 years)
4	Projection of areola and papilla forms a secondary mound (13.1 years)		Adult-type hair but no spread to medial thigh (13.4 years)		Deceleration: < 7.0 cm (2.8 in) per year	Menarche (13.3 years) Regular menses (13.9 years)
5	Adult breast contour with projection of papilla only (14.5 years)		Adult-type hair with spread to medial thigh but not up linea alba (14.6 years)		Cessation at about 16 years	Adult genitalia

Pubertal Milestones in Boys

Tanner stage	Standard	Genitalia*	Pubic hair*	Growth	Other
1		Prepubertal Testes: < 2.5 cm (1.0 in)	Prepubertal, villus hair only	Basal: about 5.0 to 6.0 cm (2.0 to 2.4 in) per year	Adrenarche
2		Thinning and reddening of scrotum (11.9 years) Testes: 2.5 to 3.2 cm (1.0 to 1.28 in)	Sparse growth of slightly pigmented hair at base of penis (12.3 years)	Basal: about 5.0 to 6.0 cm (2.0 to 2.4 in) per year	Decrease in total body fat
3		Growth of penis, especially length (13.2 years) Testes: 3.3 to 4.0 cm (1.32 to 1.6 in)	Thicker, curlier hair spreads to the mons pubis (13.9 years)	Accelerated: about 7.0 to 8.0 cm (2.8 to 3.2 in) per year	Gynecomastia (13.2 years) Voice break (13.5 years) Muscle mass increase
4		Growth of penis and glands, darkening of scrotum (14.3 years) Testes: 4.1 to 4.5 cm (1.64 to 1.8 in)	Adult-type hair but no spread to medial thigh (14.7 years)	Peak velocity: about 10.0 cm (4.0 in) per year (13.8 years)	Axillary hair (14.0 years) Voice change (14.1 years) Acne (14.3 years)
5		Adult genitalia (15.1 years) Testes: > 4.5 cm (1.8 in)	Adult-type hair with spread to medial thighs but not up linea alba (15.3 years)	Deceleration and cessation (about 17 years)	Facial hair (14.9 years) Muscle mass continues to increase after Stage 5

Causes & Risk Factors of abnormal puberty

Causes may include:

• Heredity
• Hormonal disorders – including polycystic ovary syndrome (POS)
• Genetic disorders
• Problems in the pituitary or thyroid glands that produce the hormones necessary for body growth and development
• Chromosome disorders that interfere with normal growth processes
• Eating disorders
• Excessive exercise
• Tumors
• Infections
• Chemotherapy
• Other underlying medical condition or injury 

Symptoms & Types of abnormal puberty

Symptoms may include:

• Lack of breast development by age 13
• Lack of pubic hair by age 14
• More than 5 years between breast development and first period
• Period hasn’t started by age 16
• Breast growth, period, pubic hair and other signs of puberty occur before age 7 or 8

Types of Puberty Disorders:

• Delayed puberty – puberty hasn’t started by age 13
• Precocious puberty – puberty begins too early, before age 7 or 8 in girls
• Contrasexual pubertal development – development of male characteristics in females
• Premature thelarche – breast development without any other signs of puberty
• Premature menarch – periods start without any other signs of puberty
• Premature adrenarche – appearance of pubic hair without any other signs of puberty

Diagnosis & Tests for abnormal puberty

Diagnosis starts with a detailed medical history and a thorough physical exam, including pelvic and breast exams when necessary.

Diagnostic testing may include:

• X-ray of the hand/wrist – to determine bone age
• Blood tests – to measure hormone levels and check for chromosomal abnormalities and other conditions
• MRI (magnetic resonance imaging) or CT scan – to rule out abnormalities in the brain or pituitary gland
• Thyroid testing
• Ultrasound – to examine the health of the ovaries and adrenal glands

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