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.