Case History:
A 31-year-old patient visited the gynecology department at SAMS-supported Dana Maternity and Child Hospital for a gynecologic consultation. Dr. Mahmoud Al-Bawab head of the Scientific Council for Obstetrics, Gynecology at the Syrian Board of Medical Specialization SBOMS met the patient at the Gyn & Obs clinic and examined with the resident doctor, Dr. Walaa Almasry whom is under his supervision. When the clinical history was taken from the patient, it was found that she had recurrent miscarriages with the failure of the cervical cerclage through the vagina four times.
Anamnesis:
None
Surgical History:
caesarean section five-year ago / transvaginal cervical cerclage four times.
Diagnostic Procedures:
The patient was examined by ultrasound which revealed a 13-week pregnancy. The cervical length measured via vaginal ultrasound was 2.8cm.
The cervix was examined visually, and it was found that there was an old rupture of the deformed cervix and presence of a semicircular ring separated from the cervix.
Management:
The decision was made to perform a cerclage through the abdomen as the last way to continue the pregnancy, and after obtaining the approval of the patient and her husband, the patient was prepared for surgery on 24-5-2022. The abdominal cerclage was performed at the level of the internal orifice of the cervix through the abdomen and the surgical procedure was performed by the supervising doctor with the participation of the resident doctor.
Follow-up:
The patient was monitored regularly following surgery until week 37 of pregnancy, when she was ready for a caesarean section and was sent home with a healthy baby.
Case discussion:
Cervical insufficiency is defined as the inability of the cervix to maintain pregnancy in the second trimester in the absence of uterine contractions.
Reasons:
- Congenital cervical anomalies such as Müller malformations.
- Acquired such as / unrepaired cervical rupture after delivery – cone biopsy – invasive dilation and scraping.
Diagnosis
The diagnosis is based on the clinical history, measurement of cervical length via vaginal ultrasound and clinical examination of the cervix.
Abdominal cervical cerclage is the last way to maintain pregnancy in patients with cervical insufficiency, as it is recommended to perform it if one of the two criteria is found:
- Failure to deliver a healthy neonate after at least one transvaginal prophylactic cerclage.
- Inability to perform the transvaginal cerclage due to the extreme shortness or absence of the cervix or marked cervical scarring or cervical defect makes the completion of the transvaginal technique impossible.
References:
1- https://www.uptodate.com/contents/transabdominal-and-laparoscopic-cervicoisthmic-cerclage?search=abdominal%20neck%20cerclage&source=search_result&selectedTitle=4~150&usage_type=default&display_rank=4