By Chiara Ghetti, MD
Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO
This consensus document was developed as a reference for physicians caring for and advising women in pregnancy following prior surgical treatment for pelvic floor disorders.
Wieslander CK, Weinstein MM, Handa VL, Collins SA. Pregnancy in women with prior treatments for pelvic floor disorders. Female Pelvic Med Reconstr Surg 2020;26:299-305.
Although the average age of women in my urogynecology practice is 55 years, there is an increasing number of reproductive-age women undergoing pelvic floor reconstructive surgery. Jonsson et al reports 25% of pelvic floor reconstructive surgeries are performed in women younger than age 45 years, some of which also include slings.1 Concurrently, the birth rate among older women is additionally on the rise. Guidance on pregnancy after surgery for pelvic floor disorders is sparse. The main objective of this study was to summarize evidence regarding the effect of pregnancy on women who previously have undergone treatment for pelvic floor disorders. This was a comprehensive literature review performed in 2018. A literature search for English language publications was performed using Medline and Scopus terms, including pregnancy, delivery, and pelvic floor disorders. Data were not sufficient for a systematic review or for issuance of formal practice guidelines. The overall evidence was Level III, expert opinion. The key findings and recommendations are summarized in three broad categories of pregnancy and childbirth: after surgery for incontinence, after surgery for pelvic organ prolapse, and after repair of obstetric anal sphincter laceration. The major findings are reviewed here.
Pregnancy after surgery for incontinence: The authors reviewed the evidence regarding stress incontinence outcomes following pregnancy and delivery after miduretheral sling retropubic colposuspension, pubovaginal sling, and artificial sling. A cohort study comparing women having undergone midurethral sling to women undergoing pregnancy and delivery without prior sling found there was not an increased risk of stress incontinence following pregnancy and delivery in women with prior sling. The remainder of cited studies consists of case reports and case series. These also suggest that women maintain continence following pregnancy after surgical treatment of stress incontinence. Regarding risk and safety concerns for pregnant women who previously have had surgery, a 2012 systematic review concluded there is not a significant risk.2 However, case reports describe the possibility of voiding dysfunction and urethral obstruction that may present in the second trimester and may require sling revision. In pregnant women with a prior sling, there are insufficient data to determine whether rates of recurrent incontinence differ between women delivering vaginally or via cesarean section. The authors of this summary concur that it is reasonable to make the decision regarding route of delivery on an individual basis.
Evidence was reviewed regarding pregnancy in women who previously have had implantation of sacral neuromodulation. Both the device manufacturer and the International Urogynecological Association recommend turning off a neurostimulator device during a pregnancy.3 Survey and case series data suggest that one-third of women may leave their device turned on. Women who did not turn off the device reported stable symptoms during pregnancy, while those who discontinued its use experienced bothersome urinary symptoms. Data are insufficient to make precise conclusions about the risks of sacral neuromodulation in pregnancy and regarding the effect of the mode of delivery on device malfunction. Again, it is recommended that sacral neuromodulation devices be turned off during pregnancy.
Pregnancy after surgery for pelvic organ prolapse: Women who undergo hysteropexy, and, therefore, retain their uterus, may subsequently experience a pregnancy. Data are very limited regarding the risk of recurrence, safety concerns, and mode of delivery. Extensive preoperative counseling is recommended before uterine-sparing procedures. This counseling should include the recommendation of effective and long-acting contraception. Preoperative counseling should discuss the possibility of a prolapse recurrence following pregnancy and the possible need for cesarean delivery. An informed discussion of prolapse management always includes conservative management; in this instance, pessary management until the completion of childbearing should be discussed for women who have not completed childbearing.
Pregnancy after surgery for repair of obstetrical anal sphincter laceration: Data on which to base recommendations regarding obstetric anal sphincter injury (OASI) vary widely. The risk of recurrence of OASI is estimated to be between 4% and 10%, and the risk appears to be similar to the risk of primary OASI. Reducing the risk of recurrent OASI was discussed in a 2014 Cochrane review and included interventions ranging from pelvic floor muscle strengthening to elective cesarean delivery.4 The risk of long-term anal incontinence with recurrent OASI may be significant. Recommendations regarding the mode of delivery after a prior OASI vary widely also. Vaginal delivery may be a safe option in women with prior OASI and no anal incontinence symptoms. Providers are urged to counsel pregnant women with a history of prior OASI extensively regarding mode of delivery options, with consideration of anal incontinence symptoms, risks of repeat OASI, and the surgical risk of cesarean delivery.
COMMENTARY
This review illustrates that overall there is a paucity of data to guide counseling for women regarding the risks and possible effects of surgery for pelvic floor disorders on future pregnancy and delivery, as well as the effects of pregnancy on surgery outcomes.
Women should be informed about the limited data available. Counseling at the time of initial surgery and during subsequent pregnancies should include the full range of management options and include contraceptive management options. Women and providers are encouraged to participate in a shared decision-making model.
REFERENCES
- Jonsson Funk M, Levin PJ, Wu JM. Trends in the surgical management of stress urinary incontinence. Obstet Gynecol 2012;119:845-851.
- Pollard ME, Morrisroe S, Anger JT. Outcomes of pregnancy following surgery for stress urinary incontinence: A systematic review. J Urol 2012;187:1966-1970.
- International Urogynecological Association. Sacral neuromodulation: A guide for women. https://www.yourpelvicfloor.org/media/Sacral_Neuromodulation_RV1.pdf
- Farrar D, Tuffnell DJ, Ramage C. Interventions for women in subsequent pregnancies following obstetric anal sphincter injury to reduce the risk of recurrent injury and associated harms. Cochrane Database Syst Rev 2014 Nov 6;CD010374. doi: 10.1002/14651858.CD010374.pub2.
