Prevalence of Uterus Prolapse in Pregnant Females of Lahore: A Cross-sectional Survey

Uterus prolapse is a common gynecological condition which is relatively less common during pregnancy. Prolapse maybe conceptualized as a type of herniation or bulge of the pelvic organs into or out of the vagina because of damage or weakness of connective tissues and muscles of pelvic floor area Objective: The objective was to determine the prevalence of uterus prolapse among pregnant females. Methods: This cross-sectional study was conducted in pregnant females. Sample size of 189 was calculated. Standardized questionnaire was used for data collection Results : A bulge or protrusion falling out that you can see or feel in your vagina was moderately present in 5.3% (10) females. Heaviness in the pelvic area was felt by 6.9% (13) females. Along with prolapse there was weakness in pelvic floor muscles and ligaments so that the leakage of urine is present in 3.7% (7) females Conclusions: Uterus prolapse is mildly present in 8.5% and moderately present among 5.3% of pregnant females varying with their age, parity and strength of pelvic floor structures. All females with prolapse have a bulge in their vagina but its severity is different in every woman.


INTRODUCTION
The lowering down of the uterus due to reduced muscular and ligament support towards or out of the vagina is known as uterus prolapse [1]. The structural, genomic, lifestyle and functional factors contribute to the dysfunction of muscles and ligaments of pelvic floor area that lead to uterus prolapse [2]. Uterus prolapse is a common gynaecological condition which is relatively less common during pregnancy [3]. In pregnancy uterus prolapse can occur in any trimester but is mostly seen in first two trimesters if it was pre-existing but newly develop in third trimester [4]. Prolapse maybe conceptualized as a type of herniation or bulge of the pelvic organs into or out of the vagina because of damage or weakness of connective tissues and muscles of pelvic floor area [5]. Uterus prolapse is found to be larger in societies those are less affluent and where parity is high, childbearing starts earlier, pre-existing family history, proceeding age, obesity, increased BMI, severe constipation are the most common risk factors. Uterus prolapse is mostly found in Spanish and British females in comparison with Asian lineage because of inherited racial changes in structure and function of pelvis as well as strength of pelvic floor muscles and ligaments [6,7]. Influencing factors for prolapse include multi gravidum with more vaginal deliveries, forceps deliveries, severe coughing, obesity [8]. Both genetic and obstetrical factors can contribute for the occurrence of uterus prolapse. Abnormality and weakness in the structure of pelvis or presence of ovarian bulk that causes repetitive increase in intra-abdominal pressure, early age pregnancy, prolonged labour, history of trauma to pelvis and higher body mass index are the predisposing factors for prolapse [9]. Pelvic floor muscles and connective tissues play a significant role in providing support to uterus and other pelvic organs so severity of uterus prolapse increases with the increasing deficiency in the pelvic floor muscles and by failure in support of connective tissues because the load shift from affected muscles to the connective tissues [10]. In some countries some daily activities are major risk factors for the occurrence of uterus prolapse in females; as carrying heavy loads during pregnancy and in early postpartum period, unprofessional doctors and attendants at the time of birth, progression in pregnancies and undernourishment because of absence of healthy food [11].
Smoking is very common risk factor in development of prolapse uterus in the women having COPD because it provokes cough, as severe coughing increases abdominal pressure that lead towards the prolapse [12]. Any surgery of pelvic area and medical treatment and care in previous pregnancy and during childbirth are linked with the occurrence of uterus prolapse [13]. Vaginal childbirth process is strongest factor for the development of prolapse because during vaginal birth neuromuscular disruption occurs as the damage occur to the levator muscles including its nerve supply that results in improper functioning of muscle. Connective tissues as ligaments hold the pelvic organs but if the damage is severe then it fails to bear the load of pelvic organs and that causes prolapse. Increasing age and menopause are contributing factors for uterus prolapse [14]. Elastin expression is a major influencing factor for prolapse as age increases the level of elastin expression decreases that results in decreasing elasticity in the ligaments [15]. Treatment for reducing uterus prolapse is physiotherapy of pelvic region by doing Kegel exercises. Physiotherapist perform assessment to rule out prolapse then tell its prevention and according to assessment a treatment is done. Physiotherapy is beneficial to reduce the severity of prolapse and its reoccurrence during pregnancy and it improves the functions of pelvic floor muscles and connective tissues by strengthening them. Different therapies are used to strengthen the pelvic floor as physical activity, coordination and behavioural therapy, training of bowel and bladder functioning, muscle stimulation and training for endurance and power and biofeedback [16].

METHODS
It was a cross sectional observational survey-based study. Data were collected from pregnant females from hospitals of Lahore: Services Hospital, Sheikh Zayed Hospital, Doctors Hospital, Hameed Latif Hospital, Lady Wallington Hospital, Sir Ganga Ram Hospital, University of Lahore Teaching Hospital and Nawaz Sharif Social Security Hospital Lahore, Pakistan. Non-probability convenient sampling technique was used to collect data. Calculated sample size was 189. Pregnant females (coming to OPD for regular checkups), Any trimester, No restriction of number of pregnancies, Age range: 25-48 years, Both hospital setups: Government as well as Private. History of trauma, History of abortions, any other medical condition like hernia, Pre-diagnosed chronic disease; Uterine fibroids, Uterine cancer, Interstitial cystitis, Endometriosis, Polycystic Ovarian Syndrome (PCOS) etc, Look alike conditions differentiated by gynecologist and urologist: Irritable Bowel Syndrome (IBS), Constipation, Urethral prolapse, Cystocele etc, Any sexual violence were excluded. A standardized questionnaire already used in published research was opted to collect data in this study.

Data Analysis:
Data were entered in SPSS latest version. Qualitative variables were presented as frequency (%) and continuous variables as mean ± standard deviation. graphs were formulated afterwards to find out the prevalence of uterus prolapse among pregnant females.

RESULTS
Results show that feeling of bulge or protrusion falling out in vaginal area was not present in 73% of patients while 13.2% of participants didn't feel it previously, 10% had mild experience while 5.3% had moderate feeling ( Table 1). Experience of heaviness in pelvic area was not felt in 46%, mild in 6.9% and moderate in 1.6% of the This work is licensed under a Creative Common Attribute 4.0 International License participants ( Table 2). Leakage of urine related to coughing or sneezing is not present in 68.3% (129), experienced previously by 28% (53), mildly by 3.7% (7) (Figure 1).  Table 2: Experiencing heaviness or dullness in the pelvic area

DISCUSSION
Study in Sweden included females that were inspected by Samuelsson et.al. According to this study 30.8% females have uterus prolapse of any stage. The uterus descend till the opening of vagina in 2% females. Age of females, muscle power of pelvic area and birth load were directly or indirectly linked with uterus prolapse but weight of female is not responsible for development of prolapse [17].