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.