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Richard Chudacoff, MD
-----Original Message-----
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net]On Behalf Of Braun,
R. Daniel
Sent: Thursday, October 24, 2002 2:58 PM
To: Multiple recipients of list OB-GYN-L
Subject: Re: Should I do an abdominal cerclage?
There was a fellow in St. Louis (in the early 80's I think) who
described a cerclage done vaginally with development of a bladder flap
and opening the culdesac and passing the stich through the Uterosacral
ligaments intraperitoneally. This sounds like she might be a candidate
for that procedure
Dan
-----Original Message-----
From: jafar6 [mailto:jafar6@optonline.net]
Sent: Wed 10/23/2002 6:51 PM
To: Multiple recipients of list OB-GYN-L
Cc:
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
