"A Stitch in Time..."
Monday, September 11, 2006
Kenneth F. Trofatter, Jr., MD, PhD
Recently, we helped care for a woman carrying twins conceived by in vitro fertilization. She had a long history of infertility associated with polycystic ovary syndrome (PCOS) and at age 38 had all but given up hope of ever carrying a pregnancy. Our infertility group, and her primary obstetrician, had sent her to us for consultation at 12 weeks’ because of her age and the multiple gestation. She had no other significant medical problems and the discussion was very straightforward. We talked about PCOS-associated risks of hypertensive disorders and gestational diabetes and we also talked about the age-related risks of fetal chromosomal abnormalities and her options for prenatal diagnosis. She was well-educated and there was little new information I could provide her with on these topics.
We then talked about fetal complications specific to twin pregnancies and finally we got around to the subject of preterm labor. In brief, I informed her that she was at greater risk for PTB, not only because of the twins, and this being her first pregnancy, but also because of her underlying PCOS for reasons that are poorly understood and unrelated to any other medical complications either she or the twins might develop during the pregnancy. My specific concern was related to a condition called “cervical incompetence” that seems to haunt infertility patients with PCOS. Of all the things we discussed, this worried her the most. After all the time (and money) it had taken to conceive, the last thing she wanted was “to deliver too early and at my age have children who have problems resulting from prematurity.” When she left that day, I scheduled her to return at about 20 weeks’ for ultrasound evaluation of the babies and her cervix.
Cervical incompetence represents loss of integrity at the internal cervical os (the junction of the cervix and the uterus) that results in progressive cervical change from the inside out. Lots of factors can contribute to cervical incompetence and we will save that discussion for another day. Before the availability of ultrasound, however, the diagnosis was almost never made before a woman had delivered prematurely, or lost one or more pregnancies, with a history of 'silent' cervical dilation, usually presenting in the advanced stages of labor, preceded by minimal painful contractions. Over the last 10 years, we have learned that ultrasound evaluation of cervical length and configuration can help to identify cervical incompetence and certain women at increased risk for premature delivery.
When our patient came back at 20 weeks,’ her baby girl and boy looked fine. Her cervix measured 42 mm in length (very good!) but “slight funneling is noted at the internal cervical os.” No cause for immediate concern or action, but with that finding, she did buy herself a follow up ultrasound. Although scheduled for the next week, she could not keep that appointment. When she did return two weeks later, she now had “U-shaped funneling of membranes in the cervical canal to within 3 mm of the external cervical os” (very BAD!). To make a long story short, she was admitted to the hospital that day and underwent placement of an emergency (“rescue”) cervical cerclage (stitch around the cervix). At the time of the surgery, “the cervix was 1-2 cm dilated and membranes were clearly visible just within the cervix.” If something had not been done at that point, she surely would have delivered extremely prematurely, probably within days. Although the surgery went well, she understood that she still wasn’t out of the woods for early delivery and complications, especially those related to infection.
There is a happy ending to this story. She eventually carried the babies to 36 weeks’ before spontaneously rupturing membranes, having the cerclage removed, and delivering two beautiful healthy children who got to leave the hospital with her two days later. Technically, she had two “near term” births, but that was so much better than losing two babies at 22 weeks or, perhaps even worse, having two babies survive at 23-24 weeks with severe sequelae secondary to their prematurity. Like I said before, in the case of PTB, every little bit helps. Multiple factors contribute to PTB, but the key to reducing rates is to successfully anticipate risks and identify specific factors in individuals that might lend themselves to timely intervention.
Labels: cerclage, cervical incompetence
6 Comments:
At Wed Aug 22, 10:12:00 AM 2007,
honeybumblebee said…
Thank you so much for sharing this story. I am 27 years old and have PCOS. I tried to conceive for 4 years and went to a fertility specialist who helpd me conceive with ovulation induction. My pregnancy had been fine for 20 weeks. I went into pre term labor at 22 weeks. I was 3.4 cm dilated when arriving at the hospital. My membranes were also bulging. There was nothing that could be done and my daughter was delivered by c section weighing 1lb and 1/2 an oz. She died 2 days later. I was diagnosed with an incompetent cervix weeks later from my medical reports. They have advised a cerclage for a subsequent pregnancy. I just wish there was something that could have been done. the dr that delivered my baby (which was not my regular ob) advised I should have been treated high risk due to PCOS and undergoing infertility. Thank you for sharing
Eboni
At Wed Aug 22, 06:02:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
Eboni: I am so sorry. One of the reasons I wrote this post to begin with is that not many physicians realize the risk for cervical incompetence in patients with PCOS. They are usually well aware of the other risks such as gestational diabetes and pregnancy-induced hypertensive disorders. I certainly hope things turn out better in the next pregnancy with a cerclage. Thanks for reading! Dr T
At Fri Aug 24, 08:44:00 AM 2007,
honeybumblebee said…
thanks so much for responding to my post. I have a question. I have an appt coming up the the fertility specialist who helped me conceive the first time. He doesnt know of my loss, so I will be informing him and will bring along copies of my prenatal and delivery records. Is there anything you would recommend I do going into another pregnancy. Is there a specific specialist I should see? A perionatologist? a maternal fetal medicine specialist?
Thanks for listening
At Fri Aug 24, 05:58:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To honeybumblebee Aug 24: I would ask your infertility doctor for a referral to a specialist in Maternal-Fetal Medicine (still often referred to as a Perinatolologist). Try to find someone who believes in and knows how to place a GOOD cerclage! This is usually done at about 13 weeks into the pregnancy. In my own practice, even after the cerclage is placed, we will often begin serial evaluation of cervical length by ultrasound starting between 16 and 18 weeks. One other thing you might consider is asking about the use of progesterone (or 17-OH-P) beginning at about the same time in the pregnancy. Recent studies that have been, and will be, published, suggest that progesterone may be of benefit in reducing the risk of preterm birth in women with either short or 'incompetent' cervices. Good luck my friend and let me know how things turn out some day! Dr T
At Tue Jun 03, 05:27:00 PM 2008,
PREGO10 said…
HEllo, I am 18 weeks pregnant with my 10th child. I had preterm labor at 22 weeks with my last pregnancy with twins. I had serial ultrasounds to check my cervical length which was 1.5mm at 22 weeks. I made it to 36 weeks and delivered via c-section after 3 contractions 2hours apart put my cervix at 8 cm. I however had no funneling with my last pregnancy. this pregnancy (singleton) I have had a few minor contraction off and on since 14 weeks. I lost my mucus plug at 17 weeks and had an cervical length of 40mm and no funneling. this week I had more mucus plug that was pink tinged. They checked a cerviacl length. I had 11mm of funneling and 30mm left of cervix. I am 1/2-1cm dilated. My doctor said that since I have had all the other babies 36 weeks or greater that they are just goinh to watch me every 2 weeks. I have pelvic pressure all the time and it is painful at time. I had a little bit of this with the twins before I went into preterm labor, but it was not the same. Do you have any advise for me? I am really worried about the funneling more than the cervica length. I think my ob is A QUACK AND THAT THEY SHOUYLD AT LEAST SEND ME TO A PERINATOLOGIST FOR A SECOND OPINION.
At Wed Jun 04, 07:41:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To PREGO10: GO GET THE SECOND OPINION. With all the pregnancies you have had and the events of your last pregnancy, you may well have developed cervical incompetence over time and it would be better to have a cerclage placed sooner than later if that is the case! Best wishes and let us know how things turn out! Dr T
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