BACKGROUND AND PURPOSE:

• Actual risks regarding symptomatic pelvic organ prolapse (POP) remain unclear, including whether cesarean delivery has a protective effect
• Åkervall et al. (AJOG, 2019) compared the age-related prevalence of symptomatic POP and effect of vaginal vs cesarean delivery

METHODS:

• Nationwide matched cohort study (2008-2014)
  • Swedish Medical Birth Register and Statistics
  • Surveys were postal and internet-based questionnaires that contained validated questions for pelvic floor disorders
  • One-to-one matching based on age and BMI in women aged 40 to 64 years
    • The procedure succeeded in 99.8% of women, resulting in an adequate distribution of age and body mass index (kg/m2) between matched groups
• Definitions:
  • Symptomatic prolapse: Defined by the question “Do you have a sensation of tissue protrusion (a vaginal bulge) from your vagina?”
  • Symptom frequencies: Defined by positive response the question “Sometimes and Often”
• Participants
  • Nulliparous
  • P1 via cesarean delivery
  • P1 via vaginal delivery
  • Parous women were all assessed 20 years postnatally
• Data analysis
  • Logistic regression analysis was used to obtain estimated, age-related values of symptomatic prolapse

RESULTS:

• 14,335 women were included
  • Nulliparous: 9136
  • P1 cesarean: 1412
  • P1 vaginal: 3787
• Prevalence of symptomatic prolapse
  • Similar in nulliparous and P1 cesarean groups (below 5% across ages 40 to 64 years)
  • Accelerated in women after vaginal delivery up to 65 years of age
    • Estimated probability increased from 3.8% at 40 years to 13.4% at 64 years of age
    • Time to POP symptoms following vaginal delivery appeared to be at least 20 years among women giving birth in their early twenties
• At age 64 the estimated probability of symptomatic prolapse after vaginal delivery compared to cesarean section (P<0 .0001)
  • Vaginal delivery: 3.4 % (95% CI 9.4 to 18.9)
  • Cesarean delivery: 1.1 % (95% CI 0.4 to 2.5)
• Calculated reduction of symptomatic prolapse by cesarean section at 64 years of age was 92%

CONCLUSION:

• The most important factor for symptomatic prolapse was the interaction between vaginal delivery and aging
  • After a vaginal delivery, there was a fourfold increase in POP from 40 years to 64 years of age
  • At age 64, the probability of symptomatic POP was twelve times higher after vaginal vs cesarean deliver (i.e., 92% reduction of symptomatic POP by cesarean section at 64 years of age)
• Authors acknowledge that age is not a modifiable risk factor and therefore research should determine adverse events at vaginal delivery that may be avoided to prevent POP later in life

Learn More – Primary Sources:

Symptomatic pelvic organ prolapse in middle-aged women – a national matched cohort study on the influence of childbirth

Related ObG Topics:

Pelvic Organ Prolapse: Uterosacral Ligament Suspension or Robotic Sacrocolpopexy?

Mode of Delivery and Risk of Pelvic Floor Disorders, Quantified Over Time

Comparing the Use of Mesh Against Standard Repair for Prolapse