Cervical Incompetence and Cerclage - 11 - Rescue Cerclage (2)
Friday, September 26, 2008
Kenneth F. Trofatter, Jr., MD, PhD
She was begun on IV antibiotics (the same “cocktail” mentioned in my last post) and also started on magnesium sulfate. A Foley catheter was placed in her bladder. Her white blood count was noted to be mildly elevated at 14,300 but the differential was normal. Her urine analysis and, subsequently, a culture were negative as were cervical cultures for gonorrhea and Chlamydia. She remained stable overnight on the magnesium sulfate and antibiotics with no further change in her cervix. At that point we had a frank discussion regarding the potential risks and benefits of attempting to place a cerclage with which she elected to proceed with the comment “what have I got to lose by trying at this point anyway.” Points of the counseling did include that the procedure would be risky and that the chances for success were low and that it could precipitate delivery, but that delivery seemed imminent regardless and the baby was remote from good viability…
1) The patient was given an oral dose of indomethacin 100 mg and taken to the operating room
2) As she was receiving her fluid bolus for the spinal anesthetic, the Foley catheter was clamped off
3) She was prepped (but not deeply in the vagina) and draped
4) A weighted speculum was placed in the vagina and the cervix visualized with retractors
5) The cervix was noted to be at least 4-5 cm dilated and 100% effaced with membranes bulging at the external cervical os – indeed, with each breath she took, the membranes appeared to be ready to completely prolapse into the vagina – and the fetal head was visible above the membranes
6) The rest of the vagina was then gently prepped with betadine solution, avoiding direct contact with the membranes
7) The cervix was grasped on its anterior lip with a sponge stick and drawn slightly downward
8) A suture of #1 chromic was then placed very superficially around the cervix, starting and ending at the 12:00 o’clock position 1 to 1.5 cm up the cervix
9) This was gently cinched up (without pushing directly on the membranes, and when the knot was being tied, just before the cervix was closed, a Foley catheter was placed into the cervical canal - the knot was then tied securely and the Foley bulb inflated
10) The cervix was then grasped on its anterior lip again and a cerclage was placed using a double-strand #5 Ethibond beginning at the 12 o'clock position approximately 1 to 1.5 cm above the initial stitch
11) When the 12 o'clock position was reached, this was cinched up and then tied as described in our previous posts, deflating and removing the Foley catheter, just as the knot was being tightened
12) The chromic suture placed initially was then cut out of the cervix
13) The vagina was irrigated with warm saline and then dried
14) The Foley catheter draining the bladder was then released, allowing the bladder to drain freely
15) There was no evidence of ruptured membranes at the conclusion of the procedure and the final cerclage was approximately 2.5 cm up the cervix
16) The external cervical os was still patulous but membranes were restored to above the level of the cerclage and less than 0.5 cm diameter of cervical canal was left
17) Following the procedure, the patient was continued on magnesium sulfate for 24 hours, placed on indomethacin 50 mg q6h for 72 hours, cefazolin 2.0 g q6h pending results of the urine culture obtained at admission, azithromycin 500 mg per day for 5 days, and metronidazole 500 mg tid intravenously until discharge
18) She was discharged 4-5 days postoperatively to modified bedrest at home on metronidazole 500 mg bid and is still pregnant a month following her cerclage
One of the points I did not mention earlier is that during our preoperative discussion, the patient was told if the membranes completely prolapsed into the vagina before or after starting the procedure, I probably would not continue with the operation. Although techniques, such as pushing on the membranes with a moistened sponge and performing an amniocentesis to decompress the uterus, have been used successfully under these circumstances (and I have done so on occasions in the past when patients asked that “everything possible be done”), the risk for rupturing membranes and infection are so high during and after the procedure, I have leaned toward using this a ‘deal breaker’ when the pregnancy is so remote from a reasonable outcome for the baby. And, it should also be mentioned, that one condition always discussed with the patient, and must be agreed to before I attempt to place a rescue cerclage, is that anytime following the procedure they develop clear evidence of intrauterine infection, they must allow me to remove the cerclage and proceed with delivery.
Using the management protocols, surgical techniques, and criteria we have outlined in the last two posts, we have actually achieved ‘success’ rates (in terms of pregnancy prolongation to ‘good viability’, generally in excess of 28 weeks and minimal, if any, maternal or fetal morbidity) in more than 95% of our cases of rescue cerclage.
Labels: cerclage, cervical incompetence, cervical insufficiency; premature labor
6 Comments:
At Sat Sep 27, 06:13:00 AM 2008,
susan said…
After reading these blogs now I remember why I searched for you high and low when the patient needing a rescue cerclage was a good friend. It is always amazing to watch you do rescue cerclages on anybody, but when it is someone that you have celebrated a long awaited pregnancy with and know outside in the real world it is even more special. I don't know if I have ever circulated on a case where I was so impressed as the one you performed on my friend. We are very lucky to have you, not only for your superior skills, but also for your passion for the profession and the women you care for!
At Mon Sep 29, 04:37:00 AM 2008,
Anonymous said…
Dear Dr T,
Thank you for writing such detailed comments on this topic. When I first had a 2nd tri loss at 26 weeks in 2005, I could not find any valuable information nor advice on the internet. Then I had another loss at 22 weeks in 2007. Now I am coming to 20 weeks & have placed a cerclage at my 14th week. It is encouraging to read positive comments on cerclage amidst all the opposing comments on the internet. Some questions I have pls - are the cerclages only placed when contractions have totally stopped? Other than abnormal discharge, bleeding & pelvic pressure, are there any other signs I should watch out for that might indicate my cerclage is in trouble? And any common complications that occur with cerclages that I should take note of? Would appreciate your comments pls.
My sincere thanks,
shawn
At Tue Sep 30, 11:45:00 PM 2008,
Carrie McBride said…
Let me first say thank you for this blog and please forgive me for posting off topic. I have a Dr's appointment coming up and am trying to gather at least a broad impression of what I am up against. I realize this is forum is not intended for medical advise . . . I simply trying to gain an understanding of my situation.
I have had two pregnancies and two c-sections. During my second pregnancy I developed poly (twins and one was anencephalic). During the c-section (at 37 weeks after 2 weeks of turb to prevent labor) the Dr. said my uterus was thin and that we should discuss it before I get pregnant again.
Well, at that point I couldn't even comprehend what he was saying . . . I had been told my daughter (with anen) was going to die any minute and my son though healthy - wasn't crying yet.
At my six week check up I asked the NP if that meant I couldn't have more children and she said "no" that I shouldn't have a problem unless I have twins again and it just meant that I would be advised to schedule an early c-section.
Everything I can find about uterine rupture seems to relate to trail of labor and VBAC. But what are the risks of simply carrying another baby and delivering by c-section at 37 or 38 weeks? Does the uterus heal itself? Is there any way to evaluate the uterus before pregnancy? I have no doubt my uterus was thin I was HUGE (my son was 7.5 lbs and my daughter was 4.5 plus all the extra fluid). I had also been fighting labor for weeks. Is there a difference between normal thinning of the uterus related to labor and what my OB observed?
I will be asking him all of this in a couple of weeks too. I just found this site and was hoping you might be able to lend some insight into uterine rupture.
Thank you.
At Mon Oct 06, 05:15:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
Susan: Thank you so much. You made my eyes water. I REALLY DO love what I do. Kind regards, Dr T
At Mon Oct 06, 05:22:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Shawn: If someone is actively laboring, I will not place a cerclage, but by the same token I will do so if the cervix has advanced changes and the patient been contracting but we were able to suppress the uterine activity (even if they are still having occasional contractions). As I have mentioned in these posts, almost all patients with cervical incompetence will eventuallly begin to contract, so I consider uterine activity only to be a relative contraindication. As for things to look out for: increased watery, mucously discharge; malodorous discharge; pelvic pressure; bleeding; uterine contractions; pelvic pain - especially if it becomes more constant; rupture of membranes. Infection and tearing through the cerclage in active labor are two major complications. Infection can lead to premature rupture of membranes, chorioamnionitis, fetal infection, and placental abruption. Best of luck to you and I hope everything turns out well. Dr T
At Mon Oct 06, 05:28:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Carrie: I am not putting you off, but the person who will be in the best position to answer all those questions is the surgeon who did your c/section. Scar tissue is not like the rest of the uterine tissue which has the remarkable capacity to hypertrophy, stretch, and contract. Scar tissue can be stretched to the point that you can literally see through the wall of the uterus to the baby, even before completely rupturing. Your doctor will be able to tell you what she/he saw and what sort of reapproximation of the incision they were able to make. If you had a low transverse scar, it has a reasonable chance of remaining intact until you get to around 37 weeks when an amnio could be done to assess fetal lung maturity before going ahead with another c/s. I will be curious to hear what your doctor tells you, so please let me know. Thanks for reading. Dr T
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