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Pregnancy and delivery following midurethral sling surgery.

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Aftermath of a MidurethralSling Placed in the First Trimester: A Case Report

BACKGROUND  

Urinary incontinence (UI) occurs in up to 25% of women1
Stress urinary incontinence (SUI) is more common in postmenopausal women, but has been reported in 12% of women under the age of 402
The midurethral sling (MUS) has become the most common surgical treatment for SUI but women in this younger age group are generally counselled against surgical management of SUI until they are done child-bearing3

 

CASE REPORT

Baseline Information

Patient CH was a 40 year old gravida 5, para 2
Mandarin-only speaking.
Six year history of infertility and recurrent miscarriages, told it would not be possible to get pregnant without assisted fertility. 
Past medical history of hypothyroidism. 
No surgical history.

 Pre-Operative History

Ten year history of urinary frequency, urgency, rare urge incontinence, nocturiaand occasional SUI when coughing or sneezing. 
Referred to a tertiary urology practice and underwent videourodynamics.
Testing confirmed a stable bladder and a positive stress test with evidence of incontinence. 
She was consented for an MUS, a pregnancy test was not done before surgery.

 

Operative Note

In July 2017 she had she had an MUS (Altis, single incision, Coloplast Canada, Ontario, Canada).
 

Acute Post-Operative History

On post-operative day 2 she presented to the emergency department with symptoms of urinary retention. 
Pelvic ultrasound showed she was 6 weeks pregnant. 

Antepartum History

She developed worsening symptoms of frequency, nocturia, difficulty voiding and was referred to our tertiary urogynecologyunit at 23 weeks gestation. 
She was initially managed conservatively but at 34 weeks she had severe urinary retention and had to perform intermittent self catheterization (ISC).

Delivery Note

She had an uncomplicated elective caesarean section (CS) at 39 weeks gestation that resulted in the birth of a healthy, male infant weighing 3.72kg. 

 

Postpartum History

At 2 months postpartum her symptoms had improved and she was able to effectively empty her bladder.
At 10 months postpartum she reported worsening symptoms of post-void dribbling, urinary frequency, nocturia, occasional SUI and rare urge incontinence.
Urodynamics demonstrated a low volume capacity bladder of 250ml, a stable detrusor muscle, and no evidence of recurrent SUI.
It was felt she was suffering from symptoms of chronic overactive bladder syndrome that pre-dated her MUS surgery .

DISCUSSION

Take Home Point #1: Non-Surgical Options for SUI

Patient CH was not counselled around non-surgical options for treatment of SUI. 
Conservative treatment modalities for SUI include symptom-alleviating treatments  (lifestyle/ behavioural intervention and intravaginal devices), pelvic floor muscle therapy (PFMT), and weight loss4.
These are particularly advisable in women of child-bearing age.

 

Take Home Point #2: Outcomes of MUS after Pregnancy

There are three large case series reporting on polypropylene MUS and pregnancy in the literature5-7.
Postpartum continence levels range from 60-84%5-7
Incontinence during pregnancy is an identified risk factor for postpartum incontinence7.
There are five cases in the literature describing an MUS placed during pregnancy8,9,10,11
In the current literature there are only two cases similar to our case that reported significant urinary retention associated with MUS in pregnancy10,11

 

Take Home Point #3: Options for Delivery after MUS

The optimal mode of delivery has not been established.
In nulliparous women without SUI during the pregnancy elective CS should be considered, as the first vaginal delivery contributes most to the development of SUI12
In women who develop SUI in pregnancy, it is felt that damage to the urethral sphincter has already occurred and that an elective CS may not be of benefit13
In our case she did not report SUI in pregnancy and we proceeded with an elective CS in an attempt to avoid displacement of the sling during vaginal delivery.

 

Take Home Point #4: Pre-operative Pregnancy Testing

Patient CH did not undergo pregnancy testing before her MUS surgery. 
Pre-operative pregnancy testing in pre-menopausal women considering surgery should be mandatory.
The prevalence of incidentally found pre-operative positive pregnancy tests ranges from 0.34% to 2.4%15,16,17.

 

CONCLUSION

This case report adds clinical information to the body of knowledge around outcomes of MUS during and after pregnancy. 
It highlights the importance of pre-operative counselling in women who are of child-bearing age.


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