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Occlusive trachelorrhaphy for repeated abortion due to cervical incompetence
OCCLUSIVE
TRACHELORRHAPHY TO CERVICAL HERBERT
H.
HALL,
FOR REPEATED INCOMPETENCE M.D., NEW
YORK,
ABORTION N.
DUE
Y.
N RECENT literature the importance of sphincter action of the internal OS during pregnancy has been stressed. Danforth, discussing the paper of Rubovits, Cooperman, and Lash, objected to the contention that incompetency of the internal OS alone was responsible for abortion. He suggested that the whole structure of the cervix itself might be involved. This view finds support in the report by Fisher, who quotes a high abortion rate in women whose cervices had been amputated. This may possibly be caused by the inability of the amputated cervix to function properly as a sphincter to the uterine cavity during pregnancy. In the case here reported the patient had lost two consecutive pregnancies after a high amputation of the cervix.
I
Mrs. M. M., aged 36 years, blood type B, Rh positive, was seen first on June 18, 1953. She was then about five weeks pregnant and speculum examination showed the vaginal portion of the cervix to be absent. She stated that in 1949 she underwent a vaginal operation and inquiries made of .her attending physician disclosed this to have been an amputation of the cervix for erosion and chronic inflammation. IIer pregnancy continued uneventfully until the twenty-sixth week when the membranes ruptured. Ten days later she delivered a 2 pound male infant that did not survive delivery. She conceived again four months later and was given supportive hormonal therapy. This pregnancy terminated at the twelfth week in abortion. At that time a complete absence of the cervix was noted and it was evident that the cervix must have been amputated at or above the level of the internal OS. Only anteriorly was t.here a small lip of cervical tissue left. After her recovery from the miscarriage a hysterogram confirmed these findings. It was felt that the reason for her failure to carry her pregnancies was the absence of a competent cervix, so that, after the corpus uteri enlarged in pregnancy, the lower end of the cavity widened, as it would normally, and the contents virtually “dropped out of the uterus” due to the absence of the cervix. An attempt to reconstruct the internal OS was considered technically impossible since there was no tissue available for this purpose. It was decided, therefore, to permit her to conceive again and to occlude the entrance to the uterus by suture as soon as possible after that event. The patient became pregnant again, with the last menstrual period on Jan. 16, 1954. On Feb. 23, 1954, after a positive pregnancy test, she was admitted to the hospital. Under intravenous Pentothal anesthesia the vagina was exposed and the entrance to the uterine cavity was occluded by a mattress suture. Using Nylon filament, the suture was placed in such a fashion that it would encircle the opening of the uterus and two 34 inch Iengths of polyethylene tubing were used to prevent the suture from cutting through. and oral
The patient had been receiving progesterone by injection this was continued for two weeks following the operation. progesterone and stilbestrol in increasing dosage. The
vaginal
further discharge
course of this or bleeding.
pregnancy
was
uneventful,
for seven days preoperatively After that time she received and
there
was
no pain
and
no
226 At following she was minutes. cavity. upon a taneous 5 pounds
the thirty-fourth week of pregnancy the patient had a severe bout of IfiarrilVa and that the membranes ruptured. Soon after this, uterine contractions set in and admitted to the hospital. At that time the contractions occurred regularly ,?ver;v five Vaginal examination showed the suture in its original position occluding the uterine Considerable thinning of the lower segment was noted. The suture was rllut lrheredilatation of about 5 cm. was noted. Further dilatation followed rapidly and spondelivery of a living female infant followed within 45 minutes. The baby weighed 4 ounces and was in good condition. She survived the neonatal period uneventfully.
Summary
and Conclusion
1. A case of repeated miscarriage following a high amputabion of the cervix is reported. 2. Support is given to the contention that amputation of the c!erris has a high abortion rate in subsequent pregnancies. 3. An operative procedure for the management of such cases is described and further trial of this method is suggested. References AM. J. OBST. & GYNEC. 62: 644, L!I.‘I. Fisher, J. J.: Lash, A. F., and Lash, S. R.: AM. J. OBST. k GTMW. 59: 68, 1950. Rubovits, F. E., Cooperman, N. R., and Lash, A. F.: AM. J. 1953.
OBST.
&
GYXH’.
66:
%!I,
TRACHELORRHAPHY TO CERVICAL HERBERT
H.
HALL,
FOR REPEATED INCOMPETENCE M.D., NEW
YORK,
ABORTION N.
DUE
Y.
N RECENT literature the importance of sphincter action of the internal OS during pregnancy has been stressed. Danforth, discussing the paper of Rubovits, Cooperman, and Lash, objected to the contention that incompetency of the internal OS alone was responsible for abortion. He suggested that the whole structure of the cervix itself might be involved. This view finds support in the report by Fisher, who quotes a high abortion rate in women whose cervices had been amputated. This may possibly be caused by the inability of the amputated cervix to function properly as a sphincter to the uterine cavity during pregnancy. In the case here reported the patient had lost two consecutive pregnancies after a high amputation of the cervix.
I
Mrs. M. M., aged 36 years, blood type B, Rh positive, was seen first on June 18, 1953. She was then about five weeks pregnant and speculum examination showed the vaginal portion of the cervix to be absent. She stated that in 1949 she underwent a vaginal operation and inquiries made of .her attending physician disclosed this to have been an amputation of the cervix for erosion and chronic inflammation. IIer pregnancy continued uneventfully until the twenty-sixth week when the membranes ruptured. Ten days later she delivered a 2 pound male infant that did not survive delivery. She conceived again four months later and was given supportive hormonal therapy. This pregnancy terminated at the twelfth week in abortion. At that time a complete absence of the cervix was noted and it was evident that the cervix must have been amputated at or above the level of the internal OS. Only anteriorly was t.here a small lip of cervical tissue left. After her recovery from the miscarriage a hysterogram confirmed these findings. It was felt that the reason for her failure to carry her pregnancies was the absence of a competent cervix, so that, after the corpus uteri enlarged in pregnancy, the lower end of the cavity widened, as it would normally, and the contents virtually “dropped out of the uterus” due to the absence of the cervix. An attempt to reconstruct the internal OS was considered technically impossible since there was no tissue available for this purpose. It was decided, therefore, to permit her to conceive again and to occlude the entrance to the uterus by suture as soon as possible after that event. The patient became pregnant again, with the last menstrual period on Jan. 16, 1954. On Feb. 23, 1954, after a positive pregnancy test, she was admitted to the hospital. Under intravenous Pentothal anesthesia the vagina was exposed and the entrance to the uterine cavity was occluded by a mattress suture. Using Nylon filament, the suture was placed in such a fashion that it would encircle the opening of the uterus and two 34 inch Iengths of polyethylene tubing were used to prevent the suture from cutting through. and oral
The patient had been receiving progesterone by injection this was continued for two weeks following the operation. progesterone and stilbestrol in increasing dosage. The
vaginal
further discharge
course of this or bleeding.
pregnancy
was
uneventful,
for seven days preoperatively After that time she received and
there
was
no pain
and
no
226 At following she was minutes. cavity. upon a taneous 5 pounds
the thirty-fourth week of pregnancy the patient had a severe bout of IfiarrilVa and that the membranes ruptured. Soon after this, uterine contractions set in and admitted to the hospital. At that time the contractions occurred regularly ,?ver;v five Vaginal examination showed the suture in its original position occluding the uterine Considerable thinning of the lower segment was noted. The suture was rllut lrheredilatation of about 5 cm. was noted. Further dilatation followed rapidly and spondelivery of a living female infant followed within 45 minutes. The baby weighed 4 ounces and was in good condition. She survived the neonatal period uneventfully.
Summary
and Conclusion
1. A case of repeated miscarriage following a high amputabion of the cervix is reported. 2. Support is given to the contention that amputation of the c!erris has a high abortion rate in subsequent pregnancies. 3. An operative procedure for the management of such cases is described and further trial of this method is suggested. References AM. J. OBST. & GYNEC. 62: 644, L!I.‘I. Fisher, J. J.: Lash, A. F., and Lash, S. R.: AM. J. OBST. k GTMW. 59: 68, 1950. Rubovits, F. E., Cooperman, N. R., and Lash, A. F.: AM. J. 1953.
OBST.
&
GYXH’.
66:
%!I,