Pelvic organ prolapse (POP) is common in gynaecological practice, however is a rare encounter in pregnancy. The reported incidence of POP in pregnancy is 1 case per 15,000 deliveries. POP can be diagnosed as a pre-existing condition or first manifestation during pregnancy. It can lead to significant antenatal and intrapartum complications including severe cervical oedema and dystocia, urinary retention, pretem labour, uterus rupture and fetal demise.

We report a case of favorable outcome in a pregnant patient with Stage 3 POP. A 30 year old, G3P2 with history of POP diagnosed 2 years prior to current pregnancy. She was treated with ring pessary since first trimester which self dislodged at 28 weeks of gestation. Unfortunately, this remained unaddressed until she presented with painful red mass protruding out from vaginal after having contractions and leaking liquor at 34 weeks. Upon assessment, she was in pain and tachycardic. Per abdomen, the gravid uterus was corresponding to 34 weeks of gestation, head not palpable per abdomen with estimated fetal weight of 2 kg. Examination of the external genitalia revealed an edematous cervix protruding out 8 cm from the introitus which was tender to touch and irreducible. The POP examination was Aa 3/Ba 5/C 8/gh6/pb1/TVL 10/Ap3/Bp 5/D 5 (Stage 4 UV prolapse). The cervix was dilated 2 cm and the fetal presentation was still 1 cm above ischial spines with ruptured membranes. An emergency lower segment caesarean section was decided and performed with the fetal head and prolapsed cervix replaced back gently. A healthy baby girl was delivered with a weight 2.38 kg. Postoperatively, the cervix remained prolapsed but reducible, hence a 75 mm size ring pessary was inserted. Patient opted for continuation of ring pessary treatment postpartum and declined surgical intervention in the intermediate term.

To date, there is no consensus on the management of POP in pregnancy. The treatment should be individualized depending on severity of the prolapse and patient’s preference. The management of POP antenatally is mainly conservative with bed rest in Trendelenburg position and good genital hygiene. The use of vaginal rings and pessaries to improving support for the pelvic organs and to alleviate the symptoms have been recommended. Laparoscopic uterine suspension during pregnancy had been reported and showed a favorable outcome. Most literatures suggest that cesarean section will be a safer mode of delivery. On the contrary, few cases of spontaneous vaginal delivery had been reported to be uneventful. Karatayli et al had reported a successful treatment with caesarean hysterectomy followed by abdominal hysteropexy.

In conclusion, obstetricians should be aware to this rare entity and provide close surveillance in POP in pregnancy to reduce fetomaternal risk and complications.