Antepartum cervical cerclage operations

Antepartum cervical cerclage operations Analysis from

SATORLJ Honolulu,

at Kapiolani

1957 through

NISHI

Maternity

and Gynecological

Hospital

1966

JIMA,

M.D.

Hawaii

From 1957 through 1966, 46 cervical cerclage operations were done during #regnancy at the Kapiolani Maternity and Gynecological Hospital in Honolulu, Hawaii. During this time, 43,834 obstetric deliveries occurred. There were 3,451 abortions and 47,285 pregnancies. Thus, one cerclage procedure was done in about every 953 deliveries or 1 cerclage in 1,028 pregnancies. The cerclages were carried out in 37 patients; 6 had the operation performed twice and one had it done 4 times. The majority of the operations were of the Shirodkar type. Prior to the cerclage, these 37 patients had a total of 166 pregnancies with 32 living children and a fetal survival rate of 19.3 per cent. Of the 46 cerclages done, 29 resulted in success with a fetal survival rate of 63.0 per cent. In the successful cases, 22 were delivered vaginally and 7 by cesarean section.

WHEN CERVICAL incompetence as a cause of second trimester abortions became established as a clinical entity, numerous articles dealing with this problem began to appear from many areas of the world. Lash and Lash,l in the United States, Palmer and La Cornme,? in France, and Shirodkar,” in India, were among the early pioneers who recognized and treated this condition. The former two groups devised corrective procedures for this defect in the nonpregnant women. Sternberg, Page,” and Barnes6 have also done this with other techniques. Shirodkar, using homologous fascia lata, devised a simple surgical method of constricting the cervix during pregnancy. Since then, many modifications of closing the cervical OS during pregnancy with various suture materials have been attempted.?2 ‘1 ‘2 lo, llv I’, 13, I4 Benson and Durfee15 have also done this through the transabdominal approach.

With the advent of the Shirodkar procedure, the impetus to increase fetal salvage was initiated at our hospital and the first Shirodkar operation during pregnancy was performed in 1957. Material In the 10 years from 1957 through 1966, there were 46 cerclage procedures performed during pregnancy at Kapiolani Maternity and Gynecological Hospital. During this time, there were 43,834 deliveries and 3,451 abortions giving a total of 47,285 pregnancies. Therefore, this gave an incidence of 1 cerclage operation in every 953 deliveries or 1 cerclage procedure in every 1,028 pregnancies. The number of cerclages done per year is shown in Table I. Excluding the first year 1957 when only one cerclage was done, the average per year was about 4.4 cerclages. These procedures were done on 37 patients. Six had the operation performed twice; in 4 of these the first operation resulted in a failure and the second operations resulted in successful fetal outcome. In one of the 6 the two operations were a failure

From the Kapiolani Maternity and Gynecological Hospital. Presented at the Thirty-fifth Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Gleneden Beach, Oregon, Oct. 2-5, 1968. 273

Table I. Number of cerclage procedures done from 1957 through 1966 at Kapiolani Maternity and Gynecological Hospital __---

Table III. Possibly contributing the causation of cervical the 37 patients

factors in incompetency in 1 N;:-iTdiik

1957

1

1958 1959 1960 1961 1962 1963 1964 1965 1966 ___. 10 years

4.582 ‘,,(I25 4,395 4,34H 4,408 4,482 4.232 4,238 4,234 3,890

G .i 4 6 2 4 2 11 5 46

397 376 324 342 350 ? ‘) 0 ii2 333 359 318

43,834

3,45 I

Table II. Types of rrrclagr suture

4,979 5.401 4,719 4,690 4,758 4,802 4,564 4,57 I 4,593 4,208

Previous dilatation and curettage Cervical trauma Laceration Amputation Tracheloplasty Operative deliveries Midforceps Breech Possibly congenital Unknown (one case in primigravida with a virilizing lipoid cell tumor of the ovary) -. ----

material

Table IV. Number various Weeks’

A. Shirodkar

Mersilene

type

strip

Homologous No. 1 black B.

McDonald Mersilene No. 28 wire No. 1 black

fascia silk

type silk

lata

2

2 10

47,285

and types of

1 No.

18 ‘,

of batients 40 36 3 1 6 3 ‘> ;

and in the other one both operations were successful. In the individual who had thr operation performed 4 times, the first operation failed and the next 3 were successful. Of these 37 patients 15 were Caucasian. 10 Japanese, 7 mixed race, 3 Chinese, and 2 Filipino. The ages of the patients ranged from 15 to 39 with the average age being 28.3. Parity ranged from 0 to 5 and averaged I .2 in the 37 patients prior to cerclage. The gravidity ranged from 1 to 13 with the average being 4.2 prior to cerclage. Table II shows the types of cerclages performed with the various suture materials. With the advent of the Mersiiene strip, the Shirodkar procedure as modified by Barter, llusbabeck, Kiva, and Parks,” has been thr operation most often carried out in these patients.

of cerclages weeks of gestation gestation 12 14 16 17 18 19 “(I 21 ‘)3 -... 23 “4

No.

done at

of cerclages

done

, c

The diagnosis of cervical incompetency was considered when there was a history of repeated second trimester abortions. Some possibly contributing factors are shown in Table III. Danforth’” has suggested three causes fol cervical incompetence : ( 1) mechanical injury to the cervix, (2) abnormal cervical structure without any injury, and (3) functional abnormalities which release factors causing cervical effacement prematurely. Congenital cervical incompetence has been mentioned as a cause of second trimester abortions by TrythalI,l’ Mann, McLarn, and

Volume Number

104 2

Antepartum

cervical

cerclage

275

Hayt,l* Roddick, Buckingham, and Danforth,lg Ranney,*O Adducci,21 and Okla and Lesinski.a2 In our series, there were 2 patients who had second trimester abortions three times starting with the first pregnancy and possibly these could have been considered as cases of congenital incompetency of the cervix. The indication for the cerclage was in 42 instances a dilated or dilating cervix with effacement and a bulging amniotic sac. All of these patients were not in labor. Four patients had the procedure done before dilatation and effacement, and of these 2 had a history of cervical amputations. One had repeated midtrimester abortions totaling 5 abortions and the other had 2 premature deliveries with no living children. Results were successful after cerclage in the latter 2 instances. The time of surgical intervention varied from the twelfth to the thirty-first week of gestation. The average was 20.1 weeks. Pregnancy was maintained for an average of 11.2 weeks after the procedure. In patients with successful results, the pregnancies were maintained for an average of 15.8 weeks postoperatively and the average length of gestation was 37 weeks. Table IV shows the weeks’ gestation when the cerclages were done. Sodium pentothal, cyclopropane, and nitrous oxide with oxygen were used in 28 cases and spinal anesthesia in 16 cases. One patient had caudal anesthesia and another had no anesthesia. Adjunctive therapy such as progesteronetype injections, relaxin (Releasin) , isoxsuprine hydrochloride, vaginal sulfonamide and nitrofurazone creams, lututrin (Lutrexin) , and various antibiotics were used in varying dosages in these patients pre- and postoperatively.

Table V. Comparison of results before and after cerclage procedure in the 46 cases

9 from premature onset of labor. In the 29 successful cases, 22 were delivered vaginally : 20 normal spontaneous deliveries, 1 low forceps, and 1 partial breech extraction. One patient received buccal Pitocin induction. Of these 22 cases, there were 6 premature births: 5 pounds, 6vd ounces at 39 weeks of pregnancy ; 4 pounds, 9 ounces at 32 weeks; 3 pounds, 14ys ounces at 34 weeks; 3 pounds, 1 lyz ounces at 35 weeks; 2 pounds, 13 ounces at 30 weeks; and 2 pounds, 1 l’/; ounces at 30 weeks. Seven patients were delivered by cesarean sections : 5 electively and 2 because of dystocia labor after removal of the Mersilene strip. Of these latter 2, one had a premature infant of 3 pounds, 15 ounces at 35 weeks of pregnancy when premature labor started. There were no major bleeding complications associated with the surgical operation. There was one case of amnionitis, requiring removal of the Mersilene strip with resulting abortion and subsidence of the infection. Another patient required Diihrssen’s incision of the cervix for delivery because of cessation in cervical dilation when nearly completely dilated. The third patient developed a chronic draining sinus from the cerclage area 2 months after an elective cesarean section and this necessitated removal of the Mersilene strip.

Results Table V shows the comparison of the results in the 46 cases prior to and after the cerclage procedures. There were 17 failures, 8 resulting from premature rupture of the amniotic sac and

The occurrence of cervical incompetency even though rare is a major cause of fetal loss in the second trimester of pregnancy. Stromme and Haywa23 found it to account for 16 per cent of an over-all pregnancy loss

A. No. of pregnancies prior Number of diving children cerclage Fetal survival rate B. No. of cerclage procedures Number of living children cerclage Fetal survival rate

to cerclage prior

166

to 32 19.3% 46

after 29 63.0%

Comment

276

Nishijima

of 1.63 per cent in the second trimester. Oul data showed it to be quite rare as compared to others. Picot, Thompson, and Murphy”’ had 3 cases in 1,000 deliveries while according to Taylor and HansenC’” the condition occurs about once in 500 pregnancies. There could have been many undiagnosed cases at ollr hospital. Alertness on our p;lrt in diagnosing this condition may result in further fetal salvage. It is difficult to assess the relationship of cervical trauma in the causation of cervical incompetency. In our data nearly half of thr cases had some form of cervical trauma. Nearly one fourth of our ccrclages wrrc done after the twenty-fourth week of gestation. These could have been done earlier in gestation. Better results ma); have occur& if cerclage procedures werr done briorc~ marked bulging of the amniotic sac with cervical dilatation took place. ‘I‘herefore, the only clinical method of assessing this ~~oulcl be to do a careful speculum examination at weekly intervals from about the twrlfth we& of pregnancy. Nearly half of our failures resulted from sudden rupture of the amniotic sac after either loosening; or pulling out of the portion of the Mersilene strip in the posterior fornis

arca. Perhaps the placement of two or t1irc.t concentric multiple prlrse-string sutures bvith the use of Mcrsilcnr strip and starting at the level of the internal OS may prevent the, membranes from rupturing. Hofmcister and associate?’ have recently presented their. rt’sltlts with this modified tylx of cer\-ical cerclagc. In casts where severr cer\-ical kcr;itious and amputations arr present, the Mersilenc strip tends to slip off from the posterior CCvico\,aginal aria. In these cases, :I cfwlagc procedure with the use of the IOWCY portion of the paraccrvical ligaments and the utcros;tcral ligaments to anchor the Mrrsilenr strip x recommended by l nonprt‘gnant woman, ;I m&od using ligatures at the :Inatomic internal 0s alrcl at the histolo,+ internal OS 215 rc~conmmcnd~cl by Mann, McLam, and Hayt’” may he helpful. ‘I‘his study has shown that incrcascd ff*tal salvage can hi accomplished by treating patients with cclyical incompetency. This involves nlakinx an accurate diagnosis cvith and using- the col,rcct the proper f4iolog) lxocedurc at thus opportune time either durina the pregrlant or nonprcgnant atatcl.

REFERENCES 1.

2.

3. 4. r 63:

7. 8. 9.

10. Ii. 1’.

Lash, A. F., and Lash, S. R.: A%f. J. 0~s~. & GYNEC. 59: 68, 1950. Palmer, R.. and La Comme, M.: GynCc. 1x1 ohst. 47: 905, 1948. Shirodkar, V. H.: Antiseptic 52: 299, 1955. Sternberg, W.: Internat. J. Fertil. 2: 71, 1957. Page, E. W.: Obst. & Gynec. 12: 509, 1958. Barnes. A. C.: AI\I. J. OBST. & GYNEC. 82: 920, 1961. McDonald, I. A.: J. Obst. & Gynaec. Brit. Emp. 64: 346. 1957. Stromme, W. B., Wagner, R. M., and Haywa. E. W.: Minnesota Med. 49: 393, 1966. Barter, R. H., Dushaheck, J. A., Riva, H. I,., and Parks. J.: AM. J. 0~s~. & GYNEC. 75: 511. 1958. Marshall. B. R., and Evans, ‘I’. N.: Obst. SC Gynec. 29: 759, 1967. Lewis, G. C., and Reed. T. P.: Ohst. si Gynec. 13: 498, 1959. Johnstone, J. W.: J. Ohst. Pr Gynaec. Brit. Emp. 66: 144. 1959.

13. If.

15. 16. 17. 18. 19.

20. "1. 22. '-,) 'j

Durfee, R. B.: Obst. & Gynec. 12: 91, 1958. Ritter, H. A.. and Ritter. P. J.: Obst. k Gynec. 17: 342, 1961. Benson, R. C., and Durfcc, R. B.: Ob\t. & Gynec. 25: 145, 1965. Danfnrth, D. N.: Clin. Obst. & (;yncv. 2: 45, 1959. Trythall, S. W.: J. Michigan State M. Sot. 57: 711, 1958. Mann, E. C., h1cLarn, W. D.. and Hayt, 1). B.: A~I. J. OHS?.. & C;YNEC. 81: 209. 1961. Roddick, J. W., Jr.. Buckingham, J, C!., alld Danforth. 1). N.: Obst. & Gvnec. 17: 562. 1961. Ranney, B.: :1~. J. 0~s~. Sr G~xF,(:. 86: 52. 1963. Adducci. J. E.: Pacific Med. & Surg. 74: 32.5, 1966. Okla. J.. xnd Lesinski, J,: AYN. J. 0~s~. & GYKEC. 97: 13. 1967. Strommr. W. B., and Haywa. E. TV.: Ahl. ,J. OBST. t GYKEC. 85: 22.1, 1963.

Vollme

104

Antepartum

Nunher ?

24. Picot, H., Thompson, H. G., and Murphy, C. J.: Obst. & Gynec. 12: 269, 1958. 35. Taylor, E. S., and Hansen, R. R.: J. A. M. A. 171: 1312, 1959. 26. Hofmeister, F. J., Schwartz, W. R., Vondrak,

cervical

cerclage

277

B. F., and Martens, W.: AM. J. OBST. 8~ 101: 58, 1968.

GYNEC.

1024 Piikoi Street Honolulu, Hawaii

96814

Discussion

DR. RALPH C. BENSON, Portland, Oregon. We have been interested at Oregon in the failure as well as the success of cerclage. We believe this . . operation IS now so well established that its value is virtually unassailabie. The question of fetal salvage is the major one and I estimate the average to be about 75 per cent. This particular report, however, quotes a slightly lower percentage. I think that this is a reflection of the basic conservatism of the medical profession in Honolulu. I personally have noted this and our residents who enjoy a period of service at Kapiolani Hospital agree. On the other hand, I believe that an even greater success story might have come from this group if they had followed some of the suggestions which Dr. Peterson made. I was struck by the fact that the temporary operation was used in some 12 cases and this is either an admission of the fact that it may have been done too late without much likelihood of success or that there wcrc problems other than cervical incompetency. I think, then, that if Dr. Nishijima could insist that his colleagues be even more alert to opportunity, an improved rate of salvage will result. There is much more to be said for the permanent type of operation in contrast to the temporary (McDonald) operation. I realize it is much simpler to just put a purse-string suture about the cc)rvix, but we’re thinking not in terms of one baby but of a family for patients who have had a disastrous obstetric career, Because of their past history. successful individuals after cerclage deserve an elective cesarean section. DR. WALTER S. KEIFER, Seattle, Washington. I feel strongly that an incompetent cervix can be diagnosed prior to pregnancy, and I am convinced that success can be better achieved if the operation is done, as Dr. Benson said, in a permanent fashion in the nonpregnant state. I have not had much luck when I find these membranes bulging at 3 to 4 cm. dilation. Dr. Peterson and I find that the diagnosis of the incompetent ccrvix can be made in a nonpregnant state by balloon hystrrosalpingography.

DR. CHARLES F. LANGMADE, Pasadena, California. We have had a similar size series over almost the same number of years and our esperience has been about the same. These operations were all done with No. 2 nylon sutures, many in concentric rings, and to disagree a bit with Dr. Keifer, it is our feeling that the reinforcement of the membranes is the most important factor rather than reconstruction of the internal 0s. One case in this series is unusual and I hope will be worth presenting to this group. The patient had had five previous abortions, three of which were in the second trimester. She had had a procedure done in Northern California with the use of talcum powder and she came down to Southern California early in the next pregnancy. After the fourth month, all the patients with a history such as this were seen every week and when dilatation occurred, the suture would be put in. At the fourth month, she had dilatation and the No. 2 nylon suture was put in. At the fifth month she went into labor with strong uterine contraction and the suture was cut, which is one advantage of this procedure, and she aborted. Following the abortion, she had tremendous hemorrhage which did not respond to intravenous hormones, dilatation and curettage, and other emergency measures. She was taken to the operating room for a hysterectomy and at this point the problem was encountered. An emergency hysterectomy, following the development of a talcum powder granuloma of the lower uterine segment between the bladder and the uterus, makes rapid, easy dissection difficult. The operation in this case was prolonged, the patient was bleeding heavily, and moderate difficulty was encountered in the area of the granuloma. DR. JESSE A. RUST, San Diego, California. This brief case report, I believe, is significant in respect to salvage. In 1964, a 22-yrar-old patient had a Shirodkar operation performed at what was estimated to be about 6% months’ gestation. Two weeks later, with the onset of strong uterine contractions, the

278

Nishijima

band was cut and she promptly was delivered of a 2 pound, 7 ounce infant that has thrived. Now, gravida 2, her last menstrual period started on Jan. 24, 1968. At the present time, she is 4 weeks from term. On May 9, 1968, we pcrformed a cerclage operation using Mersilene tape. Healing over the tape was complete. On Aug. 21, 1968, at 7 months (just the time she went into labor in her first pregnancy), she was admitted to the hospital with a brown discharge and 20 to 30 second contractions every 4 to 5 minutes; the cervix was totally uneffaced, membranes intact. She was given Vasodilan and light sedation and was noted, during a 48 hour period of close observation, to have repeated episodes at the end of of “labor.” Vaginal examination this time revealed a completely effaced cervix with the band easily palpable under a few millimeters of cervical tissue, vertex presenting at station zero, membranes intact. Preparations were being made to remove thr band and let her be delivered when she asked why we didn’t let her go home. After due consideration and explanation of the risk to her, wr did just that. She is now at 36 weeks with what appears to IX a good-sized baby. She has had repeated episodes of “labor” and reports that a phenobarbital atropinr tablet is the most effective medication. She vows that if it is a boy, she will name it Braxton Hicks. I wonder if occasionally we don’t give up too soon after a Shirodkar operation. DR. GLEN G. RICE, Seattle, Washington. 1 like to remember hearing Dr. Shirodkar’s comment in Seattle a few years ago when a rather critical questioner at the noon round table said. “Dr. Shirodkar, how can it be in a country such as yours where the population pressures are so great, that you spend your time compounding the Dr. Shirodkar stood up, thought fat problem?” iL moment, and then, in his beautiful classical English, said, “Doctor, I imagine my practice is quite similar to yours. I see many people who have too many babies, and I try to help them. And I see people who can’t have babies, and I try to help them.” And he sat down and there was no riced for further discussion. DR. RICHARD L. TAW, Los Angeles, California. In those cerclages that have been done in our hospital the 72 hours immediately postoperative have been particularly critical. We have increased our yield by being particular about the kind of

anesthesia that was used. Not only do nx: havt to prevent pain but also it is important that. an anesthetic agent be used that suppressrz th(* uterine muscle. Fluothanc is an excellent anesthetic agent for this. Another modality to suppress uterinr contractions should hc= quite obvious to this group fin vicxw of our expcrienrc hc~rc; and that is intravenous alcohol. It does work vti’ry well. It helps prevent postoperative infections to he careful where you put your fingers during thl% procedure. Do not get thrm too far up insidr> the cervix. I would add a kvord of warning abotlt the multiple strip technique: I have had the unfortunate cxprrirnce of losing a cervix as lveli as n baby by embarrassing the blood supply to the cervix. DK. NISHIJIMA (Closing c j . Dr. Prtprson‘s rec.ommendations on the LW of radiology in diagnosing cervical incompetency and the USA trf the Doptone apparatus to detwt early fetal hrart rate arr excellent: WC hope to do this also. In our cases some of the ccrclagc operations should have bcacn done carlirr in gestation in order to incrt%ase our frtal sal\:agc rate and Dr. Benson’s recommendation to do this is ccsrtainly pertinent. Dr. Keifer brought out thr importance of diagnosing this condition prior to prcgnanc!- and treat+ this cer\iral dcfcrt hetwren prrgnancic,s. 1 helicvc that this type of thrarapy may hc the procedure of rhoice in certain rxcs. Howew~~. when thr paG,mt is swn in pregnancy with A bulging bag and painless dilatation of thr c-r>llis. then a crrvical ccarclagc must IX done at I hiA time.

Dr. Rl~sr inquired as to lvhat {VP do abo~lt the Mersilenc strip when thr patient goes into laljor. WC cut and wtnove thr Mersilenc suture, sincefailure to do this may cause sepsis and/or ut(.rinr rupture. Maternal drath from sepsis, where the incompetcant o$ had brcn sutured, has t)c~~~n reported. Rupture of the uterus following a Shirodkar suture has also hrcn rrported. Dr. Taw stated that the 72 hours postoprrativcly was the critical period for these patirnrs. In our cases, this period was the fifth to Ihc* Gxth postoperative day. At this time thp mcmbranes would rupture or premature labor \vc)rlld start. Perhaps these resulted from operative manipulation or by placing the Mersilene ahove the internal ox art-a.