Method
After 24 hours administration of the antibiotics cefuroxime and metronidazole, a cerclage is first placed according to McDonald. This is placed as high as possible using a mersilene tape connected with 2 blunt needles (Ethicon BT 3-5 mm 40 cm). Supplementary descriptions can be found in Spätling et al. 5. Our aim is to use a safe procedure which stabilizes the cervix and provides effective protection against ascension of microbes; thus we always perform cerclage first, even if the cervix is not affected. This also makes it easier to push back the amniotic membranes in case of a prolapse. Furthermore, the cerclage protects the membranes from possible injury during manipulations in the cervical canal.
After two lateral holding threads (Vicryl 0, CT-2 plus) have been placed in the portio uteri, the inside of the cervical canal is de-epithelized with a serrated curette (Aesculap ER 580R). The curettage is performed vigorously with the aim of removing the epithelium of the cervical canal in order to achieve complete adhesion of the walls. This is supported by joining of the walls by means of 2-4 single button sutures using a fine curved needle (diameter 14 mm, Vicryl 2-0, Ct-3). The threads are cut off close to the stiches to prevent ascension of microbes by means of a wicking effect.
A thin 3-5 mm wide epithelial strip is removed from the surface of the portio uteri with an angled scalpel (Swan-Morton) intended for conization. If you begin with the posterior cervical lip, the bleeding will only slightly impair vision. Despite the strong blood flow, no further blood-reducing measures are necessary. The wound surfaces are sutured together continuously (Vicryl 0, CT-2 plus) including the holding threads. An even, not too superficial suture at a suture distance of approx. 4 mm facilitates healing, which results in a complete vaginal dermis at the end of the pregnancy.
A tamponade soaked at the tip with povidone-iodine solution is placed for 24 hours.
Antibiosis with cephalosporins combined with metronidazole is continued for 5-7 days. A low dose bolustocolysis with 4 micrograms of fenoterol initially every 6 minutes, halved on the 2nd day to every 12 minutes is given for 2-3 days 6. The dose is not increased so as not to conceal contractions caused by an early infection. We always supplement 20 mmol magnesium/day 7.
The inflammation parameters (C-reactive protein, leukocytes) were monitored by taking several blood samples daily. The temperature was measured every eight hours. The patient was instructed to report at the first sign of feeling ill or having pain, however slight, as this is considered an early indicator of infection. The amount of amniotic fluid was checked daily by abdominal sonography. The abdomen was checked manually by a doctor three times a day.