Emergency Cerclage Operation in Late Case of Incompetent Int.os.
Presented by
Dr. Narayan M. Patel
M.D.,D.G.O. FICS
Emeritus Professor Muni. Medical college
Postal address--
Mahalaxmi Institute of medical teaching, 3,Shantiniketan park, Naranpura,Nr.Sardar Patel Colony, AHMEDABAD- 380 014 (Gujarat) INDIA T.N.(079) 27682572, Mobile;- 98252 95530 E mail:- narayanpatel1932@yahoo.com
Incompetent Internal os
One of the most common cause of habitual abortion is incompetent internal os. If diagnosed in time and treated the results are vary gratifying. To diagnose it, one has to suspect, expect, treat and diagnosed. The saying that stitch in time saves nine (nine months of pregnancy) holds good here. Trans abdominal and trans vaginal sonography has made diagnosis easy, by seeing shortening cervix and also herniation of membrane, provided the obstetrician keeps this possibility in mind. Patient usually is in second trimester of pregnancy. There may be a history of previous mid- trimester abortion. Regular and care full follow up, and routine P/V examination will detect opening up of internal os.
Incompetent Internal os One of the constant complaint with Pt .of incompetent os with pregnancy is, heaviness in lower part of abdomen, desire to pass urine even she has passed urine, only few minutes back. Incompetent os patients are highly fertile patients. They conceive again and again, just to abort. The reason of high fertility is short and open cervix. A simple procedure like dilation and curettage, makes many patient to conceive. Contrary to it, supra vaginal elongation of cervix in a case of prolapse, is a cause of infertility. We are presenting here a case who came vary late with cervix 3 cm. dilated and with bulging membranes, seen at speculum examination. It is a late cases of incompetent os. If nothing was done, she was to abort in few hours to few days.
Incompetent Internal os
This pictures shows how this patient came to us with bulging membrane. Cervix almost 3 cm. dilated.. It was a vary late case for emergency cercalage operation with success rate not more than 25%. Since liquor appeared clear and membrane still shining, indicating that amnionitis has not occurred, we decided to take a chance in this case, to do what is called emergency cerclage operation. Pt. was admitted in ward with high Trendelenberg position. She was given heavy sedation and tocolytic drugs and antibiotics. She was not allowed to even sit up in bed. After 2 days of such rest and as there was no leaking of membrane, she was taken to operation theater. In theater also she was given high Trendelenberg position and deep general anesthesia with Haolthane supplement, to relax the uterus. Spinal anesthesia does relax uterus and should not be employed. Suture material used was Prolene No-1 on 40 mm. atraumatic curved round body needle.
Picture-1 All these pictures were taken at the time of operation in operation theater.
Cervix held by 2 Allis forceps at operation. Bulging membrane seen at the beginning of the operation.
Anterior lip of cervix was held by 2 Allis forceps. To push membrane in, you have to be very gentle, & have patience. Deep general anesthesia and high tredelenburg position helps to reduce membrane. We use wet peanut on straight artery forceps to push membrane in. Some people use No 20 Foley catheter with tip cut. After putting in Foley, it is distended with 50 to100 cc distilled water. This method helps in reducing bulging membrane. I have no experience of this technique.
Picture 2
Picture 3
Picture-4
We used wet peanut to reduce membrane. In picture No 2 & 3, you see membranes are being gently reduced with a lot of gentleness and patience. Gentle pressure to be given more on cervix side rather than on membrane side. In picture No-4 membranes all reduces completely and surgeons finger is in, to push membrane, as high as possible. Next step is suturing, that is known as cerclage operation.
Picture No-4
Anterior lip of cervix is held by Allis forceps. Another Allis is applied at the vesico- cervical junction, on ant. vaginal wall.
First suture is to be passed, entry at 1 o'clock position on left side, and exit at 10 o'clock position, on right side of the patient. Upward pull on the Ellis applied on ant. vaginal wall, helps to pass needle in the vesico- cervical space, at the level of internal os, without damaging bladder. The suture is pulled and second suture to pass from point of exit of first stitch to exit at 5 o'clock position on posterior part of cervix.
Picture-5
Picture-6
Needle coming Out.
Third stitch
Second stitch
Second suture to be pass from 11 o'clock position to come out at 5 o'clock position in posterior part of cervix..
Third stitch is from left side of patient at 1 o'clock position to come out at 5 o'clock position, near exit of second stitch. Thus it is a triangular loop with 3 stitches and not circular 4 stitches.
Suture is completely tied & knot is seen at 5 o'clock position
Tying of thread where assistant put his finger in cervix and as surgeon is making the knot tight, the assistant withdraws his finger gradually.
The end of operation where internal os is seen completely closed.
The patient was kept in hospital for 3 to 4 days with foot end raised, and bed rest. Antibiotic and tocolytic drugs also given. She did well, & she was lucky to continue pregnancy and delivered normally at 34 weeks, a living child.
This operation was done in year 1995 by my teacher, Late Dr. R. M.Nadkarni and I assisted him in this operation. He believed in taking 3 stitches to make a triangular loop and not circular. I have also performed 3 emergency cerclage independently latter on.. Our method differs from McDonad method where 4 to 5 stitches are taken as shown in the picture
Late Dr.R.M. Nadkarni
Conclusion
We have presented a late case of incompetent int. os coming with bulging membranes. One should always try this technique. Your first unsuccessful attempt gives you experience to be successful in the next such case, so do try. Points in favor of better results are :(1) No leaking membrane. (2) Bright shining membrane. (3) Liquor looking clear through membrane. (4) Good anesthetist to give deep anesthesia. (5) Experienced and gentle surgeon. (6) Suture material No.1 Prolene on 40 mm atraumatic round body needle.
I do not have experienced of using Mersilene tap or thread. Points unfavorable for successful out come are:-(1) Leaking membrane (2) Dull looking membrane. (3) Liquor does not look clear through membrane instead looks dirty grey due to amnionitis, as in this case. (4) Patient having temperature. (5) Inexperienced surgeon and (6) Inexperienced anesthetist.
We are coming to the end of this presentation. By seeing this presentation, if few surgeons are attempting it, and be instrumental in saving few babies, my efforts are worth. Dr.Narayan M.Patel. INDIA
Thank you