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Grand Rounds

Pelvic Organ Prolapse: Effect of Maternal Age and Mode of Delivery

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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

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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

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