Uterine Prolapse in the Neonate

By Alan Johnson, Stephen W. Unger, and Bradley M. Rodgers Charlot tesvi l le, Virginia

�9 The rare condition of neonatal uterine prolapse is usually associated with congenital spinal defects and is often resistant to simple reduction. Previously, t reatment has been primarily surgical and often deforming, In this case report a silastic-ensheathed pessary fashioned from a rubber Penrose drain allowed a nonoperative, simple and permanent cor- rection, permitting the more important, yet less obvious, associated defects to take therapeutic pre- cedence.

INDEX WORDS: Neonatal uterine prolapse.

U 'TERINE prolapse is a condition usually associated with multiparity in the meno-

pausal female. In the neonate this rare problem usually presents in the first few days of life, carries increased morbidity with progressing time and inflammation, and further distresses the family and physicians already involved in caring for associated defects. While the majority of the literature on neonatal uterine prolapse is confined to obstetric and gynecologic journals, the pediatric surgeon may be asked to diagnose and treat this entity. The ease of treatment and importance of early intervention are illustrated by a recent case treated by the Pediatric Surgical Service at the University of Virginia Medical Center.

CASE REPORT

SF (#90-94-03) a 1-day-old white female, the 4200 g product of an uncomplicated term pregnancy, was trans- ferred to the University of Virginia Hospital for evaluation and treatment of a ruptured myelomeningocele. At delivery there had been no evidence of uterine prolapse. Pertinent physical findings on arrival at our hospital included a rup- tured lumbar meningomyelocele with associated L 4 sensory level, spastic flexor tone of both lower extremities, bilateral clubbed feet, and protrusion of an edematous mass through the vaginal introitus (Fig. 1). The infant underwent an uncomplicated repair of the myelomeningocele and casting of both feet on the first day of life. By the third day of life the

From the University of Virginia School of Medicine, Department of Surgery, Division of Pediatric Surgery, Charlottesville.

Address reprint requests to Bradley M. Rodgers, MD, Professor and Chief, Division of Pediatric Surgery, Univer- sity of Virginia School of Medicine, Box 181, Charlottes- ville, VA 22908,

�9 1984 by Grune & Stratton, Inc.

prolapse worsened with crying or straining and could no longer be easily reduced. Consultation with the pediatric surgical service was requested. Ultrasonography and barium enema with vaginogram and cystogram demonstrated the mass to be the prolapsed uterus with distortion of the bladder and rectum by the uterine fundus. On the sixth day of life the child underwent reduction of the uterine prolapse under general anesthesia. Placement of a pessary fashioned from a rolled penrose drain with a silastic covering (Fig. 2) main- tained the reduction. The pessary was covered with Furacin (Norwich-Eaton, Norwich, NY) ointment and a traction suture was left in the posterior fornix to facilitate removal. The pessary was removed 1 week after placement and no recurrence of the prolapse has occurred in the following 24 months.

DISCUSSION

Conovius repor ted the first case of uter ine prolapse in 17237 Findley, reviewing the l i tera- ture in 1917, noted numerous neurological mus- cu la r and spinal anomal ies accompany ing the condit ion of u ter ine prolapse in the neonate, including hydrocephalus , spina bifida, meningo- myelocele, spast ic or pare t ic lower extremit ies , kyphosis, and lordosis. 2 He pos tu la ted tha t the u ter ine prolapse was due to a defect in sacral innervat ion, resul t ing in pelvic floor weakness. Noyes in 1927 ci ted 24 cases of neona ta l uter ine prolapse most of which pursued a rap id ly fatal course due to the associa ted spinal defects in the pre-ant ib io t ic e r a? Autops ies pe r fo rmed on some of these infants demons t ra ted the muscle fibers of the pelvic floor and per ineum to be infi l t rated with fat. Noyes s ta ted the condit ion to be of l i t t le cl inical impor tance when associa ted with forms of meningomyelocele , due to the h ighly mor ta l i ty of this condit ion, but emphas ized tha t if u ter ine prolapse was seen in a neonate wi thout a menin- gomyelocele then an occult spinal defect should be suspected. He also noted tha t in adul t s with u ter ine prolapse, there was a 28% incidence of spinal bifida occulta, a ra te a lmost three t imes tha t expected in the normal populat ion. 3

Cases of neonata l geni ta l prolapse have been repor ted in which no spinal defects could be isolated. The et iology of these has been ascr ibed to bir th t r a u m a and associated increased fetal abdomina l pressure, pelvic skeletal deformit ies , and abnormal i t ies of the cervix. M a l p a s subdi- vided the causes of prolapse into p r imary , those

210 Journal of Pediatric Surgery, Vol. 19, No. 2 (April), 1984

UTERINE PROLAPSE 211

Fig. 1. Complete prolapse of the uterine cervix through the vaginal introitus.

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caused by congenital deformity allowing pro- lapse through a weakened or abnormal pelvis, and secondary, those caused by abnormal stresses on a presumably normal suspensory apparatus. 4 In the secondary anomaly, present- ing at birth, simple reduction was sufficient therapy. However, in the primary anomaly, pre- senting with spinal defect and prolapse in the first few days of life, simple reduction was invari- ably followed by re-prolapse. When simple reduction has not been successful, operative ther- apy has been recommended including sugges- tions for amputation of the cervix and complete hysterectomy or suture closure of the labia majo- ra. A unique, nonoperative reduction of neonatal uterine prolapse was reported by Dixon, and associates, in 1974, utilizing a pessary. 6 In their newborn patient the pessary had to be replaced once due to recurrence, but by five days from the first placement the pessary was removed without recurrent prolapse. These authors felt that the use of topical antibiotics on the pessary lessened the risk of vaginitis developing during therapy. Our modification of this method included plac- ing a silastic outer sheath on the Penrose rolled pessary to lessen the tissue inflammation caused by direct contact of the Penrose's rubber surface with the vaginal mucosa. We used a Furacin

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Fig. 2. Small pessary fashioned from a rolled penrose drain ensheathed with silastic. The tethering suture is left long to fascilitate removal of the pessary. Prior to insertion the pessary was coated with Furacin ointment.

coating to decrease the risk of subsequent infec- tion. The pessary was left in place for seven days with no evidence of inflammation. This allowed the prolapse to be reduced through the weakened pelvic floor, presumably caused by the associated spinal malformation and exacerbated by the lax- ity of fetal tissues caused by the maternal hor- monal stimulation. It appears that the pessary reduction successfully holds the uterus in place while the laxity of the pelvic floor subsides, allowing permanent correction of the neonatal uterine prolapse.

REFERENCES

1. Conovius CD: DeBinis Casibus Anatomico Patholog- icic Acta Medicorum Berolinensium II: 106, 1723

2. Finley P: Prolapse of the uterus in nulliparous women. Am J Obstet Dis Wom 75:12-21, 1917

3. Noyes H: Uterine prolapse associated with spinal bifida in the newborn with report of a case. Am J Obstet Gynecol 13:209-13, 1927

4. Malpas P: Genital Prolapse--Allied Conditions, (Chap 2). The actiology of genital prolapse, pp 31-38, 1955

5. Ajabor LN, Okojie SL: Genital prolapse in the new- born. |n t Surg 61:496-497, 1976

6. Dixon RE, Acosta AA, Young RL: Penrose Pessary management of neonatal genital prolapse. Am J Obstet Gynecol 119:855-857, 1974