Case 2
A 40-year-old 4 Gravida/2 Para (14 weeks and 6 days) was admitted to
hospital with a loss of amniotic fluid. On the same day an amniocentesis
was performed without complications. The indication for amniocentesis,
besides maternal age, was a megacystis, an intracytolpasmatic sperm
injection and abortus imminens at 10 weeks. At the time of
amniocentesis, a retroamnial hematoma was visible by ultrasound. The
aspirated amniotic fluid was tinged with old blood. The patient reported
two unremarkable pregnancies which ended in spontaneous delivery. After
one early abortion, the patient did not have a curettage.
At the examination on admission, the patient showed old-blood discharge
diluted with amniotic fluid, the cervix was not shortened, and the
cervical canal was closed. Microscopically and microbiologically there
was no evidence of infection. No amniotic fluid could be seen in
sonography.
Course of events
As the leakage persisted and the fetus continued to show an hydramnios
the prognosis was discussed with the patient, including the risks for
mother and child. When asked about an alternative to terminating the
pregnancy, we explained the procedure of complete closure of cervical
canal and external os and the positive outcome of the case described
above (see case 1). The patient then decided she wished to have the
procedure, combined with a cerclage after McDonald according to the
procedure described above. This was performed under spinal anesthesia on
the 4th day after rupture of the membranes (15 weeks and 2 days) without
any complications. Intravenous antibiotics (3 x 1.5 g cephalosporin)
were administered over 11 days. In contrast to the first patient,
metronidazole was not administered i.v., but was applied as a vaginal
suppository after removal of the tamponade. As in the first case,
Lactobacillus preparations were subsequently administered to support the
formation of normal vaginal flora. On the 3rd postoperative day the
C-reactive protein increased from 0.4 to 1.3 mg/dl, sank to 0.8 mg/dl on
the 3rd day and remained at this level until the
patient was discharged”. After an inconspicuous exam and with sufficient
amniotic fluid, the patient was discharged at 16 weeks and 6 days of
pregnancy. The rest of the pregnancy was without any complications.
At 37 days and 0 days the cerclage tape was removed during a speculum
examination and revealed a completely smooth-skinned portio uteri.
A spontaneous delivery was planned. The patient requested a primary
c-section, which we performed at 38 weeks and 0 days under spinal
anesthesia without complications. In the same session, the cervical
canal was opened using a Hegar dilator. A boy (2890 g) was delivered
from vertex presentation (Apgar 9/10/10, pH arterial 7.29). The boy
showed a slight stridor, which did not regress and led to home
monitoring by pulse oximetry at the age of three months. The cause of
the stridor was diagnosed as unilateral vocal cord paralysis, the cause
of which could not be found. An enquiry to the parents, six years after
birth, showed that the vocal cord paralysis had worsened, so that a
tracheotomy had had to be performed at the age of seven months. The
operation was excluded as the cause of the stridor. Despite his
handicap, the boy, now six and a half years old, has developed well. The
mother would decide to have the operation again.