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cerclage patientFrom: Jafar6 (jafar6@optonline.net)Wed Jul 2 10:36:18 2003
29 year g6p0322 now 19 weeks. 1st pregnancy, premature rupture of membranes at 25 weeks with vaginal delivery of 2 lb infant now doing well, at age 6. 2nd and 3rd pregnancies, early SABs 4rth pregnancy, cerclage placed prophylactically at about 12 weeks. Ruptured membranes and contractions at 23 weeks. On day after admission, patient demands delivery. This was probably reasonable as infant was previable, and chorioamnionitis was found. Delivery of 600 female infant (breech, vaginal) that expires. Labor progressed rapidly with removal of cerclage, suggesting decreased cervical resistance. 5th pregnancy. Prophylactic cerclage placed (McDonald) at 11 weeks. At about 22 weeks, funneling of membranes slightly past cerclage. Shirodkar placed. Ruptured membranes at 23 - 24 weeks. Cerclage pulled about a week after rupture and labor induced (patient's insistence- see below). Cesarean (classical) done for fetal decelerations. 1.5 lb male infant now doing well at age 2. Our perinatal group did not place any of the cerclages. Patient was referred to our center only after rupture of membranes or labor. Patient would strongly push for delivery in both cases, about 1-2 days after admission (for multiple personal reasons, including no one to watch her other child). She is also obese, 5'4" 280 lb, which makes contraction monitoring/fetal monitoring and surgery more difficult. A tubal ligation was requested just before the last delivery but not done because by state law, papers need to be in place several days prior to delivery for state funded patients. 6th and current pregnancy (sorry for the long lead-in) gets even more complicated. Private physician calls right after cerclage, placed at 18 weeks asking for advice. Patient appeared to have long cervix, but it was partially amputated circumferentially, posteriorly. The physician repaired the tear (debriding the edges) and then placed a cerclage (McDonalds) proximal to the tear. After the cerclage placement, a longitudinal laceration (not bleeding) was seen going from above the level of the cerclage vertically close to the vaginal fornix (about 1.5 - 2 cm). This was debrided and repaired with interrupted suture. Patient discharged 3 days later and comes to our center at 19 weeks for evaluation. Cervix measures at least 4 cm by ultrasound. The cerclage is in place about 2.5 cm from external os. Minimal funneling of the membranes is seen, to about 1 cm above the cerclage. I can feel a suture line going vertically, posteriorly from the cerclage about 2 cm vertically towards the posterior fornix of the cervix. By palpation, the cervical area above the cerclage is very soft and mobile. One could easily imagine the cervix distal to this point as being sewn on as an afterthought. I couldn't feel or see the suture line or rent from the posterior partial amputation. I told the patient: 1. Unknown but very elevated risk of preterm and possibly previable delivery. Possible permanent damage to infant from prematurity and associated complications. 2. Chance of uterine rupture through lower segment, posteriorly, where cervix was repaired. Chance of serious life-threatening maternal hemorrhage or emergency surgery. This may cause death of fetus. Small chance of ruptured uterus from vertical cesarean scar. 3. Possible benefit from abdominal cerclage. At 20 weeks, in a 280 lb woman with a vertical c/section scar and history of chorioamnionitis, the surgery could be difficult to impossible. 4. Prolonged hospitalization (weeks or months, may be necessary) 5. A termination of pregnancy seems safer for the patient. One of my associates suggested that we cannot or should not take care of this patient because her physician did not refer to our center early in pregnancy in multiple instances, and that this patient has been demanding and often opposing our medical recommendations in the past. I personally question the continuation of the cerclage procedure in the presence of these findings. Her doctor called today and suggested a cube pessary and advised me where to find one. I think he wants to "wash his hands" of this case. I told him that I have no knowledge as to whether a pessary would help. I told the patient we might not be able to take care of her here, but did not spell out reasons why. I told her that her case might be beyond our expertise and that I would seek advice of experts. I have done 4 abdominal cerclages, but never in a woman this heavy, this late in pregnancy or with a prior vertical cesarean scar. Any suggestions? Thanks in advance, Gary Kleinman, MD MFM, Genetics (no, she doesn't look like an (Ehler's-Danlos II) Bridgeport, CT
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