OBSTETRICS & GYNAECOLOGY
Comprehensive Clinical Notes
Source: D.C. Dutta's Textbook of Obstetrics & Gynaecology
Topic 1
TWIN PREGNANCY
(Multiple Gestation)
Topic 2
UTERINE PROLAPSE
(Pelvic Organ Prolapse)
For MBBS / MD / PG Entrance Preparation
TOPIC 1: TWIN PREGNANCY
Chapter reference: D.C. Dutta's Obstetrics — Chapter on Multiple Pregnancy (Multifoetal Gestation)
1. DEFINITION
Twin pregnancy is the development of TWO fetuses simultaneously in the uterus. When more than two fetuses develop simultaneously, it is called Higher Order Multiple Pregnancy (triplets, quadruplets, etc.).
Incidence of twins: 1 in 80 pregnancies (Hellin's Law). Triplets: 1 in 80², Quadruplets: 1 in 80³.
2. TYPES OF TWIN PREGNANCY
A. Monozygotic (MZ) Twins — Identical Twins
Arise from a SINGLE fertilized ovum (zygote) that splits into two. Always same sex, same genetic makeup, blood group identical.
- Incidence: ~1 in 250 pregnancies — CONSTANT worldwide (not influenced by race/heredity/drugs)
- Cause: Unknown; possibly defect in zona pellucida or inner cell mass
- Always same sex and genetically identical
B. Dizygotic (DZ) Twins — Fraternal / Non-identical Twins
Arise from fertilization of TWO separate ova by TWO different sperms. May be same or different sex. More common than MZ twins.
- Incidence: Variable — influenced by race, heredity, maternal age, parity, drugs (ovulation induction)
- May be different sex — genetically like ordinary siblings
- Always dichorionic diamniotic (DCDA)
| Monozygotic (Identical) | Dizygotic (Fraternal) |
|---|---|
| Single ovum + Single sperm | Two ova + Two sperms |
| Always same sex | May be same or different sex |
| Identical genotype | Different genotype |
| 1 in 250 (constant) | 1 in 80 (variable) |
| Can be: DC/DA, MC/DA, MC/MA | Always DCDA |
| Not inherited — sporadic | Familial — maternal side mainly |
3. CHORIONICITY — KEY CONCEPT
The most important classification in twin pregnancy is based on CHORIONICITY and AMNIONICITY (number of placentas and amniotic sacs).
FIGURE 1: Chorionicity Based on Timing of Zygote Division (MZ Twins)
Fertilized Egg Splits at Different Times → Different Chorionicity Day 0-3 (Morula stage): ┌─────────────────────────────────────────────┐ │ DICHORIONIC DIAMNIOTIC (DCDA) │ │ 2 Chorions + 2 Amnions + 2 Placentas │ │ Most common MZ type (~30%) — SAFEST │ └─────────────────────────────────────────────┘ Day 4-8 (Blastocyst stage): ┌─────────────────────────────────────────────┐ │ MONOCHORIONIC DIAMNIOTIC (MCDA) │ │ 1 Chorion + 2 Amnions + 1 Placenta │ │ ~70% of MZ twins — Risk: TTTS │ └─────────────────────────────────────────────┘ Day 8-13 (After implantation): ┌─────────────────────────────────────────────┐ │ MONOCHORIONIC MONOAMNIOTIC (MCMA) │ │ 1 Chorion + 1 Amnion + 1 Placenta │ │ Rare (~1%) — Very HIGH RISK │ │ Risk: cord entanglement + TTTS │ └─────────────────────────────────────────────┘ Day 13+ (Gastrulation): ┌─────────────────────────────────────────────┐ │ CONJOINED TWINS (Siamese Twins) │ │ Incomplete division — very rare │ └─────────────────────────────────────────────┘
ALL dizygotic twins are DCDA. Chorionicity matters more than zygosity for pregnancy outcomes.
Determining Chorionicity by Ultrasound
FIGURE 2: USG Signs to Determine Chorionicity
FIRST TRIMESTER USG (Best time: 11-14 weeks) DCDA (Dichorionic) MCDA (Monochorionic) ┌─────────────────┐ ┌─────────────────┐ │ TWIN PEAK SIGN │ │ T-SIGN │ │ (Lambda Sign) │ │ │ │ ▲ │ │ ───┬─── │ │ ╱│╲ │ │ │ │ │ ╱ │ ╲ │ │ │ (thin │ │ ╱ │ ╲ │ │ │ membrane)│ │Thick membrane │ │ │ │ │> 2mm │ │Thin membrane │ │Triangular wedge │ │< 2mm │ └─────────────────┘ └─────────────────┘ Triangular tissue of T-junction of placenta projects into membrane at inter-twin membrane placental insertion
4. DIAGNOSIS OF TWIN PREGNANCY
A. Symptoms (Patient Complaints)
- Excessive nausea/vomiting (hyperemesis) — due to high hCG
- Uterus larger than dates from early pregnancy
- Excessive weight gain and abdominal distension
- More fetal movements felt
- Breathlessness (due to high uterus pushing diaphragm)
B. Clinical Signs (Examination Findings)
- Uterus larger than dates — fundal height > expected weeks
- Palpation of 3 poles (heads/breech) — diagnostic if 3 poles felt
- Palpation of 2 fetal heads
- Auscultation: 2 fetal heart sounds at different areas, rate differing by >10 bpm
- Polyhydramnios — associated in ~12% cases
C. Investigations
- Rule / Standard (USG - Gold Standard): Confirms multiple gestations from 6-7 weeks. First trimester USG at 11-14 weeks determines chorionicity (twin peak sign vs T-sign)
- hCG levels: Higher than normal single pregnancies
- AFP (Alpha-fetoprotein): Elevated in twin pregnancy
- CBC/Hb: Anemia more common — check regularly
5. COMPLICATIONS OF TWIN PREGNANCY
Twins carry significantly higher risks than singleton pregnancies — both maternal and fetal.
A. Maternal Complications
| Complication | Reason | Note |
|---|---|---|
| Anaemia | Iron + Folate demand doubled | Very Common |
| Pre-eclampsia/Hypertension | 3-5x higher risk | Common |
| Gestational Diabetes | Higher due to placental hormones | Common |
| Hyperemesis Gravidarum | Excessive hCG production | Early pregnancy |
| Polyhydramnios | Especially in MCDA (TTTS) | ~12% |
| Preterm Labour | Uterine overdistension | Most common cause of loss |
| Antepartum Haemorrhage | Placenta praevia more common | Serious |
| Postpartum Haemorrhage | Uterine atony after delivery | Common |
| Operative delivery | Cesarean rate higher | ~50-60% |
| Maternal mortality | Overall risk higher | Serious |
B. Fetal/Perinatal Complications
- Preterm birth (<37 weeks) — most common cause of perinatal mortality in twins
- IUGR — Intrauterine Growth Restriction — one/both twins
- Twin-to-Twin Transfusion Syndrome (TTTS) — specific to MCDA
- Congenital malformations — more common in MZ twins
- Cord entanglement/prolapse — especially MCMA twins
- Malpresentations — breech/transverse common
- Perinatal mortality — 5-6x higher than singletons
- Twin B at higher risk than Twin A
- Vanishing twin syndrome — resorption of one fetus in first trimester
C. Twin-to-Twin Transfusion Syndrome (TTTS) — Special Topic
TTTS occurs ONLY in Monochorionic twins (shared placenta) due to arteriovenous anastomoses.
FIGURE 3: Twin-to-Twin Transfusion Syndrome (TTTS)
TTTS — Blood Flow Imbalance in Shared Placenta
DONOR TWIN (Pump Twin) RECIPIENT TWIN
┌───────────────┐ ┌───────────────┐
│ SMALL │ ─────► │ LARGE │
│ Anaemic │ Blood │ Polycythaemia
│ OLIGURIA │ flow │ POLYURIA │
│ Oligohydramn.│ │ Polyhydramn.│
│ 'Stuck twin' │ │ Heart failure│
│ IUGR │ │ Hydrops │
└───────────────┘ └───────────────┘
▼ ▼
May die from May die from
severe anaemia cardiac failure
+ IUGR + Hydrops
Diagnosis: USG — Oligohydramnios (DVP<2cm) in one
Polyhydramnios (DVP>8cm) in other
Quintero Staging of TTTS
| Stage | Features | Status |
|---|---|---|
| Stage I | Oligohydramnios/Polyhydramnios present | No bladder visible yet |
| Stage II | Donor bladder NOT visible | Stuck twin |
| Stage III | Abnormal Doppler (absent/reversed end-diastolic flow) | Compromised |
| Stage IV | Hydrops in either twin | Severe |
| Stage V | Intrauterine death of one or both | Critical |
Treatment of TTTS: Fetoscopic laser ablation of anastomotic vessels (definitive), Serial amnioreduction (palliative), Septostomy
6. ANTENATAL MANAGEMENT
A. General Antenatal Care
- Register early — book by 8-10 weeks
- Increased frequency of ANC visits — every 2 weeks after 28 weeks, weekly after 36 weeks
- Iron + Folic acid supplementation doubled — Iron 60mg BD + Folic acid 5mg OD
- Diet advice — high calorie, high protein
- Bed rest advised from 28-32 weeks — reduces preterm labour risk
- Cervical length monitoring by TVS — shorten cervix (<25mm) = risk of preterm
- Progesterone (vaginal) for cervical length <25mm to prevent preterm labour
B. Monitoring Schedule
| Timing | What to Check | Why |
|---|---|---|
| Every visit | Blood pressure, weight, urine protein | Detect pre-eclampsia early |
| Each trimester | USG for growth, liquor, Doppler | Detect IUGR/TTTS |
| 11-14 weeks | NT scan + chorionicity determination | CRITICAL — first trimester |
| 18-22 weeks | Anomaly scan (both twins) | Malformations |
| 24 weeks onwards | Repeat growth scans every 4 weeks | For DCDA |
| Every 2 weeks (MCDA) | Growth + Doppler + AFI | TTTS surveillance |
| 28 weeks | CBC, Blood glucose | Anaemia + GDM |
| 36 weeks | Presentation, Bishop score | Plan mode of delivery |
7. PRESENTATIONS OF TWINS
FIGURE 4: Presentations in Twin Pregnancy
POSSIBLE PRESENTATIONS OF TWINS Twin A Twin B Frequency ────────────────────────────────────────────── Vertex + Vertex = ~45% (Most common) Vertex + Breech = ~35% Breech + Vertex = ~10% (Risk: locking!) Breech + Breech = ~5% Transverse + Any = ~5% LOCKED TWINS: ┌─────────────────────────────────────┐ │ Twin A = Breech, Twin B = Vertex │ │ Chins interlock — EMERGENCY │ │ Occurs rarely but life-threatening │ │ Zarst maneuver / C-section needed │ └─────────────────────────────────────┘
Most common presentation: Vertex-Vertex (45%). Most common indication for C-section in twins: Malpresentation.
8. INTRAPARTUM MANAGEMENT (Labour & Delivery)
A. Prerequisites for Vaginal Delivery
- Both twins vertex presentation
- Adequate pelvis
- No other obstetric complication
- Senior obstetrician present
- Neonatology team available
- OT ready for emergency cesarean
- Two IV lines, blood available
B. Cesarean Section Indications
- Twin A in non-vertex presentation
- MCMA twins (cord entanglement risk)
- Previous cesarean section
- Fetal distress
- Placenta praevia
- Very preterm twins (<32 weeks) — many units do C-section
C. Management of Labour — Step by Step
FIGURE 5: Intrapartum Care Flowchart
INTRAPARTUM CARE FLOWCHART FOR TWINS
FIRST STAGE
├─ IV access (2 lines), blood grouped & cross-matched
├─ Continuous CTG (both twins — dual CTG monitor)
├─ Epidural recommended (for emergency manoeuvres)
├─ ARM of Twin A when head is engaged
└─ Partogram monitoring
DELIVERY OF TWIN A (normal vertex delivery)
└─ Clamp and cut cord IMMEDIATELY
INTERVAL BETWEEN TWINS (should be <30 min)
├─ Check lie of Twin B by abdominal palpation + USG
├─ Auscultate FHR of Twin B continuously
├─ If Twin B is VERTEX → await spontaneous labour
├─ If Twin B is OBLIQUE → external cephalic version (ECV)
└─ If Twin B is TRANSVERSE → internal podalic version (IPV)
+ Breech extraction
DELIVERY OF TWIN B
└─ Watch for cord prolapse, fetal distress
THIRD STAGE
├─ Active management (oxytocin 10 units IV/IM)
├─ Higher risk of PPH — Oxytocin infusion continued
└─ Examine placenta — count amnions and chorions
Internal Podalic Version (IPV) is done ONLY for Twin B — NEVER for singleton or Twin A!
9. PRETERM TWINS — MANAGEMENT
- Twins naturally deliver earlier: Mean GA at delivery ~37 weeks (DCDA), 35-36 weeks (MCDA)
- Tocolysis with nifedipine or indomethacin if <34 weeks
- Corticosteroids (Betamethasone 12mg IM x2 doses, 24 hrs apart) — given if 24-34 weeks
- Magnesium sulfate — for neuroprotection if <32 weeks
- NICU team to be on standby
10. TIMING OF DELIVERY (RCOG / DC DUTTA GUIDELINES)
| Type | Recommended Delivery | Reason |
|---|---|---|
| DCDA uncomplicated | 37-38 weeks | Elective delivery |
| MCDA uncomplicated | 36-37 weeks | Earlier due to shared placental risks |
| MCMA | 32-34 weeks | Very high risk — early delivery |
| TTTS Stage I-II | 34-36 weeks | After laser therapy |
| TTTS Stage III-V | 32-34 weeks | After stabilization |
| Complicated twins (IUGR/FD) | Individualized | Depends on Doppler/CTG |
Monochorionic twins are always delivered EARLIER than dichorionic twins because of shared placental risks.
11. POSTPARTUM CARE
- Watch for Postpartum Haemorrhage (PPH) — uterine atony most common
- Oxytocin infusion (20-40 units in 500ml NS) after delivery
- Examine placenta — count lobes, count umbilical cord vessels
- Check inter-twin membrane histology — confirm chorionicity
- Breastfeeding support — twin breastfeeding techniques
- Psychological support — parenting twins is demanding
- Contraception advice before discharge
EXAM MEMORY BOX: Twins → Hellin's Law (1:80) | Chorionicity by USG at 11-14 weeks | Twin peak vs T-sign | TTTS only in MC twins | IPV only for Twin B | Active 3rd stage mandatory | MCQ favourite — TTTS Quintero staging
TOPIC 2: UTERINE PROLAPSE
Chapter reference: D.C. Dutta's Gynaecology — Chapter on Genital Prolapse / Pelvic Organ Prolapse
1. DEFINITION
Uterine prolapse (Descensus uteri) is the descent or herniation of the uterus from its normal anatomical position downward through and out of the vaginal canal, due to weakness or damage to the supporting structures of the pelvis.
Normal position of uterus: Anteverted, anteflexed, in the axis of the vaginal canal, supported by ligaments and pelvic floor muscles.
2. SUPPORTS OF THE UTERUS — ANATOMY
The uterus is supported by several structures. Weakness in any causes prolapse:
FIGURE 6: Supports of the Uterus
SUPPORTS OF THE UTERUS DIRECT SUPPORTS (Most Important): ┌──────────────────────────────────────────────┐ │ 1. Pelvic floor muscles (Levator ani) │ │ — Pubococcygeus, Iliococcygeus, │ │ Ischiococcygeus (Coccygeus) │ │ 2. Perineal body │ │ 3. Urogenital diaphragm │ └──────────────────────────────────────────────┐ LIGAMENTOUS SUPPORTS: ┌──────────────────────────────────────────────┐ │ Transverse Cervical (Mackenrodt's) │ ← MOST IMPORTANT │ — Cardinal ligaments │ │ Uterosacral ligaments │ │ Pubocervical ligaments │ │ Round ligaments (Weak — maintain AF only) │ └──────────────────────────────────────────────┘ NOTE: Round ligaments do NOT support against prolapse! MACKENRODT's ligaments are the STRONGEST support.
3. DEGREES / CLASSIFICATION OF UTERINE PROLAPSE
FIGURE 7: Degrees of Uterine Prolapse
DEGREES OF UTERINE PROLAPSE NORMAL POSITION: ┌──────────────────────────────────┐ │ Uterus in normal position │ │ Cervix at ischial spine level │ └──────────────────────────────────┘ FIRST DEGREE: SECOND DEGREE: ┌─────────────────────┐ ┌─────────────────────┐ │ Cervix descends │ │ Cervix at introitus │ │ within vagina │ │ or protrudes out │ │ Does not come out │ │ on straining │ │ Felt on examination│ │ Body still inside │ └─────────────────────┘ └─────────────────────┘ THIRD DEGREE (Procidentia): ┌──────────────────────────────────────────┐ │ COMPLETE PROLAPSE of uterus │ │ Entire uterus + vagina outside │ │ Vagina inverted completely │ │ Cervix and body both outside vulva │ │ Associated with cystocele, rectocele │ └──────────────────────────────────────────┘
| Grade | Description | Key Feature |
|---|---|---|
| First Degree | Cervix descends within vagina; does not come out | Felt only on examination |
| Second Degree | Cervix at or just outside vaginal introitus | Visible on straining/standing |
| Third Degree (Procidentia) | Entire uterus + inverted vagina lies outside vulva | Always visible; most severe |
POP-Q System (Pelvic Organ Prolapse Quantification)
Modern standardized system using hymen as reference point (0). Points above hymen = negative, below = positive.
- Stage 0: No prolapse — all reference points above hymen
- Stage 1: Leading edge > 1cm above hymen
- Stage 2: Leading edge within 1cm of hymen (above or below)
- Stage 3: Leading edge > 1cm below hymen but not complete eversion
- Stage 4: Complete eversion (procidentia)
4. ASSOCIATED PROLAPSE CONDITIONS
Uterine prolapse is rarely alone. It is usually associated with prolapse of adjacent organs:
| Condition | Meaning | Note |
|---|---|---|
| Cystocele | Bladder descent into anterior vaginal wall | Most common association |
| Urethrocele | Urethra descent with cystocele | Often together |
| Cystourethrocele | Both bladder + urethra descend | Most common anterior prolapse |
| Rectocele | Rectal descent into posterior vaginal wall | Second most common |
| Enterocele | Peritoneal sac containing bowel into vaginal vault | Rare; seen in procidentia |
| Vault prolapse | After hysterectomy — vaginal apex descends | Post-hysterectomy complication |
FIGURE 8: Associated Prolapse — Anterior, Central, Posterior
CROSS-SECTION: STRUCTURES IN PROLAPSE
ANTERIOR WALL UTERUS POSTERIOR WALL
▼ ▼ ▼
┌──────────┐ ┌──────────┐ ┌──────────┐
│ Bladder │ │ CERVIX │ │ Rectum │
│ │◄──────►│ & │◄──────►│ │
│CYSTOCELE │ │ BODY │ │RECTOCELE │
└──────────┘ └──────────┘ └──────────┘
↓ ↓ ↓
Ant vaginal wall Descends into Post vaginal wall
bulges forward vaginal canal/ bulges backward
outside vulva
5. ETIOLOGY (CAUSES)
A. Predisposing Factors
- Congenital weakness of pelvic floor and ligaments
- Race — more common in white/Asian women than black women
- Connective tissue disorders (Marfan syndrome, Ehlers-Danlos)
B. Precipitating Factors — MOST IMPORTANT
The most important cause of uterine prolapse is damage and stretching of supports during childbirth (obstetric trauma).
- Obstetric causes (MOST COMMON):
- Multiple pregnancies and deliveries (grand multipara)
- Prolonged labour — weakens levator ani and ligaments
- Difficult instrumental delivery — forceps/ventouse
- Large baby delivery
- Premature bearing down before full dilatation
- Poor perineal repair after episiotomy/tear
- Increased intra-abdominal pressure:
- Chronic cough (COPD, bronchitis) — common cause in India
- Chronic constipation — straining at stool
- Ascites, large abdominal tumors
- Heavy manual labour, lifting heavy weights
- Hormonal/Menopausal:
- Estrogen deficiency after menopause → ligaments and pelvic floor atrophy
- Most women present years after menopause
Most common cause: Grand multiparity + Obstetric trauma + Chronic raised intra-abdominal pressure. Most common symptom: Something coming down per vaginum (feeling of lump).
6. CLINICAL FEATURES
A. Symptoms
| Symptom | Cause | Note |
|---|---|---|
| Dragging/bearing down sensation | Most common symptom | Worse on standing, relieved lying down |
| Feeling of something coming down | Pathognomonic complaint | Patient notices bulge/lump at vulva |
| Difficulty in walking/sitting | In severe prolapse | Due to external prolapse |
| Backache (low) | From stretched ligaments | Worse at end of day |
| Frequency of micturition | From cystocele/urethrocele | Incomplete bladder emptying |
| Stress urinary incontinence (SUI) | Leakage on cough/sneeze | With cystocele/urethrocele |
| Urinary retention | In procidentia — kinking of urethra | Paradoxical retention |
| Constipation / Incomplete defecation | From rectocele | Digitation to defecate |
| Leukorrhoea / Discharge | Congestion and infection | White/yellow discharge |
| Bleeding/Ulceration | Decubitus ulcer on prolapsed cervix | From friction with clothes |
| Infertility/Menstrual changes | In young women | Less common |
B. Physical Examination Findings
- General: Anaemia, evidence of chronic cough, malnutrition in some
- Inspection: Bulge at introitus visible on straining — type of prolapse identified
- Cystocele: Smooth anterior vaginal wall bulge (like cyst), appears on straining
- Rectocele: Posterior vaginal wall bulge, may contain bowel loops
- Speculum examination: Identify cervix position, any decubitus ulcer
- Bimanual examination: Assess uterine size, mobility, tenderness
- Rectal examination: Confirm rectocele
C. Decubitus Ulcer — Important Finding in Procidentia
The exposed cervix and vagina develop ulcers due to friction against clothing:
- Site: Anterior lip of cervix and anterior vaginal wall
- Character: Punched out, clean margins, non-tender usually
- Discharge: Purulent/blood-stained
- Biopsy mandatory to rule out malignancy
7. INVESTIGATIONS
- Routine: CBC, urine analysis, urine culture (UTI common), blood group
- Pap smear/Cervical biopsy: Mandatory before surgery — rule out cervical cancer
- USG pelvis: Assess uterus, ovaries, kidney (for hydronephrosis)
- Urodynamic studies: For stress urinary incontinence assessment before surgery
- IVU/CT urogram: If urinary tract involvement suspected
- Endometrial sampling (D&C): If menstrual abnormality present
8. MANAGEMENT OF UTERINE PROLAPSE
Management depends on: Grade of prolapse, Age of patient, Desire for future fertility, Associated medical conditions, Patient's preference
A. Conservative Management
Conservative treatment for: Grade 1 prolapse, elderly high-risk patients, women desiring future pregnancy, those refusing surgery
- 1. Pelvic floor exercises (Kegel exercises):
- Repeated voluntary contraction of pubococcygeus muscle
- 30-80 contractions per day in 3 sets
- Effective for Grade 1, prevention, stress incontinence
- 2. Pessary treatment:
- Ring pessary (most common) — inserted into vagina to support uterus
- Shelf pessary for procidentia
- Gelhorn pessary for procidentia with SUI
- Changed every 3-6 months — patient monitored
- INDICATION: Waiting for surgery, elderly unfit for surgery, pregnancy, patient preference
FIGURE 9: Ring Pessary Mechanism
RING PESSARY — How It Works Side View: Cross-Section of Vagina: ┌────────────────┐ ┌─────────────────────┐ │ Uterus │ │ Uterus │ │ ↑ │ │ ↑ │ │ Cervix │ │ Cervix │ │ ↑ │ │ ↑ │ │ ╔══════╗ │ │ ╔════════╗ │ │ ║ RING ║ │ │ ║ RING ║ │ │ ╚══════╝ │ │ ╚════════╝ │ │ (in upper │ │ Rests in │ │ vagina) │ │ vaginal fornix │ └────────────────┘ └─────────────────────┘ Ring supports uterus from below — prevents descent Must be changed every 3-6 months
- 3. Local estrogen cream:
- For postmenopausal women — improves vaginal tissue quality
- Estriol cream applied vaginally before surgery
- Helps in healing and reduces complications of surgery
B. Surgical Management — Definitive Treatment
Surgery is the definitive treatment for symptomatic prolapse in fit women who have completed their family.
Types of Operations:
- 1. Fothergill's Operation (Manchester Operation):
For young women who want to preserve uterus and fertility- STEPS: Anterior colporrhaphy + Amputation of cervix + Suturing of cardinal (Mackenrodt's) ligaments in front of cervical stump + Posterior colpoperineorrhaphy
- Preserves uterus — patient can still get pregnant after this
- Best for Grade 2 prolapse in premenopausal women
- 2. Vaginal Hysterectomy + Pelvic Floor Repair:
Standard operation for completed family, perimenopausal/postmenopausal- Uterus removed vaginally
- Anterior colporrhaphy (repair of cystocele)
- Posterior colpoperineorrhaphy (repair of rectocele + perineum)
- Vault supported by attaching to uterosacral/cardinal ligaments
- Most commonly performed definitive surgery
- 3. Pelvic Floor Repair Only (Colporrhaphy):
- Anterior colporrhaphy — for cystocele/urethrocele alone
- Posterior colpoperineorrhaphy — for rectocele + perineal laxity
- When uterus is still in normal position but bladder/bowel prolapsed
- 4. Sacrospinous Fixation / Sacrocolpopexy (Vault Prolapse):
- After hysterectomy — vaginal vault is fixed to sacrospinous ligament
- Laparoscopic sacrocolpopexy — gold standard for vault prolapse
- Mesh used for support in abdominal approach
- 5. Le Fort's Operation (Colpocleisis):
Only for elderly women who are sexually inactive and unfit for major surgery- Anterior and posterior vaginal walls sutured together — closes vaginal canal
- Uterus remains inside — not removed
- Small channels left for uterine drainage
- Simple, fast, low blood loss — good for very old/frail patients
- IRREVERSIBLE — no coitus possible afterward
| Patient Profile | Surgery of Choice | Key Point |
|---|---|---|
| Young, fertility desired, Grade 2 | Fothergill's (Manchester) Operation | Preserves uterus |
| Completed family, any grade | Vaginal Hysterectomy + PFR | Standard operation |
| Cystocele only | Anterior colporrhaphy | No hysterectomy needed |
| Rectocele only | Posterior colporrhaphy | No hysterectomy needed |
| Post-hysterectomy vault prolapse | Sacrospinous fixation / Sacrocolpopexy | Laparoscopic best |
| Very elderly, sexually inactive, unfit | Le Fort's Operation (Colpocleisis) | Fast, safe, irreversible |
Pre-operative Preparation
- Treat decubitus ulcer — local antibiotics, estrogen cream 4-6 weeks before surgery
- Treat UTI if present — culture-specific antibiotics
- Treat anemia — iron supplementation
- Pap smear and biopsy if ulcer present — rule out cancer
- Bowel preparation — for rectal/posterior wall surgery
- Estrogen cream vaginally for 6 weeks in postmenopausal women — improves tissue quality
Post-operative Care
- Urinary catheter for 3-5 days (bladder rest after anterior repair)
- Liquid diet initially, then normal diet
- Avoid straining/constipation — stool softeners
- Avoid coitus for 3 months
- Pelvic floor exercises from 6 weeks post-op
- Follow up at 6 weeks, 3 months, 6 months, annually
9. STRESS URINARY INCONTINENCE (SUI) — Associated Problem
SUI = Involuntary leakage of urine on physical exertion (cough, sneeze, exercise, laughing). Caused by inadequate urethral support due to cystocele and pelvic floor weakness.
SUI is the most common urological complaint in women with prolapse. It may be MASKED in procidentia (kinked urethra causes urinary retention instead).
| Treatment | Description | Note |
|---|---|---|
| Conservative | Kegel exercises, weight loss, avoid caffeine | First line, Grade 1-2 |
| Physiotherapy | Biofeedback, electrical stimulation | For muscle retraining |
| Surgery | TVT (Tension-free Vaginal Tape) / TOT | Gold standard |
| TVT | Mesh tape placed under mid-urethra via suprapubic route | Burch colposuspension older alternative |
| TOT | Tape via transobturator route — less retropubic risk | Preferred by many now |
10. PROLAPSE IN PREGNANCY
- Usually Grade 1-2 only — Grade 3 is rare in pregnancy
- Improves during pregnancy — as uterus enlarges, it rises out of pelvis
- Conservative treatment preferred — ring pessary
- Surgery deferred until 3 months postpartum
- Risk of preterm labour with procidentia — careful monitoring needed
- Elective C-section in procidentia at term to avoid perineal trauma
11. PREVENTION OF UTERINE PROLAPSE
- Antenatal: Pelvic floor exercises from early pregnancy
- Intrapartum: Avoid prolonged labour, early recognition of obstructed labour
- Avoid vigorous fundal pressure (Kristeller maneuver)
- Proper perineal repair after episiotomy/laceration
- Postnatal: Early pelvic floor exercises after delivery
- Family planning: Limit number of pregnancies
- Treat chronic constipation, cough early
- Hormonal: HRT in postmenopausal women for at-risk patients
EXAM MEMORY BOX: Prolapse → Mackenrodt's (cardinal) ligament MOST IMPORTANT support | Decubitus ulcer — biopsy mandatory | Fothergill's for young (fertility preserved) | Le Fort's for old unfit | Vaginal hysterectomy + PFR for completed family | TVT/TOT for SUI | Procidentia = urinary RETENTION not incontinence (kinked urethra)
QUICK REVISION — HIGH-YIELD EXAM POINTS
Twin Pregnancy — Must Remember
- Hellin's Law: Twins 1:80, Triplets 1:6400 (80²), Quadruplets 1:512000 (80³)
- MZ twins incidence constant (1:250) — DZ twins variable (racial, drugs, age)
- Chorionicity by 1st trimester USG at 11-14 weeks: Twin peak sign (DCDA) vs T-sign (MCDA)
- TTTS: ONLY in monochorionic twins. Donor = oligohydramnios + anaemia. Recipient = polyhydramnios + polycythaemia
- Quintero staging I-V. Treatment: Fetoscopic laser ablation (definitive)
- Most common presentation: Vertex-Vertex (45%)
- Locked twins: Twin A breech + Twin B vertex — chin interlock — emergency
- IPV (Internal Podalic Version) ONLY for Twin B
- Interval between twins: < 30 minutes
- PPH active management mandatory — uterine atony most common 3rd stage complication
- DCDA delivery at 37-38 wks | MCDA at 36-37 wks | MCMA at 32-34 wks
Uterine Prolapse — Must Remember
- Most important support: Cardinal (Mackenrodt's / Transverse cervical) ligaments
- Most common cause: Grand multiparity + obstetric trauma + raised intraabdominal pressure
- Most common symptom: Feeling of something coming down per vaginum
- Decubitus ulcer: Biopsy mandatory to rule out malignancy
- Procidentia: Urinary RETENTION (not incontinence) — kinked urethra
- Pessary: Ring pessary most common — changed every 3-6 months
- Fothergill's (Manchester op): Young women + fertility desired
- Vaginal hysterectomy + PFR: Completed family — most common definitive surgery
- Le Fort's (Colpocleisis): Very old, frail, sexually inactive — closes vagina
- TVT / TOT: Surgery for stress urinary incontinence
- Preop: Treat ulcer + UTI + anemia; Estrogen cream 6 wks; Pap smear mandatory
