Discussion
The happiness of both families with their children, who are now 11 and 6
years old, as well as the argument of one of the mothers that the
publication of the procedure could perhaps save some children and spare
mothers the trauma of losing a child, prompted me to publish this
article.
We have been able to accept the increased risk of such an operation in
the case of ruptured membranes, since we have a great deal of experience
with the complete closure of the cervical canal and the external os. In
addition, in our maximum care hospital we are able to closely monitor
the patients clinically and biochemically around the clock - always in
the knowledge that even the slightest indication of an infection
endangering the mother will terminate the pregnancy. It is worth
mentioning that, for an indication of ruptured membranes, we have only
performed this operation in the two cases described here.
The reason for the poor assessment of the complete closure of the
cervical canal and the external os is due, on the one hand, to the
difficulties involved in systematizing this approach and in conducting
corresponding clinically controlled studies. On the other hand, the
randomized study by Brix 8 gives the impression that
they also investigated the complete occlusion of the cervical canal and
external os. In fact, in the described group, neither was the cervical
canal closed after de-epithelization, nor was the external os suture
performed after removal of the superficial epithelium. In their study,
they did not set a real barrier to prevent ascension of microbes, which
we consider to be an essential prerequisite for the success of the
procedure. In addition, they only investigated the prophylactic approach
in cases of habitual abortion. In our opinion, the complete occlusion of
the cervical canal and the external os is successful with a therapeutic
approach, with massively shortened portio and with amniotic sac prolapse5. In seemingly hopeless cases, we were able to
prolong the pregnancy by many weeks and the patients did not have to
spend many weeks in hospital. The feared risk of a severe infection was
much lower than expected.
We therefore consider the term “complete occlusion of the cervical
canal and the external os” necessary to point out the importance of
deep de-epithelialization as a prerequisite for the merging of the
structures. In the cases described here, this procedure not only sealed
the amniotic fluid leakage, but also hindered ascension of microbes. It
may also stabilize the cervix. We consider the routine additional
application of cerclage important for the success of the therapy, as it
promotes healing by keeping the pressure away from the affected part of
the cervix. We prefer the McDonald cerclage, as it can be performed with
much less tissue traumatization.