Pregnancy and labor after TVT‐plasty

Abstract

According to ULMSTEN, permanent tightening of tissue can be achieved by tension-free transvaginal prolene tape insertion. No reports have so far been published in the literature describing the topography and function of the prolene tape in women subsequently becoming pregnant and giving birth. We report the case of a 39-year-old woman, gravida V/para V, who underwent TVT-plasty (tension-free vaginal tape) after her fourth pregnancy because she wanted to have no further children. The woman reported symptoms of genuine stress urinary incontinence since having given birth to her fourth child. All four children had been delivered spontaneously without episiotomy and perineal laceration. The decision to perform TVT-plasty according to Ulmsten et al. (1) was made after failure of conservative treatment (biofeedback) and urogynecologic diagnostic work-up. Postoperatively, the patient could empty her bladder spontaneously and without residual urine, stress tests were negative, and she considered herself cured. The patient became pregnant with her fifth child three months after the intervention. No urinary incontinence or residual urine was described throughout the course of her pregnancy. Ultrasound assessment during pregnancy (follow-up every 4 weeks initially and every 2 weeks from the 31st week of pregnancy; Fig. 1) revealed an unchanged topography of the prolene tape (at the level of the transition between the middle and distal third of the urethra) and of the bladder neck (inclination angle 45±15°, urethrovesicular angle 104±20°, distance of the internal urethral orifice from the lower edge of the symphysis 29.6±14.2 mm at rest, 25.5±9.4 mm during Valsalva’s maneuver, and 31.9±4.2 mm during straining). The patient reported mild pain at the suprapubic sites of incision during the final weeks of pregnancy. Topography of the prolene tape during the 31st week of pregnancy as depicted by introitus ultrasound; U=urethra; S=pubic symphysis. a) Mediosagittal view with suburethral visualization of the prolene tape (white arrow). b) Transverse angulated view at the level of the middle urethra with suburethral visualization of the prolene tape (black arrows). The child was delivered by primary cesarean section after completion of the 37th week of gestation. Three months later, continence without residual urine was preserved. The position of the prolene tape continued to be unchanged at ultrasound, the suprapubic complaints had disappeared, and bladder neck topography was likewise unchanged. Only one case report exists in the literature regarding the management of pregnancy and delivery following TVT-plasty (2). Dainer et al. (3) published an evaluation by questionnaire of 40 vaginal deliveries and 47 cesarean sections in women having undergone various types of interventions for incontinence. In that study, postpartal continence was preserved in 73% of the women with spontaneous delivery as opposed to 95% of those having undergone primary cesarean section. Based on these results and the lack of guidelines how to manage pregnancy and delivery after TVT insertion we decided to deliver our patient by cesarean section. This decision was based on a tentative risk of a deterioration of the effect of the tape on the urethra due to sharing forces in the birth canal and the risk of retrosymphyseal loosening of the tape during labor. The following conclusions can be drawn from the case presented here: 1. Pregnancy does not affect the topography and function of the prolene tape. 2. Delivery by primary cesarean section can preserve the topography and function of the tape. 3. Women after persistent urinary incontinence despite conservative treatment, who still want to have children, should not be excluded from surgical treatment. Recommendations how to deliver patients following TVT-plasty are required.