Cervical Incompetence and Cerclage - 6 - Evaluation and Decisions in Midtrimester
Saturday, September 06, 2008
Kenneth F. Trofatter, Jr., MD, PhD
However, let me start again with a situation that I consider to be relatively ‘straightforward’ – the patient who presents at 18-22 weeks with little or no cervical length and membranes bulging near, at, or even through the external cervical os. This patient is going to usually deliver imminently and I have selected the range of gestational ages because the baby is previable at this point (although 22 weeks is getting very close to that as a possibility) and the importance of this will become more apparent in a moment.
One does not have a lot of time to make decisions under these circumstances, but the patient needs to be adequately evaluated before a recommendation for therapy can be suggested. The main focus of the evaluation is to try to establish whether or not overt intrauterine infection (chorioamnionitis) is driving the process – and that is sometimes not as easy as one might think – because if it clearly is, then the only therapeutic choice is delivery. When a patient in this situation hits the door, the first steps we take after obtaining vital signs (blood pressure, pulse, temperature) include: a complete blood count with differential; blood type and screen; a catheterized urine analysis and culture; cervical cultures for gonorrhea and Chlamydia (if these can be obtained safely – otherwise they may be deferred); a vaginal slide to look for evidence of bacterial vaginosis; and vaginal fluid to screen for ruptured membranes; an ultrasound to assess fetal size, evidence of anomalies, and Doppler flow studies if indicated; and, oftentimes blood chemistries to include electrolytes and liver function tests.
The patient is then connected to a uterine contraction monitor if that is possible, although one must realize that most patients will have contractions or some degree of uterine irritability once the cervix has gotten to this stage and I have found this to be only a relative contraindication to treatment. If cervical change has been documented by ultrasound, I usually do NOT perform a digital exam on the cervix – saving any further evaluation in that regard until the patient is in the operating room if it appears a cerclage will be attempted.
Although I do not routinely perform an amniocentesis on all patients in this situation, there are many providers who do and so do I in selected cases. When amniocentesis is done, the primary purpose, again, is to look for evidence of overt intrauterine infection (when this is not clearly apparent by physical examination or laboratory studies) as might be reflected by the presence of white blood cells, low amniotic fluid glucose levels, and positive amniotic fluid cultures. We do not routinely screen for inflammatory cytokines in the amniotic fluid at this time.
The next step is to put the pieces of the situation together, have a frank discussion with the patient and her family, and provide options for management. If the patient has a fever (not related to a urinary tract infection), and/or high white blood count and differential suggestive of acute infection, and/or a tender uterus with painful contractions and pain between contractions, and/or a purulent cervicovaginal discharge, the presumptive diagnosis is chorioamnionitis and the only safe option is to allow delivery – indeed, delivery is inevitable regardless of what we might do to intervene. The baby is previable and the mother’s life and future fertility may be at risk. I usually begin broad spectrum antibiotic coverage and, if necessary, recommend augmenting the labor process with oxytocin or misoprostol.
If overt infection is not clearly present, then the patient has basically two options – undergo ‘conservative management’ and wait to see what happens or undergo cerclage. I make several points during the counseling session: if delivery appears imminent and remote from fetal viability, she is told this bluntly (or if some cervical length remains and we honestly cannot predict when delivery might occur, she is also told this); if a cerclage is placed, it may precipitate delivery; if infection develops, regardless of the decision to perform cerclage or not, the "ballgame is over" and delivery will be necessary. While the patient is making her decision, I usually will begin indomethacin 50-100 mg initial dose followed by 25-50 mg every 6 hours and an antibiotic cocktail of a cephalosporin (or ‘penicillin’), azithromycin, and metronidazole administered intravenously. Most patients will opt for cerclage under these circumstances simply because they feel like “what have I got to lose” if the chances for the baby are otherwise hopeless.
The decisions are a little tougher when the baby is in the range of potential viability, especially from 23 weeks on. As in most neonatal intensive care units with high volume services, our neonatal survival rate between 23 and 24 weeks is in the range of 30-50% and it goes up dramatically from that point on, although at the earlier gestational ages, there is also a very high risk of long-term morbidity and mortality secondary to complications of prematurity. Patients at these gestational ages are evaluated and begun on the same treatment regimen I have detailed above with the addition of corticosteroids to accelerate fetal lung maturation. Usually we provide consultation with one of the neonataologists as well.
Under these circumstances, if the membranes are above or at the external cervical os, I still offer cerclage as an option – although the risks are clearly delineated that we could precipitate a delivery as a result of the procedure itself at a time in pregnancy when even days can have a significant impact on potential outcome for the baby. If the membranes have completely prolapsed into the vagina, the success of the procedure is so low with the risk of rupturing membranes during the procedure and the risk of subsequent infection following the procedure so high, that I will usually advise only conservative management with bedrest, antibiotics, corticosteroids, and tocolytic therapy in the hospital until delivery.
Although many years ago, before the dramatic advances in neonatal intensive care, I would perform cerclages if appropriate up to 30 weeks gestation, it is difficult to justify that now – indeed, I have to think long and hard before even offering it as a possibility once a pregnancy has reached 26 weeks. In our next post, I will detail the technique I have used for cerclage placement in these situations for the better part of 20 years…
Labels: cerclage, cervical incompetence, cervical insufficiency; premature labor
14 Comments:
At Wed Sep 10, 09:51:00 PM 2008,
Anonymous said…
What is the harm in attempting circlage if the pregnancy is 26+ weeks? Doesn't every day continue to matter for preventing long term morbidity?
At Thu Sep 11, 03:31:00 PM 2008,
Anonymous said…
Dr. Trofatter I read your articles with great interest. I would like to know your opinion about what else should be done after a cervical cerclage had been placed. Do you recommend rest, reduction/interruption of the professional activities, specific medication, etc.
I miscarried, had a septum removal surgery and I miscarried the second time at 17wks (this time twins).
Now I am pregnant again and a cerclage had been done (13wks). Obviously I would do anything to have this baby. Thank you for your time.
At Sun Sep 14, 04:28:00 PM 2008,
Anonymous said…
pls help my wife was 11+5 and had a realy heavy bleed rushed to a+e and got that dreeded news she was having a misscarrage went to have a scan to confrom it and saw baby at 12 weeks all fine the thing is she passed a clot type thing that was about 6-8cm in lenth the a+e dept said that it probable was the baby and that the rest would pass and she was 1cm open in her cervics pls help was this twins and ones gone or what pls as i have never seen as much blood come out of my wife ever as i did that night the doctors cant or wont say a+e didnt even tissue test the colt and we were in such a panic that we didnt think to ask them to till it was to late and my wife is still bleeding now at 18+5 weeks and has just passed a few colts roughly the size of a thumb nail
At Mon Sep 15, 02:36:00 PM 2008,
Anonymous said…
Dear Dr. Trofatter
I wrote a couple of weeks ago and I have a new question. I am 35 years old and I lost my first baby 4 weeks ago due to PROM at 22 weeks after a short cervix of 1.5cm with funneling was diagnosed. Now at my first postpartal visit 4 weeks later my cervix is still 1.5 cm open (bleeding stopped 4 days ago, no fever). My Gyn told me that only women after several deliveries usually present with this finding and that by paplation there is no injury/tear. Is this finding typical for cervical incompetence? Do I have a even worse prognosis for a future pregnany with this finding? Am I at a higher risk for infection? When should I be checked again? My Gyn did not want to check me again before a next pregnancy occured.
Thank you very much in advance for answering my questions!
At Tue Sep 23, 12:33:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Sept 10: There may be greater risk of precpitating a delivery earlier than might have occurred as the result of complications during and following cerclage placement that late i n pregnancy. And, as you say, "every day counts" at that point. Don't worry, I have done many that late, but the risks and benefits and patient consent and understanding are all very important issues that need to be taken into account.
Dr T
At Tue Sep 23, 12:39:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Sept 11: You are in one of the highest risk categories because of the congenital uterine abnormality and the structural abnormalities that this has led to at your internal cervical os. With your history, I would ordinarily recommend restriction of intercourse and avoiding exertional activity. I presume your doctors are going to perform serial cervical exams by ultrasound even with the cerclage in place. You might be a good candidate for weekly injections of 17-hydroxy progesterone or daily application of vaginal progesterone (we have used Prochieve). In most instances, I also place women in your situation on metronidazole 250-500 mg twice daily for the duration of the pregnancy (or at least until you have reached a point of good viability for the baby). Best wishes and let me know how things turn out! Dr T
At Tue Sep 23, 12:42:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Sept 14: i am unclear as to why your wife is having bleeding. Do your doctors have any idea? Is the baby growing well? Is the fluid around the baby normal? Does the baby have any abnormalitis that they can see? Regardless, if she continues to bleed, she is at very high risk for developing an ascending infection, rupturing the bag of waters, and delivering early. I wish you the best, but I certainly hopes the bleeding stops soon.
Dr T
At Tue Sep 23, 12:47:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Sept 15: You may be one of those individuals who has a connective tissue disorder as the cause of their cervical incompetence. That would place you at greater risk in a subsequent pregnancy and is certainly an indiaction for an early and well-placed cerclage by an experienced operator. You would probably also be a good candidate for progesterone therapy during another pregnancy as well.There is not much that can be done between pregnancies to evaluate the cervix reliably. Let us know what happens after you conceive again. Thanks for reading and kind regards. Dr T
At Sun Sep 28, 06:32:00 PM 2008,
Anonymous said…
I had a cerclage put in at 21 weeks because when we went in at 20 weeks for my scan, my cervix was 2.3 cm and at 21 weeks it was 1.9.
I am now 26w5d pregnant. At my 26 wk cervical measurement the dr. said my cervix was a little shorter than my 24 wk u/s. It was 2.7 at my 24 week.
The U/s tech also noticed that I may have a blood clot. The peri said it is not umcommon. I am on bed rest now. Is there anything else I can being doing to prevent any complications? Thank you!
At Fri Oct 03, 06:20:00 AM 2008,
Anonymous said…
How often can a cerclage become infected after placement? What are the most common bacteria? What would be the complications? Is it worthwhile to ever culture the cerclage?
At Mon Oct 06, 05:39:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Sept 28: Thre is no literature to support doing this, but I usually place anyone who has had a 'rescue cerclage' on metronidazole (an antibiotic that is very effective against anaerobic bacteria) prophylactically at least until they are beyond 30 weeks. The usual dosage I use is 500 mg two or three times per day. Other than that,your prospects look very good for getting a baby from this pregnancy doing just what you are doing now. Let us know how things turn out! Dr T
At Mon Oct 06, 05:44:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Oct 3: The vagina has as many bacteria as the gut. It is amazing to me that more cerclgaes don't result in significant infections. Typically, such infections are caused by many different organisms and often look like 'bacterial vaginosis', but I have found that putting patients who develop evidence of the same after cerclage placement on metronidazole 500 mg two to three times per day will often suppress the discharge and may reduce the risk of ascending infection. I give this to all patients in whom I place a rescue cerlage and leave them on it indefinitely (at least unntil they are past 30 weeks). Thanks for reading. Dr T
At Mon Oct 20, 07:42:00 AM 2008,
Liz said…
Dear Dr. T-
I have a complicated case. In my last pregnancy (IVF) I went into preterm labor at 22 weeks with twins. From weeks 14-22 I felt a lot of pressure and tightening but my cervix never changed. At 22 weeks I went into the hospital with round the clock contractions and the next day my cervix had shortened substantially from 3.1-1.6. I was given the normal mix of tocolytics (indocin, turb, nifedipene) and then kept on the nifedipene for the duration. Slowly but shortly over the next five weeks (I was hospitalized the whole time) my cervix began to shorten and then dilate. Finally at 27 weeks I began to bleed and the babies had to come out. My son had an abruption and lived only 28 hours. My daughter is alive and kicking and doing great at 2yrs old. My question is this-I am now 15 weeks and have been feeling lots of tightness/pressure since 11 weeks. My cervix has not changed at all and everything looks fine. Would you recommend cercalge? I am talking to my peri tomorrow also about progesterone shots but am interested in exploring my options. I am panicked that this tightness is just the precursor to preterm labor again and am hoping that everything stays status quo. What is your advice and assessment of this situation? Otherwise I am totally healthy and this was a natural conception.
Please help!
-Liz
At Wed Oct 22, 06:36:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
Liz: From what you have told me, you may be a good candidate for progesterone. I would also follow your cervix weekly by ultrasound and at the first sign that it is starting to shorten, place a cerclage before you get into the situation you were in with the twins. Best wishes and check back with us along the way! Dr T
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