Pelvic organ prolapse (POP) is a highly prevalent condition affecting about 50% of parous women1, 2. There is a lifetime risk of 11.9% of undergoing an operation for its surgical correction1, 3. Vaginal hysterectomy with or without colporrhaphy is the most common primary operation performed for POP, which is claimed to have a long-term recurrence rate of 29 - 30%3-4.
The aetiology of POP is not well understood, but it is thought to be multifactorial. Weakening of the pelvic floor as a result of injury to levator ani muscles is widely accepted as an underlying factor. Vakili et al.5 reported that women with diminished levator ani contraction strength and a widened genital hiatus are more likely to develop recurrent POP following a primary procedure. Several other factors such as age, obesity, high parity and advanced stage of an initial prolapse have been reported to be associated with recurrent POP1, 6, 7. It has also been suggested that the recurrence of POP may be due to persistent unrecognised support defects. Alternatively, new defects may occur in a different compartment predisposed to recurrence due to the redistribution of forces following a primary operation[1, 6, 7].
Most importantly, only a proportion of POPs and recurrent POPs are symptomatic. Olsen et al.1 reported that only 10-20% of women seek medical treatment for their symptoms, although an estimated 50% of parous women lose pelvic floor support resulting in POP. Recent studies by Miedel et al.8 and Diez-Itza et al.9 demonstrated the same situation with recurrent POPs, with only one third or less of them being symptomatic. Hence, it is debateable whether clinicians should embark on aggressive primary procedures to prevent recurrent POPs, which may not be symptomatic.
Almost all studies quoting the rate and nature of recurrence have been carried out on North American populations and so data may not be applicable to other populations with different characteristics and expectations. The primary objective of our study was to estimate the incidence of recurrent POPs following traditional vaginal hysterectomy with or without colporraphy as a primary procedure in an Irish population. Our secondary objective was to explore the nature of recurrent POP.
Studies indicate that cannabis (marijuana) is the most frequently used recreational substance (after tobacco and alcohol) in pregnancy despite being under-reported. The prevalence is expected to increase with the recent wave of interest in medicinal and recreational cannabis use, resulting in the reconsideration of its classification in terms of clinical and legal risks, in the backdrop of campaigns for its decriminalisation and legalisation gradually sweeping the world. This paper reviews the likely impact on the ethics of the use of cannabis in pregnancy, and implications for obstetricians, midwives, general practitioners, psychiatrists, and other clinicians managing such patients.
Aims and method As drug policies pertaining to cannabis use become more liberalised, the prevalence of cannabis use in pregnancy could increase. However, there is limited guidance available for clinicians. This paper presents a narrative review of literature published in the past 16 years (2006–2021) to (a) address the impact of legalisation and decriminalisation on the risks, ethics and support of women who use cannabis during pregnancy and (b) develop guidance for clinicians. Results Both national and international trends suggest increased use of cannabis over the past decade, while the risks of cannabis use for recreational or medicinal purposes in pregnancy remain unmitigated. Clinical implications This review confirmed that the recommendation of cannabinoid-based products for pregnant and breast-feeding women is currently premature. More research is needed to address safety concerns. We discussed navigating ethical concerns and suggest targeted management strategies for clinicians treating pregnant women who choose to use cannabis.
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