Successful use of transabdominal isthmic cerclage in the management of cervical incompetence

Abstract

In August 1984 a 27-yr-old para 1 + 2 in the 8th wk of pregnancy was seen at the antenatal clinic in Bellshill Maternity Hospital. The patient’s first pregnancy had been in 1980. She went into spontaneous labour at T + 10 days. After 12 h in labour acute fetal distress developed during the second stage. Vaginal examination showed the cervix to be fully dilated: the vertex was right occipito-posterior at zero -2 cm. The patient was delivered by emergency caesarean section under general anaesthesia. At operation there was difficulty in disimpacting the vertex from the pelvis and a tear was sustained at the left angle of the lower segment incision extending to the cervix. This tear was repaired in 2 layers and the operation was completed with a blood loss of 1200 ml. In her second pregnancy a year later she was admitted at 19 wk gestation with spontaneous rupture of the membranes and aborted 24 h later. At the follow up visit 6 wk later a cervical laceration on the left side extending to the vault was noted. In view of this and the unsuccessful pregnancy trachelorrhaphy was performed 2 months later. In February 1982 the patient was seen at 12 wk gestation in her third pregnancy. The cervix was very short and scarred at the left fornix. In view of these findings cervical cerclage was performed 1 wk later when a McDonald suture of 2 layers of black silk was inserted. The patient was allowed home 5 days after operation, but was re-admitted at 20 wk gestation with spontaneous rupture of the membranes. Speculum examination confirmed the presence of liquor in the vagina. The cervix was closed and the suture in place. The patient continued to drain liquor for 5 wk when uterine activity commenced and following removal of the suture she aborted 3 h later. E. coli was grown from a high vaginal swab, although there was no evidence of intra-uterine infection on histological examination of the placenta and membranes. After this pregnancy a further attempt at vaginal repair of the cervical laceration was made in February 1983. Thereafter Cervical Resistance Studies were performed in August 1983, using the technique of Anthony et al. [l]. The cervix was noted to be lacerated on the left side and the laceration extended to the vaginal vault with