Keywords : gravid uterus prolapsed through rectum
Rectal prolapse occurs much more frequently in women than in men and is most common in people over sixty1. The condition is often concurrent with pelvic floor descent and prolapse of other pelvic floor organs such as uterus or bladder. Although multiple pregnancies are often implicated in the etiology, 35% of patients are nulliparous 2. Pregnancy is one of the predisposing conditions of rectal prolapse, which can be brought on by severe diarrhea in some patients. Despite knowing the above the following case came forth as a surprise and a challenge too.
Mrs. AB, 20 years old, an unbooked primigravida was admitted from the casualty on 9th May 2004 with 11 weeks amenorrhea, loose motions since 3 days and something coming out of the rectum since two hours while she was passing motion. The woman was very pale, dehydrated, had tachycardia and BP was 80/60 mmHg. Local examination revealed a mass 25x15 cms protruding through anal opening. Rectal mucosa was edematous and inflamed and on palpation a mass was felt behind it. (Figure 1) On P/V examination the cervix was pulled up the uterus was retroverted and turning upside down into the rectal prolapsed mass. Ultrasound probe confirmed the presence of fetus in that mass. Under general anesthesia (pentothal, scoline intubation) reposition of rectal mas was done gently (Figure 2) and a large ring pessary inserted in the
vagina to prevent recurrence after restoring anatomy. She was discharged after seven days and followed up regularly. The pessary was removed at 14 weeks at her insistence. She had regular check-up during her uneventful antenatal period. she presented at term with labor pains and fetal bradycardia for which lower segment cesarean section was performed on 17th January 2005. The puerperium was uneventful and she was discharged on 21st January 2005. At the postpartum check-up after 6 weeks she showed no abnormality.
In spite of an extensive search in PubMed, e-medicine.com, nlm.njh.gor/medlineplus and wrong diagnosis.com we are unable to find a similar case report.
After the uterus was reposed to its normal position the ring pessary prevented a recurrence till 24 weeks of gestation.
Thereafter the pelvic inlet acted as a bony pessary to support the uterus. After the involution of the uterus a recurrence is not expected the uterus being of normal size and weight. A possibility of the problem recurring in the next pregnancy can be prevented by a uterine suspension by cervicopexy or Shirodkar’s sling operation during the nonpregnant state. But we feel that the recurrence can be equally effectively prevented by a mere insertion of a ring pessany during early pregnanccy at about 8 weeks gestation and keeping it till 24 weeks of gestation.
