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Re: Should I do an abdominal cerclage?From: Lynn D. Montgomery, M.D. (apgar10@montanadsl.net)Thu Oct 24 09:47:26 2002
Gary, Have done several abdominal cerclages, the furthest along was 16 weeks. I have found that the further along, the more technically difficult to place the stitch and I can't imagine putting one in with a prolapsing bag. I would be inclined to re-do the vaginal rescue if you elect to do anything. Either way, I agree with your plan of amnio prior to the procedure. Good luck and I know you will do what is right... Lynn -----Original Message----- From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of jafar6 Sent: Wednesday, October 23, 2002 5:51 PM To: Multiple recipients of list OB-GYN-L Subject: Should I do an abdominal cerclage? 40 year g3p1011 now 19 weeks, 1 week ago for pelvic pressure, no contractions. Cervix was open 2 cm, membranes bulged slightly past cervical os. Cervix was short with very little cervix posteriorly. No signs of labor or infection. Fetus appeared normal on ultrasound. Patient declined genetic amniocentesis or serum screening. An emergency cerclage was done on day of admission. Four days later patient was urging physicians to discharge her. She was examined in anticipation of possible discharge, and cervix was found to be open 2 cm, the membranes prolapsed into the vagina, approximately 4 cm past cervical external os (by ultrasound measurement). By palpation, the opening was posterior to the cerclage, with the suture not attached to the center of the posterior lip of the cervix. There was no palpable cervix posteriorly between 5 and 7 o'clock, as high as I could feel. When this was initially presented to me, after the cerclage had failed, my initial impression was not to attempt another cerclage. I also recommended that the cerclage should be removed and induction of labor (cytotec) should be strongly considered for the safety of the mother and because of the probably inevitable loss of the fetus. The patient declined removing the cerclage, and still remained at hospital bed rest, hoping that the fetus would remain until viability. Three days later, the exam is unchanged. The membranes are not tense and could probably be reduced, if I could close the cervix. I ran the thought of an abdominal cerclage past my partners. I thought it would be the only way to grasp some tissue to keep the membranes in the uterus. I thought it would be a reasonable option to present to the patient. I realise there are significant risks to the patient. The chance of success is probably not high. I told her that I would not consider an abdominal cerclage without first an amniocentesis to rule out infection, since the infection risk would be high. The patient is all for it and ready. She wants everything done to save the baby. Opinions from colleagues are lukewarm, regarding offering the patient this option. Any opinions or suggestions? Gary Kleinman, MD Bridgeport Hospital MFM, genetics
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