Outcome of Late Second Trimester Emergency Cerclage in Patients with Advanced Cervical Dilatation with Bulging Amniotic Membranes: A Report of Six Cases Managed at the Douala General Hospital, Cameroon
Purpose. To show the feasibility of emergency late second trimester cerclage with advanced cervical dilatation and bulging of amniotic membranes. Setting. Department of Obstetrics and Gynecology of the Douala General Hospital. Method. This is a retrospective study of case files of patients who underwent emergency late second trimester cerclage with advanced cervical dilatation, some with bulging of fetal membranes between June 2003 and June 2010. The modified Shirodkar technique was employed in all the cases. Results. Altogether, six patients (100%) underwent late second trimester cervical cerclage between 24 and 26 weeks of gestational age. Four cases (66.7%) carried on their pregnancies to term that resulted in healthy live-born babies all delivered vaginally. The other two cases (33.3%) presented with preterm premature rupture of fetal membranes (PPROM) which led us to undo the stitch with eventual delivery of live-born premature fetuses which died in the neonatal intensive care unit because of complications of prematurity and neonatal infection. Conclusion. In experienced hands and in the absence of other risk factors like infection, the success rates of this procedure are encouraging with improved prognosis. Finally, the modified Shirodkar technique yielded excellent results in our series. 1. Introduction Cervical insufficiency is a well-known cause of second trimester pregnancy loss. This is usually accompanied by painless uterine contractions effecting cervical effacement and dilatation [1]. There may also be bulging of the fetal amniotic membranes through the uterine cervix and vagina [2]. In severe cases the fetal membranes could be seen protruding through the external genitalia [3]. In such cases rupture of the fetal membranes could occur resulting in painless preterm labour and delivery of a live-born fetus [4]. However, this condition usually leads to the empiric use of tocolytic agents and cerclage. Furthermore, some studies have advocated early transvaginal sonographic follow-up with or without application of fundal pressure with the aim of detecting cases with occult cervical insufficiency, thereby indicating early cerclage. Cervical incompetence can occur after operations (e.g., conisation for cervical intraepithelial neoplasia and forceful cervical dilatation for advanced abortions) or as a result of congenital weakness (e.g., after intrauterine exposure to diethylstilboestrol). Uterine malformations may also give rise to preterm labour, but common ones such as a bicornuate shape are often compatible with term labour, while those such
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