Sonawane PK*, Nanavati AM**.
(* Associate Professor, ** Registrar, Department of Obstetrics and Gynecology, K. J. Somaiya Hospital And Research Centre, Mumbai, India)
A 28 year old G2P1L1 with previous lower segment cesarean section (LSCS) done in view of breech presentation came at 26 weeks of gestation with 4-5 cm dilated fully effaced cervix with membranes bulging out of external os. Emergency cerclage was performed. With good postoperative care the pregnancy reached till term after which a healthy child was delivered by LSCS, thus justifying that rescue cerclage can be attempted as a last ditch effort.
Rescue cerclage is a cerclage performed emergently after the cervix is found to be dilated, effaced, or both, in the absence of labor pains prior to 28 weeks of gestation. Usually a cerclage is performed in the following two situations: history indicated cerclage done at 12 -14 weeks gestation for those with a high risk for preterm birth and midtrimester miscarriage, or an ultrasound indicated cerclage done when a transvaginal USG suggests cervical length less than 25 mm.
Our patient was a 28 year old G2P1L1 with previous LSCS done in view of breech presentation. She presented at 26 weeks of gestation with a feeling of heaviness in lower abdomen and something giving way through vagina. She had no complaints of pain in abdomen, leaking or bleeding PV. There was no history of abnormal vaginal discharge or fever. She had undergone a hysteroscopic resection for uterine polyp one year prior to this pregnancy. On abdominal examination, uterus was corresponding in size, fetal heart sounds were present and there was no uterine activity. On per vaginal examination, cervix was found to be fully effaced, 4-5 cm dilated with membranes bulging out of the external os. On per speculum examination the findings were confirmed.
Figure 1. Membranes bulging out of cervix.
After ruling out fetal anomalies on ultrasonography, the patient and relatives were counseled thoroughly. Decision for rescue cerclage was taken. Preoperative tocolytic was given and steep head low given under general anesthesia. Membranes were pushed back with sponge dipped in liquid paraffin with the help of a sponge holder. Purse string suture was taken with No. 1-0 monofilament nylon over external os, with the knot tied at 12 o'clock position.
Figure 2. Purse string suture at external os.
The patient was advised complete bed rest, perioperative tocolytics, antibiotics and vaginal progesterone tablets. A laxative was prescribed to prevent unnecessary straining during passage of stools. After hospitalization for 2 weeks, she was discharged at 28 weeks on request. She followed up regularly during the rest of her antenatal period which was uneventful. At 38 weeks an elective LSCS was performed in view of previous LSCS, and a 2.5 kg healthy female child was born. Knot was cut just before the cesarean section.
The decision of performing a rescue cerclage depends mainly on correct case selection, however one must remember the following factors contraindicate the procedure: active preterm labor, evidence of chorioamnionitis, rupture of membranes, evidence of fetal defects, fetal death and continuing vaginal bleeding. The two known procedures for rescue cerclage are Espinosa Flores and Wurm procedures. Espinosa Flores procedure involves displacing the herniated membranes inside the uterus with a Foley catheter, and after grasping the anterior and posterior aspect of the cervix with ring forceps, a mersilene tape or polypropylene suture is inserted from anterior to posterior direction at 9 o'clock position of cervix and the other end of the tape is taken out through a bite from posterior to anterior direction at 3 o'clock position; the knot is tied anteriorly. In the Wurm procedure two “U” stitches of polypropylene sutures are taken, one vertically (from 12 to 6 o'clock and back to 12 o'clock) and the other horizontally (from 3 to 9 o'clock and back to 3 o'clock) through the cervix.
Reposition of the membranes during the procedure is an extremely important step in a cerclage procedure. This is sometimes made easier by tilting the operating table in a head down position and filling the bladder with 600 ml of saline, but this procedure carries the cervix further cephalad making the procedure difficult to perform. Some advocate using a No. 18 Foley catheter and inflating the balloon to 30 ml, where the balloon is used to push the membranes inside the cavity and then the balloon is deflated gradually as the cervical suture is being placed. Reposition can also be achieved by giving steep head low to the patient and using a gauze dipped in lignocaine jelly or liquid paraffin to avoid frictional injury to membranes while the sutures are placed over the cervix.
Perioperative tocolysis and antibiotic coverage have been advocated to improve the outcome. While there are not many randomized controlled trials (RCT) regarding the choice and dosage of antibiotics and tocolytics to be used, a few uncontrolled retrospective studies do support the use of both perioperatively.[4,5] Sometimes the complications during a rescue cerclage are difficult to separate from the risks that are inherent to the underlying condition; risk of premature rupture of membranes with or without preterm delivery, neonatal morbidity and mortality are some of the common risks associated with rescue cerclage.
There are not many studies done with regards to the effectiveness of rescue cerclage, however the few studies available do suggest rescue cerclage to be a better option than expectant management by bed rest for patients with dilated cervix and bulging membranes. Daskalakis et al. evaluated the efficacy of emergency cerclage in cases with dilated cervix and protruding membranes and found that the mean prolongation of pregnancy (8.8 weeks) and the mean birth weight (2101 g) after cerclage placement was significantly higher from those of the bed rest group (3.1 weeks and 739 g, respectively). Only a third of the patients undergoing cerclage had preterm delivery before 32 weeks of gestation, while 94% of the patients belonging to the bed rest group delivered prematurely before 32 weeks. One RCT evaluating rescue cerclage and bed rest against bed rest alone included 23 women who were confirmed to have cervical dilatation and bulging membranes on per speculum examination at a mean gestation of 22-23 weeks. Eight of 13 women in the cerclage group required emergency suture removal for maternal or fetal indications prior to 36 weeks of gestation. Women in the cerclage group could prolong the pregnancy by 4 weeks more than those in the bed rest group (mean interval between randomization and delivery 54 days versus 20 days), there were significantly less number of preterm deliveries before 34 weeks of gestation (53% in cerclage group as against all the patients in the bed rest group who delivered before 34 weeks). There was an improvement in neonatal survival (56% in cerclage group as compared to only 28% in the bed rest group) and a significant reduction in neonatal morbidity.
There have been conflicting opinions regarding performing a rescue cerclage for prolongation of pregnancy and more RCTs and case studies are required to support the decision to perform a rescue cerclage, however with proper case selection, absence of obvious signs of infection and uterine activity and with sound technical expertise one can attempt a rescue cerclage as a last ditch effort in advanced cases.
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- Royal College of Obstetrician and Gynaecologists. Cervical Cerclage: Green-top Guideline No. 60. 2011.
- Arias F. Cervical insufficiency. In: Daftary SN, Bhide AG. Practical Guide to High-Risk Pregnancy and Delivery. Noida, UP, India: Elsevier; 2008; 262-274.
- Abo-Yaqoub S, Mohammed AB, Saleh H. The effect of second trimester emergency cervical cerclage on perinatal outcome. J Matern Fetal Neonatal Med. 2012; 25(9): 1746 -9.
- Fuchs F, Senat MV, Fernandez H, Gervaise A, Frydman R, Bouyer J. Predictive score for early preterm birth in decisions about emergency cervical cerclage in singleton pregnancies. Acta Obstet Gynecol Scand. 2012; 91(6): 744-9.
- Daskalakis G, Papantoniou N, Mesoqitis S, Antsaklis A. Management of cervical insufficiency and bulging fetal membranes. Obstet Gynecol. 2006; 107(2pt1): 221-6.
- Althuisius SM, Dekker GA, Hummel P, van Geijn HP. Cervical incompetence prevention randomized cerclage trial: emergency cerclage with bed rest versus bed rest alone. Am J Obstet Gynecol 2003; 189(4): 907-10.
Sonawane PK, Nanavati AM. An External Os Stitch As Emergency Cerclage: A Last Ditch Effort. JPGO 2016. Volume 3 No. 9. Available from: http://www.jpgo.org/2016/09/an-external-os-stitch-as-emergency.html