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Re: ruptured membranes and ShirodkarFrom: fuf@gulf.netSun Nov 30 16:46:31 1997
> >I har. >The question is would you remove the stitch.If not is she not at risk of >getting infection with the stich insitu? > >Who does emergancy cerclages and how good are >your results?Busy night! > >-- >Dr Shiraz Suleman >Consultant OB >Prince ALbert >Canada >suleman@sk.sympatico.ca > Dr. Shiraz: Good questions. A study several years back showed that pregnancy outcome is not improved by leaving a cerclage in with ruptured membranes. (Ludmir J; Bader T; Chen L; Lindenbaum C; Wong G, Poor perinatal outcome associated with retained cerclage in patients with premature rupture of membranes. Obstet Gynecol 1994 Nov;84(5):823-6 ) I agree with their findings, for the most part, but I will leave some cerclages in place after SROM. I have treated septic shock in a patient who got infected with a cerclage in place.The baby expired as soon as we noticed the sepsis. I have also had to remove cerclages with amnionitis present and some of these infections required prolonged treatment with multiple IV drugs. A mother with twins and PROM with a McDonalds who was only ruptured for about 12 hours, lost the first twin from sepsis. Still. pulling the stictch will most likely result in imminent delivery. In select patients who have carefully been evaluated for amnionitis/cervicitis, I will leave a cerclage in to obtain the benefits of steroids or time. I follow the patients with frequent temps, white counts and diffs, and an amniocentesis specimen if the situation is unclear. I would remove the cerclage early for evidence suggestive of amnionitis/cervicitis beceause of the high likelihood. I would also use a broad spectrum prophylactic antibiotic, in these patients. The buried shirodkar, although a foreign body, might be less risk than an exposed McDonald's in this case. I think that labor would be a contraindication to keeping the cerclage in place, but I am unsure. Incompetent cervix and preterm labor are often both part of the disease process and the presence of one doesnt exclude the other. Remember these points when keeping such a cerclage in place: 1. Infection is frequently responsible for ruputered membranes. 2. If labor occurs, infection is also more likely, becuase infection is a cause of a large portion of preterm labors. 3.If infection seems likely based on clinical findings it is probably there. years. 3. I use Unasyn ampicillin/sulbactam IV perioperatively. Azithromycin also helps with mycoplasm, T-strains and chlamydia (if missed) 4. I always use indocin or a nonsteroidal perioperatively. The uterus should be as silent as possible. Even normal uterine activity can cause these patients to deliver. 5. Keep them in the hospital for weeks post op. Most of my ruptures seem to occur one to three days after discharge. To get the membranes back in: 1. Fill bladder up 500-1000 ml. 2. Use stay sutures (usually need about 6-10) around the cervix. Pull the cervix over the mebranes like a parachute. 3. Nitroglycerine IV drip (I have to look up the dose) will quiet the uterus temporarily. This is occasionally helpful in reducing the membranes 4. I put a large foley (30ml bulb, filled to about 50 ml) into the cervix to try to push up the bag. I throw my first stitch (McDonald) with the foley bulb in place. This protects the bag. Make sure the bulb is removed before tying down, or better yet, throw a 2nd stitch if possible to close the cervix completely. If you leave the cervix open 1 cm., the bag will hourglass agan. 5. If you cant reduce the bag, a transabdominal amniocentesis can be done. Reduce the amniotic fluid volume down to oligo. I had a full head of hair before I started doing heroic cerclages, but I believe that they often make a significant difference Gary Kleinman Perinatologist/Geneticist I am leaving the list to move. I have unsubscribed but should be back in a week.
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