Case 1
In 2009, a patient (35 years old, 5 Gravida/1 Para) presented in my
office with a request for examination. She had suffered a rupture of
membranes in her previous pregnancy at the same time (16 weeks of
pregnancy), which led to the termination of the pregnancy. She had also
suffered another early miscarriage. I performed a vaginal exam and the
diagnosis was normal, with no sign of infection and normal fetal
development. I tried to calm the patient down and discharged her. Two
days later, at 15 weeks and 6 days she came back to the clinic with
ruptured membranes and a living fetus without any amniotic fluid. After
I had explained the necessity for a further termination of pregnancy,
the patient asked if there was really nothing else that could be done. I
mentioned the method of complete closure of the cervical canal and the
external os, which would not normally be carried out in this situation
and therefore did not correspond to the general therapeutic procedure.
The patient wanted to risk this operation.
Course of events
As expected, neither the vaginal smear nor the laboratory showed any
evidence of infection. Four days after the rupture of the membranes, the
amniotic fluid was still observed to be leaking. The fetus remained
without amniotic fluid. The patient received exhaustive information
regarding the risk that a cervical occlusion in the case of rupture of
the membranes could lead not only to losing the child but also to severe
maternal illness and even to removal of the uterus, but she wanted
maximum effort, nonetheless. The patient agreed to maximum therapy and
intensive monitoring, accepting the possibility of an unfavorable
outcome. This was the process by which the decision was made to perform
the procedure.
The procedure was performed under spinal anesthesia and tolerated by the
patient without complications. After a slight increase in leukocytes and
CRP, the infection parameters returned to normal. No further loss of
amniotic fluid was detected either subjectively or using the litmus
test. On the 3rd postoperative day a small quantity of amniotic fluid
was observed in the uterine cave by abdominal sonography. After 7 days
the quantity of amniotic fluid was still reduced but was accompanied by
good child movements. The administration of the antibiotics cefuroxime
and metronidazole, which was started four days before the procedure, was
continued until 8 days after the procedure. Thrombosis prophylaxis was
carried out with enoxaparin 4000 IU (Clexane, Sanofi Aventis, Frankfurt
Germany). On day 13 the patient was discharged home after inconspicuous
vaginal sonography and speculum examination without manual examination.
Fenizolan (fenticonazole nitrate, Recordati, Milan, Italy) was
administered prophylactically. The application of Lactobacillus
preparations is thought to support the formation of normal vaginal
flora. The patient initially presented weekly, later at 14-day
intervals. The development of the female fetus controlled by sonography
proceeded according to schedule. The speculum examination showed a
completely smooth skinned-portio uteri.
At 38+2 weeks of pregnancy a healthy girl (2850 g) was born with good
Apgar (9/10/10) and pH-values (7.37) by means of re-section under spinal
anesthesia. In the same session, the cerclage was removed, and the
closed cervical canal was opened with a Hegar dilator. The postpartum
period was uneventful for both mother and child. During the first three
years of life the girl showed temperature-associated cramps which could
be linked to the SCN1A gene. Mother and brother have the same variation,
but only the brother showed corresponding cramps in the first years of
life. On subsequent visits twice a year, the girl, now 11 years old
showed normal development with above-average school performance.