OB-GYN-L Messages for April, 2001: Re: cervical scarring

Re: cervical scarring

From: Garry Siegel

garrys@mindspring.com

Wed Apr 4 19:29:27 2001

>Although our practice does follow our patients who have had conizations
>(and no subsequent full term pregnancy) with regular cervical length
>ultrasounds, Maggie's patient was 32 weeks on 2/1, and the case in point
>occurred last week. Since she made it to 39-40 weeks, she would not have
>benefitted by cervical surveillance or cerclage! She made it to term
>despite all our technologies! She made it to 39 weeks. She doesn't have
>cervical incompetence.

GES: Agreed. Remember, most people who have cervical procedures and short cervices by exam/scan will go to term. It should not be a surprise--it is not inevitable that one at risk due to a cervical procedure will indeed have an incompetent cervix and/or preterm delivery. Retrospectively, she would not have benefitted from surveillance or cerclage, but how would you know prospectively? I agree that monitoring is appropriate, and some, unemcumbered by data, might automatically place a cerclage in the shorter cervices.

>
> It is
>>more often cerclage rather than conization which creates the scarring
>>which you describe. Nonetheless, faced with labor contractions, a
>>previous cesarean, and a rigid yet effaced cervix, the question you
>>should be asking yourself is not by what ridiculous means can we force
>>the cervix open, but rather what is the point of least resistance - the
>>cervix or the uterine scar?
>
>I don't think anyone suggested pushing forward with a stenotic os; however,
>having had many women w/ scarring due to cryos or cones, once the scar
>tissue is broken up (and I have only done this digitally), the cervix opens
>quite promptly to 3, 4, 5 cm as Dan has suggested. And then the dilatation
>progresses quite normally.
>
>>Thank your obstetrician for having the wherewithall to eliminate
>>unnecessary danger to the patient by putting a prompt and appropriate
>>end to this dangerous riddle.
>>
>I agree that persistence in labor in the face of a stenotic, scarred
>external os is not wise...regardless of prior c/s or not. One primip had
>a posterior sacculation of the uterus, with the fetus coming thru the
>posterior LUS because it was the "line of least resistance". This fetus was
>approximately +3 station and a paper thin LUS, the obstetrician was
>consulted and (eventually) believed me that this woman was closed, not
>completely dilated. But it took a spec exam since the uterus was so thin.
>C/S was uneventful.
>
>Another woman w/ previous c/s and cryo since last birth was admitted in
>labor w/ stenotic os which we could not break up digitally. Had c/s w/ a
>window.
>
>I thank those posters who gave suggestions for breaking up this scar
>tissue. I would certainly attempt this the next time I am faced w/ cervical
>stenosis. An automatic c/s without attempt at correcting the stenosis is
>*not* a benign procedure, and the techniques presented here would not cause
>any undue delay.
>
>--
>Betsy Hyde CNM
>Branford, CT
>

GES: I agree with Betsy, and disagree with Marco(which is unusual; he's always on the mark). Most of us have seen stenotic cervices (conglutination--great term, Dan) that easily go from 1/2 cm or pinpoint to 5 cm. once opened. However, the careful accoucher will be leery of this, and if the LUS is ballooned (kind of like a PG E2 induction of a 20 weeker) and tight, be careful.

Garry

-- Garry E. Siegel, M.D., F.A.C.O.G. Roswell, GA Private Practice

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