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ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology, Hôpital Antoine Béclère, Clamart, France.
Address reprint requests to: Herve Fernandez, MD, Department of Obstetrics and Gynaecology, Hopital Antoine Beclere, Paris South University Medical School, 157 Rue de la Porte de Trivaux, 92140 Clamart, Cedex, France; E-mail: herve.fernandez{at}abc.ap-hop.paris.fr.
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TECHNIQUE: With the patient in a steep Trendelenburg position, after epidural anesthesia, the fetal membranes were replaced into the uterine cavity with an inflated balloon of the type used for endoscopic preperitoneal dissection. Cervical cerclage was done by the McDonald technique.
EXPERIENCE: We have done 25 emergency cerclages with this technique. The following maternal and perinatal outcomes were assessed retrospectively: age, medical history, gestational age at inclusion and delivery, cervical dilatation at admission, preterm rupture of membranes, clinical or histologic chorioamnionitis, birth weight, admission to the neonatal intensive care unit, neonatal death, and postnatal course.
CONCLUSION: Replacing prolapsed fetal membranes with an inflated balloon is a convenient technique that allows gestation to be prolonged for an average of 31 days. Cerclage was feasible when the cervix was widely dilated (more than 4 cm); it was associated with prolongation of gestation by a median of 9 days.
Emergency cervical cerclage can be offered to women with impending preterm labor and cervical incompetence during their second trimesters. Olatunbosun and Dyck1 described cervical cerclage for a dilated cervix in which they used a swab on a sponge-holding forceps to push fetal membranes back into the uterine cavity. The main complication of emergency cervical cerclage is that membranes can rupture during the procedure, especially when the cervix is widely dilated. To prevent that, Scheerer et al2 described a technique for reducing prolapsed fetal membranes without direct mechanical contact, by filling the bladder with a 0.45% saline solution through a Foley catheter. Overfilling the urinary bladder was associated with reduction of herniated membranes. We have not found that technique satisfactory when cervical dilatation and protrusion of fetal membranes are both substantial. Therefore, we experimented with a new technique to replace fetal membranes into the uterus using a balloon designed for endoscopic preperitoneal dissection (Figure 1
). The concept was inspired by reports in which authors used Foley catheters to reduce prolapsed membranes.3,4
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Twenty-four hours after admission, the woman is transferred to the operating room, where an epidural anesthetic and prophylactic antibiotics are administered (2 g intravenous amoxicillin and clavulanic acid, Augmentin; SmithKline Beecham, Paris, France). She is placed in a steep Trendelenburg position, and her vulva and vagina are cleaned with antiseptic solution. The assistant uses two Bresky valves to expose the fetal membranes and the cervix. The surgeon grasps the cervical edges with atraumatic clamps (Figure 2) and uses a sterile inflatable balloon designed for endoscopic preperitoneal dissection (OMS PDB 1000; Autosuture, Paris, France) to manipulate the fetal membranes. The balloon inflation depends on cervical dilatation and can reach a diameter of 10 cm. The balloon then gently pushes the fetal membranes into the uterine cavity (Figure 3). A McDonald cervical cerclage is then done over its plastic mandrin (Figure 3): one purse-string suture (Mersuture no. 2; Ethicon, Issy les Moulineaux, France) is inserted as high as possible. The balloon is then deflated. The purse-string suture is tied as the instrument is withdrawn from the cervix (Figure 4). After the procedure, continued tocolysis and bed rest are prescribed.
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There was one case of clinical chorioamnionitis and no maternal deaths. Those 25 women gave birth to 35 neonates, five of whom died. Three of the deaths were in the delivery room, at gestational ages younger than 24 weeks; two died in the intensive care unit from periventricular leukomalacia. Five months after the end of the study period, 30 infants were alive, 24 free from handicap. Neurologic assessment was done by clinical examination and transfontanel ultrasonography. No particular neurologic scale was used. Histology and pathology examinations of the placenta and fetal membranes resulted in diagnoses of chorioamnionitis in 13 cases.
Seven women had cervical dilatation greater than 4 cm; two had complete dilatation. In that group, cerclage was done at 23 weeks’ gestation (range 22.5–24.5 weeks); pregnancy was prolonged for a median of 9 days (range 1–101 days); and median gestational age at delivery was 24.6 weeks (range 24–37.3 weeks). Those seven women gave birth to nine infants. Two infants died in the neonatal intensive care unit, four are alive without neurologic impairment, and three are alive with moderate motor impairment and behavior problems.
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Previous authors introduced the use of an inflatable device to replace fetal membranes. The earliest reports used Foley catheters.3,4 More recently an inflatable device that used a metreurynter pushing a bulging bag was described.6 Those techniques do not appear to be suitable for cases in which the cervix is widely dilated.6 In our study, in cases with cervical dilatation greater than 4 cm, cervical cerclage was associated with 78% postnatal survival (seven of nine infants still alive). Compared with large Foley catheters that reach a diameter of 5 cm when overfilled, the balloon in this study can be inflated to a diameter of 10 cm. Thus, our balloon device appears more useful than other techniques for replacing fetal membranes when cervical dilatation is large.
Our results for prolongation of pregnancy and term of delivery were similar to others reported.7,8 Our success rate and postnatal outcomes appear better than those of studies that used the technique described by Olatunbosun,7–9 but they are not comparable because of the substantial heterogeneity between patients and results.10 Although this procedure appears simple, women should be clearly informed of the consequences and perinatal outcomes. The possibility that the procedure might transform a neonatal death at 22 weeks’ gestation into severe prematurity (for example, around 25 weeks) necessitates parental consent to do a cerclage.
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Received July 10, 2000. Received in revised form October 16, 2000. Accepted October 26, 2000.
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2. Scheerer LJ, Lam F, Bartolucci L, Katz M. A new technique for reduction of prolapsed fetal membranes for emergency cervical cerclage. Obstet Gynecol 1989;74: 408–10.
3. Holman M. An aid for cervical cerclage. Obstet Gynecol 1973;42:468–9.
4. Orr C. An aid to cervical cerclage. Aust N Z J Obstet Gynaecol 1973;13:114.[Medline]
5. Olatunbosun OA, al-Nuaim L, Turnell RW. Emergency cerclage compared with bed rest for advanced cervical dilatation in pregnancy. Int Surg 1995;80:170–4.[Medline]
6. Higuchi M, Hirano H, Maki M. Emergency cervical cerclage using a metreurynter in patients with bulging membranes. Acta Obstet Gynecol Scand 1992;71:34–8.[Medline]
7. Lipitz S, Libshitz A, Oelsner G, Kokia E, Goldenberg M, Mashiach S, et al. Outcome of second-trimester, emergency cervical cerclage in patients with no history of cervical incompetence. Am J Perinatol 1996;13:419–22.[Medline]
8. Wong GP, Farquharson DF, Dansereau J. Emergency cervical cerclage: A retrospective review of 51 cases. Am J Perinatol 1993;10:341–7.[Medline]
9. Hordnes K, Askvik K, Dalaker K. Emergency McDonald cerclage with application of stay sutures. Eur J Obstet Gynecol Reprod Biol 1996;64:43–9.[Medline]
10. Benifla JL, Goffinet F, Darai E, Proust A, De Crepy A, Madelenat P. Emergency cervical cerclage after 20 weeks’ gestation: A retrospective study of 6 years’ practice in 34 cases. Fetal Diagn Ther 1997;12:274–8.[Medline]
This article has been cited by other articles:
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  J. Ayromlooi, H. Fernandez, V. Tsatsaris, M. V. Senat, and A. Gervaise Balloon Replacement of Fetal Membranes to Facilitate Emergency Cervical Cerclage Obstet. Gynecol., February 1, 2002; 99(2): 345 - 345. [Full Text] [PDF]
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