he Case of Pregnancies After Manchester-Fothergill Operation

Background: The Manchester-Fothergill operation (MF) has largely been replaced by Vaginal Hysterectomy (VH) however the MF procedure may permit to preserve the fertility in many cases of genital prolapse. Objective: To obtain pregnancies after MF procedure. Materials and Method: Four women submitted to MF desiring pregnancy. Results: Every patient became pregnant with deliveries near term. Conclusion: The MF operation should be taken into account in fertile women even in view of the fact that the long-term outcome is similar to VH.


Introduction
The MF operation for surgical repair of genital prolapse is an old procedure [1] that has been largely replaced by VH with anterior and posterior when necessary colporrhaphy. However, the MF operation may preserve uterus and then fertility and it is not only important for fertile women but even in some postmenopausal women that desire to avoid hysterectomy. When pregnancy is desired it should be well explained to the patient that the incidence of abortion and premature labor is increased and a caesarean section can be indicated. Moreover, the pregnancy requires more controls and physical stress, heavy works, must be avoided. We performed successfully 104 MF operations but in the present paper we report the case of four women that became pregnant after MF operation.

Materials and Method Patients
Four patients aged between 33-37, underwent the MF procedure as uterine sparing surgery for uterine descensus during 1998-2013. Two patients showed cystocele grade III and uterine prolapse of grade II and III, two patient cystocele grades III, uterine prolapse grade III and rectocele according to . The patients had one previous pregnancy with normal delivery at term. Everyone desired to preserve uterus for a future pregnancy. Every patients neurogically intact was submitted to clinical examinations and the barrier tests were performed using Simm's speculum and/or pessary to discover the presence of an eventual occulted Stress Urinary Incontinence (SUI). The need of urodynamic investigations in case of genital prolapse without reported SUI is argument of debate but we believe that an accurate basic clinical investigation may avoid the need of urodynamic tests in many cases [3]. It was well explained to the patients that the incidence of premature labor is increased as a result of the operation and a caesarean section is also indicated and informed consensus was done.

Surgery
The MF procedure was performed in every patients with particular attention to the amputation of cervix in order to avoid an excessive shortening in view of future pregnancy. Perineorrhaphy was also performed when necessary. The blood loss ranged between 100 to 180 cc. The hospital stay was 2-4 days and no complications occurred.

Results
The patients so treated became pregnant 8 to 19 months from surgery. Every patient had a natural progesterone supply by vaginal route, 200 mg every night Progeffik-Effik Italy [4] from 20 weeks of gestation and to avoid any physical stress was also strictly recommended. Clinical examination as well as ultrasound to control the uterine cervix were performed every 15-20 days or more when necessary. One patient delivered spontaneously at 35 weeks of pregnancy and one at 36 weeks, two patients had a caesarean section at 35-37 week. The new born weight ranged 2210-2685 gr.

Conclusions
The surgical management of anterior vaginal vault prolapse is still argument of debate as well as almost all if not all the female pelvic floor dislocation. The success rate of anterior colporraphy vary widely from 37 and 100% [5]. However, the results of the anterior colporrhaphy are difficult to compare because the success rate is depending on various factors for instance the degree and type of the anterior vaginal vault prolapse, central or lateral defects, the uterine prolapse, the techniques employed associated or not to vaginal hysterectomy and last but not least the method to evaluate the results, subjective or objective. Finally, the use of grafts is not generally recommended as routine for the primary repair, in view of the risks of mesh erosion and infections even if the use of biocompatible materials in the future could resolve these adverse effects. The MF procedure offers the possibility to create an autologous suspension of bladder and to preserve uterus even in case of uterine descensus. This latter aspect is obviously of importance in fertile women, even if some postmenopausal women too may desire to avoid hysterectomy when possible. Moreover, the literature offers various reports showing similar results com-paring the Manchester procedure to Vaginal Hysterectomy (VH) [6][7][8] and successful pregnancies after MF [9]. The MF operation should be taken into account by gynaecologists not only in case of fertile women, in fact the operation time is shorter and complications rate as well as morbidity are generally lower when compared to VH [7]. In conclusion, the MF operation should be offered as a valid alternative to vaginal hysterectomy in many cases of genital prolapse especially if fertility is desired.