Re: cerclage patient
From: zygote@icsi.net
Thu Jul 3 15:00:14 2003
This is clearly a case for abdominal cerclage. The indications for same should be strict
and this pt has acquired them. As much as I hate to say it, it should be as interval
procedure if it is to be done. RJC
On 2 Jul 2003 at 10:37, Jafar6 wrote:
> 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
>
Robert J. Carpenter, Jr., M.D.
St. Luke's Medical Tower # 2720
6624 Fannin, Houston, TX 77030
zygote@icsi.net 713-795-4600
FAX:713-795-4422
