Vaginal hysterectomy in combination with apical suspension is the most common approach for addressing pelvic prolapse. However, this approach is counterproductive for women who desire future childbearing. It has been unclear how to counsel patients regarding their risk of pregnancy complications or recurrent prolapse symptoms following sacrohysteropexy.  However, there have been several recent case reports of successful deliveries after surgical repair with no relapse of prolapse symptoms. [1,2,3] 

The aim of this study is to evaluate the change in Pelvic Organ Prolapse Quantification (POP-Q) score in women who had a successful pregnancy and cesarean delivery after abdominal or robotic-assisted laparoscopic sacrohysteropexy. We hypothesized that women would have significant improvement in their apical prolapse after surgery, and maintain this improvement following delivery.

We performed a retrospective review of electronic medical records of patients with a diagnosis of uterine prolapse who underwent an abdominal or robotic-assisted laparoscopic sacrohysteropexy with polypropylene mesh during an eight-year period from January 2004 to December 2012. We searched the database for the CPT code corresponding with sacrocolpopexy and further identified those patients who had a uterine-sparing procedure. All patients were evaluated with the POP-Q scoring system pre-operatively, once between 6 and 24 weeks after prolapse surgery, and again between 6 and 24 weeks after delivery. The data was tabulated and analyzed using SAS software, version 9.4 (SAS Carry, NC). Student t-test for paired design was used to compare POP-Q scores for point Aa, Ba, and C pre- and post-operatively, as well as before and after delivery.

One hundred and sixty-four were performed during the index period. We identified 8 patients who met criteria for inclusion in the study. All study subjects were of reproductive age (26 to 34 years old, mean age 32), had at least one prior vaginal delivery, and had symptomatic pelvic organ prolapse with or without urodynamic stress urinary incontinence.  All patients underwent preoperative urodynamic studies prior to surgery. Three patients were excluded from the analysis: two of them did not conceive after the initial surgery, another patient was lost to follow-up after delivery. Of the 5 remaining patients, three had an abdominal sacrohysteropexy and two had a robotic-assisted laparoscopic procedure.  Three patients had a concomitant mid-urethral sling; one had a perineal repair. All the patients conceived between 2.5 and 4 years after the initial prolapse surgery. One patient required repeat mid-urethral sling. There were no instances of recurrent apical prolapse.  We observed a significant improvement in recorded POP-Q scores for point Aa, Ba and C after prolapse surgery. There was no significant change in these scores following pregnancy and cesarean delivery (Table 1, Table 2).

We noted significant improvement of the anterior compartment prolapse (POP-Q points Aa and Ba) among study subjects. However, the apical compartment (POP-Q point C) demonstrated the most significant and persistent improvement in scores during the observation period (mean difference 4 cm, p-value: 0.004), even after successful pregnancy and cesarean delivery (Table 2). The women in our study all delivered by cesarean section; the data does not address the option of vaginal delivery after surgical prolapse repair. Other authors have reported successful cases of vaginal delivery after sacrohysteropexy without recurrent prolapse.

Conservative management with observation, pelvic floor physical therapy or pessary is currently considered first-line therapy for management of pelvic organ prolapse among women who have not completed child-bearing. This study adds to a growing body of evidence which demonstrates that women managed definitively with sacrohysteropexy can expect to successfully carry pregnancies to term without significant relapse of their symptoms or anatomical failure up to 5 years after surgery. Further research is needed to determine the long-term risk of recurrent prolapse or the need for repeat surgical prolapse repair in women who become pregnant after initial sacrohysteropexy.

Pandeva I, Mistry M, Fayyad A. Efficacy and Pregnancy Outcomes of Laparoscopic Single Sheet Mesh Sacrohysteropexy. Neurourol Urodyn. 2017;36:787-793.
Balsak D, Eser A, Erol O, Altintas DD, Aksin S. Pregnancy and Vaginal Delivery after Sacrohysteropexy. Case Rep Obstet Gynecol. 2015:3.
Albowitz M, Schyrba V, Bolla D, Schoning A, Hornung R. Pregnancy After a Laparoscopic Sacrohysteropexy: a Case Report. Geburtshilfe Frauenheilkd. 2014 Oct;74:947-949.