A 17 year old primigravida was sent on referral when she was found to have significant “ballooning” of the membranes into the cervical canal at 20 2/7 weeks gestation. She was obese and a smoker but otherwise had an unremarkable medical and pregnancy history to that point. She reported some spotting after intercourse 2 days earlier and cramping lower abdominal pain and “pressure” during her transfer to our hospital, but denied fever, chills, constant pain, frank bleeding, leakage of fluid, or symptoms of urinary tract infection. On admission, the patient was found to be having irregular uterine contractions, the uterus was nontender, and the membranes were intact. She did not have a fever. Her cervix was 4-5 cm dilated, “completely” effaced, and membranes were bulging at the external cervical os.
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.