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.