Urogynaecological problems in pregnancy & postpartum

TOG – 2022 July

Background

common in pregnancy
Severity can be reduced with PFMT

prevalence increases with POG
Rx >>> conservative or medical

multifactorial.
Pelvic floor exercises & pessaries >>>> important Rx
Previous surgical Mx can affect MOD

Recurrent UTI

AB & non-AB prophylaxis

Urinary retention

can occur at any point during pregnancy & PP

Introduction

Stress urinary incontinence
Definition

Involuntary loss of urine
on effort or
physical exertion or
on sneezing or coughing
Commonest type of incontinence in pregnancy
Causes
reduced PFM strength
higher intra- abdominal pressures
constipation
increasing with POG
MOD can affect postpartum SUI
Smoking
Mx >>>
Conservative Mx with PFMT >>
o 1st line Rx
o Prevents SUI
o decreases the severity
o no evidence on reducing urinary leakage
Intravaginal or intraurethral devices
o NICE 2019 do not recommend for routine Mx
o case-by-case basis
Surgical treatment
o Not usually considered until the woman’s family is complete
o MOD à not appear to affect SUI recurrence following surgery
Referral to urogynaecology services
Life style modification

Overactive bladder
Definition

characterised by symptoms of urgency
with or without urinary urgency incontinence
as well as frequency and nocturia
in the absence of any obvious pathology such as urinary tract infection
Epidemiology
- frequency
  o 41%
  o bladder capacity reduced > 100 mL in T3
  o fetal head engagement
  o Increasing progesterone levels à increase GFR
Urinary urgency >>
o 16 and 31%
o increasing with POG
o no association between parity

Management

No specific Rx guidelines for OAB in pregnancy
According to NICE guidelines 2019

Primarily conservative (lifestyle modifications)
o Modifying fluid intake
o Reducing or stopping caffeine intake
o Pelvic floor exercises
o Bladder retraining
Anticholinergics >>>> oxybutynin immediate release (IR) >>
o offered in pregnancy and in breastfeeding.
o lactation suppression has been noted
Intravaginal estrogens:
o Low-dose local vaginal estrogens can be used postnatally
Intravesical botulinum toxin type A (botox) injection >>
o may be used in pregnancy >> not commonly offered.
o risk of urinary retention >> clean, intermittent self- catheterization.
Percutaneous sacral nerve stimulation (SNM) >>
o Not offered during pregnancy.
o If already in situ >> medical advice >> turning off the device when planning or
during pregnancy.
o Effect of SNM on the pregnant uterus is not known.
o Studies have showed no fetal anomalies or fetal
o Pregnancy losses associated with SNM.
o Lead displacement during assisted vaginal delivery or caesarean section
Percutaneous tibial nerve stimulation >>
o no evidence regarding use during pregnancy.
LUTS may reduce 6 weeks after childbirth.
OAB symptoms at 6 weeks postpartum à NVD > LSCS
If symptoms persist >> referral to a urogynaecologist

Pelvic organ prolapse
Definition >>

loss of support for the uterus, rectum, colon or bladder
leading to the organ’s descent into or out of the vagina.
Epidemiology >>
prevalence of POP is 5–10%
worst in the third trimester
Risk factors
Pregnancy & delivery – major RF
o Forceps delivery
o Prolonged 2nd stage of labour
o LGA baby
o 3rd & 4th degree tears
Management
Managed conservatively in pregnancy & postpartum
Aim is to improve symptoms.
Altering lifestyle to reduce increased intra-abdominal pressure
o Laxatives for constipation
o Cessation of smoking if a chronic cough
o Reducing lifting heavy weights
o Diet & exercise to control and lose weight
o PFMT
o Vaginal pessaries
PFMT – prevent prolapse symptoms in longer term
Pessaries provide structural support
Advancing gestation – change in the size of the pessary
Surgical intervention is not recommended before completing her family.

Recurrent urinary tract infection
Definition for nonpregnant women
o 3 episodes of UTI in the past 12 months or
o 2 episodes in the last 6 months.

varying definitions in pregnant women
Urinary microbiome
Bacteria present in urine with no clinical infection.
Lactobacillus, Gardnerella & Streptococcus.
Affected by hormones such as estrogen.
Postpartum period – low levels of estrogen
- reduction in the Lactobacillus -increased
  susceptibility of RUTI
  Risk factors
First UTI < 15 years of age
Maternal FHx of UTI
Frequency of sexual intercourse
High parity
Lower socioeconomic status
Hydronephrosis à Dx on renal USS in preg.
Renal stones
Pathophysiology
urinary stasis
o dilatation of renal pelvis & ureters
o reduction in peristalsis of the ureters & bladder
Clinical Fx
Symptoms are the same as in nonpregnant
Epidemiology
Incidence
o UTI – 8% of preg.
o pyelonephritis – 2% of preg

Complications

preterm birth
stillbirth
chorioamnionitis
SGA
Asymptomatic bacteriuria (ASB)
Definition
o bacterial growth equal or more than 100 000cfu/mL in a urine culture
o in asymptomatic women
Most important predisposing factor à UTIs & RUTIs
Pregnant – 2–7%
Nonpregnant – 6–7%.
Not Rx ASB à UTI rate can be up to 25%.
Gram-positive – Staphylococcus saprophyticus & enterococci
Gram-negative
1st line Ix à urine dipstick analysis à Nitrites
Management
NICE 2018 AB prophylaxis in RUTIs
Similar prophylactic regimen as non-pregnant
o Trimethoprim 100 mg overnight (ON) (avoid in T1)
o Nitrofurantoin 50–100 mg ON (avoid towards term)
o Amoxicillin 250 mg ON or cefalexin 125 mg ON
Culture positive RUTI 2wkly until 36 wks & wkly until delivery
Hygiene behaviour voiding and washing after intercourse
Ascorbic acid à appears beneficial & need trials to confirm.
Limited evidence
o Canephron research level
o Methenamine hippurate urinary antiseptic à No evidence
o D-Mannose

Urinary retention during pregnancy
20% of RV uterus – more prone to UR
Risk factors

Pelvic adhesions
Uterine malformations
Deep sacral concavity
Long term consequences
Voiding difficulties
Detrusor underactivity
Increased frequency
Nocturia
After LSCS
encourage the woman to void every 3 hours
not pass urine within 6 hours, the bladder volume
Postpartum urinary retention (PUR)
common
prevalence ranging from 14.6–24.1%
Overt PUR
o the inability to void spontaneously within 6 hours of NVD, or
o after removal of catheter following LSCS
Covert PUR
o PMR >150 mL after spontaneous micturition
o confirmed on bladder USS or catheterisation
Risk factors
Epidural analgesia
Prolonged 1st or 2nd stage of labour
Instrumental delivery
Episiotomy
Primiparous
Physiological changes à increased progesterone levels
Failing to monitor postpartum UOP à painless urinary retention à bladder distension
àvoiding dysfunction à lifelong catheterisation