A Loss of Twins and Missed Opportunities for Cerclage

27 Comments:

• At Sun Jun 14, 06:56:00 PM 2009,  Anonymous said…

  Dr. T.
  I'm writing on behalf of my sister's experience, to see if you have any opinions to offer. She has had a difficult time getting pregnant. After having a septated uterus repair and being diagnosed with stage 4 endometriosis, she became pregnant with twins via IVF. Her pregnancy was complicated by intermittent heavy bleeing and a shortened cervix. She was never placed on bedrest after a sonogram showed a 23 mm cervical length and a cerclage was not placed because of the bleeding (they are unsure of the cause of bleeding). Unfortunately, one week later, after a sono showed funneling and a cervical length of 4 mm, her membranes ruptured and she delivered twin A yesterday at 19 weeks. Twin B's sac has not ruptured and they are giving her some hope that she can delay the delivery of this baby. They are not going to place a cerclage at this time, but they did start a three day course of indocin to slow the contractions. She is also on antibiotics to decrease the risk of infection. Her cervix was closed on today's ultrasound, but a cervical length was not discussed. What is your experience with a prolonged interval between the birth of twins? Do you have any suggestions on optimizing this situation and improving the chance of carrying this twin to a safe stage of pregnancy? Should we be hopeful? Thank you!

   

• At Wed Jun 17, 09:10:00 AM 2009,  Anonymous said…

  Dr T,
  Thank you so much for your blog! I wanted to get your opinion on my situation. My history includes a D+E last year at 14 wks due to a complication of CVS (PPROM, anhydramnios). I am now 21w4d with twins. At our 20 week US I was found to have a cervix shortened from 3cm at 16 weeks to 2.2 cm with funneling. I went on complete bedrest and had a follow up US yesterday with cervix at 2cm otherwise unchanged, closed external os be exam. We elected to wait an additional week on bedrest and re-evaluate at 22 weeks. My questions are a few:
  1) I have not been tested for bacterial vaginosis in this pregnancy. Should I ask for this?
  2) I wonder if I should start on progesterone shots or vaginal suppositories? They seem to have helped in short cervices, and don't seem to do any harm. The data with twins seems sparse.
  3) We may do a cerclage next week if the cervix has shortened any more. Do you have a "cutoff" length eg 1.5 cm? What do you recommend regarding medical therapy (antibiotics, indomethecin, etc)?
  4) Is there anything else that I could consider eg. pessary to help with this pregnancy?

   

• At Thu Jun 18, 04:45:00 PM 2009,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous June 17: Practices differ around the country. Some would recommend NOTHING except reduced activity, some would suggest the progesterone as well, others would suggest a cerclage even this late before the cervix changed any further and placemnet could be accomplished relatively safely. The data to support any of these approaches is sparse and to some extent the choices depend on the experiences of the providers. My admitted bias is to place the cerclage and I have the personal data to back up that approach in my hands in twins and this far along in pregnancy. To answer your questions:
  1) If you have no unusual discharge, you probably don't have BV. Usually this has a 'fishy' odor and is often irritating
  2) There is limited data to suggest there might be any value of progesterone by any rout in twin pregnancies at this gestational age
  3) I do NOT have a "cut-off" for cervical length but most of the patients I end up seeing under these circumstances have had significant cervical change with no reason to suspect that won't continue until early delivery and many are < 15 mm. The details of my approach to cerclage and medical therapy accompanying that procedure in "rescue" or "indicated" situations such as yours are detailed in my 11-part series referenced in the post above.
  4) I have found a pessary to be a useful adjunct with or without cerclage placement under your circumstances.
  Best of luck and let us know how things turn out!
  Dr T

   

• At Thu Jun 18, 05:20:00 PM 2009,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous June 14: This is a very difficult situation and the chance of a good outcome is small, but I have performed "rescue" cerclages in twins after delivery of the first after treating as your sister's doctors are doing. If infection did not drive the cervical insufficiency, there is hope under these circumstances, although infection is STILL the greatest enemy. A little trick I have used is to maintain the patients following cerclage on a drug called metronidazole (generally 500 mg 3x/day) until the pregnancy has gotten to a point of good viability after placement of the cerclage. If a cerclage is placed, your sister MUST agree to be delivered whenever there is any hard evidence of infection regardless of the gestational age. Good luck to all of you.
  Dr T

   

• At Sat Jun 20, 03:28:00 PM 2009,  Anonymous said…

  Dr. T
  I wanted to get your opinion re. my sit. am 38 almost 22wks pregnant and my apf4 turned out to be 1 in 5 DS risk. got my anatomy ultrasound and i was in normal range for spina bifida, etc.except for DS w/c is also 1 in 5. Nurse nd genetics advised me to do amniocentesis. got 3 kids youngest is 13y/o all are normal. would just like to get your point of view in regards of taking amniocentesis, chances of having DS baby, cuz reading all the comments and responses in your blogs it seems so sincere. thank you

   

• At Tue Jun 30, 01:48:00 AM 2009,  wants to know said…

  Is bleeding unusual in cervical incompetence?I was under the impression that bleeding does ccur when the cervix opens up or just before it dilates.

   

• At Thu Jul 02, 04:03:00 AM 2009,  wants to know said…

  Dr T
  Me and my wife have three miscarraiges.one at 8 weeks and the other two at 17 and 16 weeks respectively.i would like to elaborate about it in detail.
  
  preg 1
  
  was a missed abortion at eight weeks probably a chromosomal abnormality and we need not do anything about it.
  
  PREG 2
  
  We concieved naturally, all the scans were good including the downs and trisomy screening and everything went on well till week eighteen when suddenly we she had severe cramping and vomiting at about nine in the night.The cramping continued till three when she started to bleed and then her waters broke.By the time we reached the emergency the doctors said her membranes were in the vagina and she had to expell.she was suffering in pain for 20 hours and finally expelled a fetus about 18 weeks of age with all products of conception.No d&C was done again.
  
  Post 2nd preg follow up.
  
  Torch: negative
  
  apla,cardiolipin negative
  
  parents chromosomal analysis(Karyotyping)
  
  Ultrasound of non gravid uterus-normal
  
  all other blood parameters normal
  
  We also did a post mortem of the fetus and placenta which showed intraplacental clots and acute on chronic hypoxia of the fetus.No signs of placental infection were seen.
  
  We could not do a chromosomal fetal analysis.
  
  We met all the high risk specialists in town.It was very confusing as half of them just wanted to take a cervical stich and the other half came up with something called "seronegative Anti phospholipid Syndrome".I decided to go with the Seronegative diagnosis with ultrasound cervical surveilance for shortening.
  
  PREG 3
  We concieved naturally again and at 6 weeks we were started on inj.clexane 40 mg OD,Tab prgestrone 200 mg BD and Aspirin 75 mg OD.Everything went on well till the tenth week when my wife had an episode of painless bleeding.We rushed to the emergency, a scan was done which revealed a low placenta with a subchorionic bleed.My wife was given a shot of Inj Trapic following which the bleeding stopped .The aspirin was stopped and T.Duphaston(a synthetic progesterone)was started.She was put on bed rest with bathroom privileges.she bled again in the thirteenth week around half a pad painless again but this time they could not determine the cause of bleed as the placenta and risen up.Anyway the cerivcal length was assesed on week fourteen by TVS and found to be 35 mm.We were advised to continue monitoring the length every two weeks.At week sixteen by TAS her CL was 35 mm again.The placenta had risen up and everything was good ,they said.The problem started when she had a very bad episode of constipation on the 5 th day of the 17 th week.
  2:15 PM-Immedeately after the passing of stools she had back pain and lower abdominal pain.
  
  2:40-I called the gynacologist who initially told me to give her buscopan and paracetamol.
  
  3:00-The pain reduced but by now it was intermittent and my wife could say that it felt like contractions as they were comin back regularly.
  
  3:15-Our Gynac said that it could be a false labour so she asked us to take a scan at the nearby scan center
  
  3:45-we did so and the Fetal heart was 142 /min and CL BY TAS was 35 mm
  
  Our gynacologist said that she is not in true labour as the CL was alright and if the pain did not subside in an hour to come to the emergency
  
  4:00 pm
  
  She started to bleed and we rushed to the ER and from there to the labour room
  
  5:00 pm
  
  The scan was done and the sonologist said that the internal os had fully opened up and the membranes had balloned into the cervix the external os was still closed.
  
  By the time the gynac examised her the membranes were out and she said that she would have done a rescue cerclage if there was no bleeding but now nothing could be done.
  
  my wife expelled again
  
  
  
  I know that this could just be a simple case of cervical incompetence or something very complicated.I want to know what you think about follow up and what we have to do next for a successful pregnancy.

   

• At Thu Jul 02, 07:05:00 AM 2009,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous June 20: The risk is what it is and 1 in 5 is quite high. Even with a completely "normal" genetic sonogram, the risk is probably no less than 1 in 10 to 1 in 15. It is getting a little late in the pregnancy to get an answer, but if you still would like to know if the baby has Down syndrome or any other chromosomal abnormality prior to delivery, I would recommend the amniocentesis. The risk in experienced hands is only about 1/100th the risk that you are carrying a Down's baby. Good luck and let us know how things turn out. Dr T

   

• At Thu Jul 02, 07:06:00 AM 2009,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous June 30: "B;oody show" is very common once the cervix starts to dilate but sometimes will not be seen until late in the process if the cervical change is slow as it might be with an incompetent cervix.
  Dr T

   

• At Thu Jul 02, 08:26:00 PM 2009,  wants to know said…

  Dr T
  Can an incompetent cervix dilate within one hour?
  Can contractions precede dilatations of an incompetent cervix or should it always be cervical dilatation followed by contractions?

   

• At Tue Jul 07, 03:51:00 PM 2009,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To wants to know: Once an incompetent cervix starts to change, it can do so quite quickly. Contractions can precede or follow the cervical change. In patients without evidence of infection and physical evidence of cervical insufficiency, I would still consider a cerclage if the contractions could be diminished. Thanks for writing.
  Dr T

   

• At Thu Jul 09, 04:58:00 PM 2009,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To wants to know July 2: This is a situation in which I would pull out all empiric stops for therapy offering you progesterone support, extra folic acid, and low molecular weight heparin from midluteal phase on, or a soon as a pregnancy is confirmed. The low molecular weight heparin could be stopped after 24 weeks. At 13 weeks I would place a cerclage and place you on weekly injections of 17-OH-P. From 16 weeks on serial transvaginal cervical assessment by ultrasound would also be appropriate by an experienced sonographer. Regular screening for urinary tract infection and prophylactic use of a bulk laxative is also appropriate. With onset of any bleeding, I would offer a course of broad spectrum antibiotics (azithromycin - 5 days, a penicillin or cephalosporin - short course, and metronidazole). At that point I would continue the metronidazole (alone) 250-500 mg twice per day until the pregnancy reached good viability. There is no data to support this approach, but what have you got to lose and it is very safe. Best wishes and thanks for reading.
  Dr T

   

• At Sun Jul 12, 07:31:00 PM 2009,  wants to know said…

  Dear Dr T
  
  Thank you for the sincere reply.I apoke our gynacologist and she feels that next time we will just take a cerclage after the nt screening and start her on 17 p shots.She seems to be very convinced this is cervical incompetence only.
  Is this alright or do you think clexane is really necessary.
  She also feels bed rest is unnecessary I am very confused Dr T.I myself an a surgeon and i really do not know what to do.Every persons opinion is different from the others.It is very confusing.(If possible kindly deletet the above two lines while posting)

   

• At Mon Jul 13, 11:45:00 AM 2009,  Anonymous said…

  DR.T
  
  I am writing for my wife. She is 14 weeks with twins IVF. every thing was going on well in the pregnancy, untill when we went to do the last ultrasound it showed the cervix was opened ( funnel sheped),the membrane was partially out, but not reptured, an emergency Mcdonald cerclage was done and was advised bed rest. She is on terbutaline sulfate.
  Dr, our concern is that, she is having some low back ache, cramping in the lower abdomen, and some sort of pain just like before a menstrual cycle in the utrus and vagina. She is 36 yrs and had three miscarriges, two D&C, and one ectopic pregnancy
  
  We would like to know
  1. how successful is the cerclage
  for twins in 14 weeks.
  
  2.when the membrane is half out, will there be any infection to the babies, although antibiotic was given after the procedure.
  
  3. Well there be low back ache with some sort of light reddish discharge and pre menstrual symptoms, if yes, how long.
  
  4. What do you recomend, how far can this pregnancy go, and what to watch out for.
  
  Thank you.

   

• At Wed Jul 22, 09:23:00 AM 2009,  Anonymous said…

  Dr. T
  
  I just lost twins at 19 weeks due to an incompetent cervix. My ob/gyn is wanting to put in a cerclage in a few weeks before we do ivf again. Just wanted your oppinion. Thank you so much.
  
  Stef.

   

• At Tue Aug 25, 09:50:00 PM 2009,  Stephanie said…

  Hi Dr. T,
  This is Stephanie. I wrote to you several times over the summer and fall. I had the twin pregnancy, Incompetent Cervix, abrubtion at 12 weeks, cerclage, protein S deficiancy, and gestational diabetes. I had a cervical length of 1.5 at 22 weeks. I just wanted to let you know that I went on to carry the babies to 35 weeks and they were born healthy with no NICU time! I know I couldn't have made it without the cerclage. The minute they cut it i instantly dilated to 4.5 and then was at 6 cm. 20 minutes later. Thank you so much for answering my questions and easing my anxiety.
  Stephanie

   

• At Sat Aug 29, 05:10:00 PM 2009,  Alex said…

  I'm writing on behalf of my wife with twins at the 21 week mark. 2 weeks ago we had the ultrasound that showed her cervix to be 1.4cm. It was at this time we found out about what an "incompetent cervix" was about. The obstetrician told us rather casually to just go home and bed rest as much as possible. My wife obeyed this as much as she could on the couch, and in various recommended positions, and only moved when going to the bathroom. We went back to the hospital yesterday only to discover her cervix was almost non -existent. They took her down to the surgical ward immediately. She spent last night at the hospital in a reclined position in her hospital bed, and this morning they gave her a cerclage procedure. Apparently her cervix was not open or dilated, and we were told the procedure was a success. Also, they told us her cervix seems to now measure 5mm.
  
  She is going to be spending quite some time at the hospital, and we are now told she *does not* need to be in reclined position. Logic would tend to tell me that gravity plays a large part in this entire problem, and that we should probably still decline her bed to a certain extent- even if this will improve her changes 5%.
  
  Any answers would be very helpful. I'm a very concerned husband trying to get as much information as I can here. I'm very upset my wifes condition was treated very casually 2 weeks ago when we were told her cervix was at 1.4cm, as I feel we probably could have taken some more steps at that time (IE - reclined bed full time) to prevent the further shortening that has occcured.
  
  Any answers would really help.

   

• At Mon Sep 07, 06:31:00 PM 2009,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To wants to know July 12: It has been awhile since I have been back to this post. I think a good cerclage is a GREAT idea and I doubt the Clexane is really necessary. Good luck next time!
  Dr T

   

• At Mon Sep 07, 06:35:00 PM 2009,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous July 13: To have that degree of cervical incompetence T 14 weeks, even with twins, is VERY disconcerting. If your wife is to be successful, an abdominal cerclage or a well-placed Shirodkar cerclage might be necessary between or very early in another pregnancy. The prognosis now has to be considered very guarded in view of what you have described to me. Best wishes and let us know what happens.
  Dr T

   

• At Mon Sep 07, 06:36:00 PM 2009,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To Spephanie Aug 25: Thank you for the follow-up and CONGRATULATIONS!!!!! Have fun with the babies.
  Dr T

   

• At Mon Sep 07, 06:43:00 PM 2009,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To Alex Aug 29: Your wife has a long road ahead of her. Admittedly, cerclage, especially with twins, that late in midtrimester has not been proven to be a reliable approach to management, but at the time she began having problems, you were in what I consider to be a "no lose situation" and possibly a lot to be gained. But, the response of your doctor is not atypical - torn between trying to salvage a situation and not wanting to make things wors, knowing she was only a few weeks from potential viability of the babies. I really don't know if the reclined position is all that beneficial, but, personally, I would have offered the cerclage sooner than later. Hear me loud and clear though, that is by no means a "standard of care" at this point due to the lack of hard evidence. I wish you both the best with the pregnancy and please let us know how things turn out.
  Dr T

   

• At Tue Sep 08, 12:12:00 PM 2009,  Alex said…

  Dr. T - thanks very much for your information. I have the utmost respect for Doctors, but I am a little concerned that the obstetrician we are seeing didn't take my wifes condition more seriously when we learned her cervix was at 1.4 cm. We had done IVF in the USA, and moved back to Canada. So the very first time the obstetrician saw my wife, she was aware that very day her cervix was 1.4cm. As I had mentioned, we were casually told to go home and bed rest as much as possible. She even said to us when we come back in 2 weeks for the nex routine Ultrasound, it was no problem to walk up to the offices, and there was no need to be in a wheelchair or other means. In what I have learned now, I am quite shocked this was the advice she gave us.
  
  As I mentioned above, we stuck to bed rest, and returned 2 weeks later and “walked into the clinic”. The technician then revealed to us the cervix was “non existent”, and the salvage cerclage was implemented immediately. All of this happened without seeing our personal obstetrician at all.
  
  When our obstetrician finally came around to our hospital room 4 days later, I politely asked her if we should have taken my wifes condition more seriously 2 weeks before when she showed the incompetent cervix at 1.4 cm. She actually seemed angered I would have asked this, or even questioned her on this. She never gave me a proper response and actually left our room rather quickly.After inquiring around with a few people, I did read in some hospital records that it “may” have been suggested my wife be admitted immediately to a hospital then, but no beds were available. (We’re in Canada, so there is no private health care for that).
  
  On a side not, I’m not the type of person who is looking to sue a doctor, or bring another doctors name or recommendation into a situation like this and start pointing fingers. I just want to get an idea of how competent this obstetrican is we are dealing with as we may switch to someone else. Something of interest as well - 2 days after the “Shirodkar” cerclage was implemented, my wife was due for an Ultrasound to assess the situation and how well things had gone with the operation. Our obstetrician (who we had only seen and met once as our IFV was done in the USA) stood 10 feet away from the stretcher my wife was in, and never came over to talk to us. She chatted with a colleague about a personal vacation and airfare deals, amongst numerous other personal things. The entire time my wife was in tears on the stretcher outside the UltraSound room. My wife was concerned she was going to get bad news about the cerclage, and was very anxious that she was moments away from being given bad news. I’m pretty sure the personal obstetrician a pregnant woman deals with is someone who should be trying to building a bit of a personal bond with?
  
  In summary, my question is this. When it was determined my wifes cervix was 1.4 cm at 19 weeks (She’s asian, 5’1, and carrying twins), was it the right decision for our obstetrician to casually tell us to just go home and stick to bed rest until the next UltraSound we would have 2 weeks later? Or should more precautions have been taken at this time?
  
  We’re now at just over the 22 week mark and my wife has been in the hospital for just over a week. So we are keeping our fingers crossed.
  
  Thanks Dr. T - Alex

   

• At Sun Sep 27, 12:33:00 AM 2009,  scmom32 said…

  Hi Dr. T
  
  I wanted to share my story with you and ask your opinion. I am a 28 year old female from Columbia SC. I lost my twin boys 4 weeks ago at 19 weeks 5 days due to a failed emergency Mcdonalad cerclage that was done at almost 17 weeks. I went to the hospital due to bleeding and contraction and found out that 2 of the 4 stich they put in was coming out and one of the bags was being exposed.I stayed in the hospital on antibiotics for 2 days came down with a fever and and infection and had to be induced. The reason why i had a emergency cerclage placed was because my obgyn reffered me to a peri due to them thinking i was a Diabetic prior to becoming pregnant due to my A1C levels and bleeding off and on since 13 weeks and being pregnant with twins. They thought i would be in better hands. So i went to my first appointment at the peri they did a ultrasound to check my cervix and notice that that my cervix was open and one of the bags was coming down so i was admitted to have the cerclage.Let me tell you a little about my medical issues. I am a diabetic that was not being treated until i went and seen the peri. Now it is doing great and my diabetis is under controlled. I was diagnosed with PCOS about 4 years ago. I had leep done 2 years ago with 2 colposcopys. Before that i had 2 full term no complication pregnancy except for gestational diabetis. With my last 2 pregnancy including the one i lost i had to use fertility treatment like clomid. Me and my husband do want to try again in few more months. I wanted to know due to my medical issues and past failed TVC would you think another TVC would work are doing a TAC would be better for me. I heard that there alot of doctors that want give me TAC unless i have more then 1 loss. Thank you for your time.

   

• At Wed Oct 21, 05:49:00 AM 2009,  Anonymous said…

  Dr. T
  I recently lost my twins at 23 weeks. My cervical length was measured via ultrasound beginning at 17 weeks. Manual exams began at 17 weeks as well. At 17 weeks my cervix measured 4.5 cm. At 19 weeks I had a manual exam and my cervix was long and closed. At 21 weeks (my next vaginal ultrasound), my cervix had reduced to 1 cm. I was sent to the hospital and was having contractions (which I did not feel). I was admitted and put on a terbutaline pump. At 23 weeks my cervix measured 4mm and I was told there was no hope. I elected to have a D&E rather than giving birth.
  
  I know my next pregnancy will be a singleton. Will I need a preventative cerclage? What other treatments would you recommend?

   

• At Wed Oct 21, 05:36:00 PM 2009,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To scmom32 Sep 27: The type of cerclage that will work for you depends on how much cervix is accessible to work with intravaginally and NOT the number of losses you have had. And, that will depend on how much cervix was taken with the LEEP and whether or not there was any residual scarring that might make placement of a vaginal cerclage more difficult. Have the MFM doctors evaluate you either before you conceive again or very early in a subsequent pregnancy. Best wishes and thanks for writing!
  Dr T

   

• At Wed Oct 21, 06:42:00 PM 2009,  Kenneth F. Trofatter, Jr., MD, PhD said…

  To anonymous Oct 21: I am so sorry. Were you not offered a cerclage after your cervix shortened? Yes, with your nest pregnancy I would recommend a prophylactic cerclage, particularly if the physicians who care for you are not comfortable placing a rescue cerclage later in pregnancy. In addition, I have been placing patients on weekly injections of 17-hydroxyprogesterone caproate 250mg IM - in your case I would start that at about 16 weeks. Kind regards and thank you for writing.
  Dr T

   

• At Tue Oct 27, 07:54:00 PM 2009,  Anonymous said…

  Dr. T.: thank you for all of the informative information you provide on this website! My husband and I are expecting twins after IVF and a history of loss (our son was delivered at 28 weeks due to severe IUGR and passed away about one month later in the NICU and we had one other early miscarriage at 7 weeks). I have also been diagnosed with PAI-1 4G/4G and heterozygous for MTHFR. I am being treated for the blood clotting disorders with baby apirin, Folgard, extra folic acid and Lovenox.
  
  We just learned at our 20 week ultrasound that my cervix has shortened to 2.5 cm. I was put on monitoring for about an hour and showed some uterine irratibility, but no real contractions. Our peri has us coming back in for another cervical check in one week, but says she would not recommend a cerclage at this time or any other management. My OB/GYN though has already ordered bed rest at 24weeks, but I was just wondering:
  
  1) Should we more proactively advocate for a cerclage?
  
  2) Would progesterone therapy help in our situation?
  
  Any insight you might be able to provide would be greatly appreciated. Thank you!

   

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