In my last post, I detailed my approach to placement of a prophylactic cerclage. Now let’s make things a little more challenging and discuss ‘rescue’ or ‘emergency’ cerclage. Actually, these usually fall into two broad categories, challenging and heroic! The challenging ones have funneling of the membranes to just inside or even just at the external cervical os and may be accompanied by dilation of the cervix as much as 2-3 cm; the heroic ones have more advanced dilation and effacement of the cervix with membranes bulging at, and slightly through, or completely prolapsed through the external cervical os. Let me give you a couple of case examples to help illustrate my differences in management under these two situations.
The first patient is a 35 year old woman who had primary infertility problems related to polycystic ovary syndrome. She is oligoovulatory, overweight, mildly hypertensive, somewhat androgenized, has insulin resistance (but not overt pregestational diabetes), and finally conceived after 3 months of metformin therapy followed by ovulation induction and intrauterine insemination. She had first trimester screening for aneuploidy done at 12 weeks because of her age (which she passed with flying colors) and returned at 20 weeks for a genetic sonogram. The baby looked wonderful, but during the course of the abdominal examination, the sonographer thought she saw ballooning of the membranes into the cervix. We performed a transvaginal ultrasound and the membranes were found to be ballooning to within 3-4 mm of the external os without any fundal compression. In discussion with the patient, she reported some pelvic “pressure” and had noted an increase in clear, mucous discharge, but reported no bleeding, cramping pain, or gross rupture of membranes. She had no fever or uterine tenderness. She was admitted that day for cerclage placement. I intentionally did NOT perform a bimanual pelvic examination on her in the office. So, how was her case handled…
1) She was admitted to our surgical unit on L&D
2) Urine analysis and culture and CBC with differential were sent
3) An IV was placed and the patient was given an antibiotic cocktail (after obtaining the urine culture) of cefazolin 2.0 g q6h, azithromycin 500 mg, and metronidazole 500 mg q6h
4) She was also given indomethacin 100 mg by mouth
5) She was taken to the operating room and given a spinal anesthetic
6) The patient was placed in the dorsal lithotomy position and the perineum and vagina (very gently) prepped with a betadine solution
7) After the patient was prepped and draped, a foley catheter was placed, the foley was clamped so that urine would not drain from the bladder, and the bag draped over her leg so as to be out of the operative field
8) A weighted speculum was placed in the vagina and the cervix was visualized with retractors
9) She was noted to be visibly dilated 1-2 cm and membranes could be seen approximately 4-5 mm inside the external cervical os, correlating well with the ultrasound findings
10) A cerclage was then placed approximately 2.5-3 cm above the external os following the exact procedure I reported in Steps 11 to 20 in our last post
11) The foley catheter was then unclamped and allowed to drain
12) As is so often the case in these circumstances, as the bladder filled, and as the cerclage was placed around the cervix, the membranes retracted higher into the cervical canal without having to be displaced by any instrumentation or insertion of a finger into the cervical canal (Personally, I think avoiding manipulation of the membranes may be very important to the success of rescue cerclages)
13) The patient was taken from the operating room and admitted overnight
14) The foley catheter was left in place
15) The cefazolin 2 g q6h, metronidazole 500 mg q6h, and indomethacin 50 mg q6h were continued overnight
16) The foley was removed the next morning and the patient was asked to void on her own before discharge
17) She was given a prescription for indomethacin 50 mg q 6 hour to complete a 72 hour course, azithromycin 250 mg daily for 4 days, and metronidazole 500 mg twice daily (to be continued until at least 30 weeks); she was placed on a stool softener and discharged to home with instructions for modified bedrest for 72 hours and then no intercourse or heavy exertional activity
18) She was scheduled for a transvaginal ultrasound 2 weeks following the procedure to assess cervical length and the level of the cerclage placement and told to return sooner with pain, cramping bleeding, rupture of membranes, or fever
19) When she returned, the transvaginal ultrasound showed the cerclage to be placed more than halfway up her cervix with another 1.5 cm of cervical canal free of membranes above the level of the cerclage. She still had V-shaped funneling at the level of the internal cervical os. Cervical evaluation was performed every other week until 28 weeks.
20) The metronidazole was discontinued at 30 weeks, but she subsequently developed a bacterial vaginosis-like discharge (commonly seen with cerclages) and she resumed the metronidazole until delivery.
21) During the course of her pregnancy, she developed insulin-dependent gestational diabetes and was eventually delivered after removal of the cerclage at 37 weeks when she underwent induction of labor for preeclampsia.
In our next post, we will discuss the approach to cerclage placement in a slightly more challenging case….