Case 2
A 40-year-old 4 Gravida/2 Para (14 weeks and 6 days) was admitted to hospital with a loss of amniotic fluid. On the same day an amniocentesis was performed without complications. The indication for amniocentesis, besides maternal age, was a megacystis, an intracytolpasmatic sperm injection and abortus imminens at 10 weeks. At the time of amniocentesis, a retroamnial hematoma was visible by ultrasound. The aspirated amniotic fluid was tinged with old blood. The patient reported two unremarkable pregnancies which ended in spontaneous delivery. After one early abortion, the patient did not have a curettage.
At the examination on admission, the patient showed old-blood discharge diluted with amniotic fluid, the cervix was not shortened, and the cervical canal was closed. Microscopically and microbiologically there was no evidence of infection. No amniotic fluid could be seen in sonography.
Course of events
As the leakage persisted and the fetus continued to show an hydramnios the prognosis was discussed with the patient, including the risks for mother and child. When asked about an alternative to terminating the pregnancy, we explained the procedure of complete closure of cervical canal and external os and the positive outcome of the case described above (see case 1). The patient then decided she wished to have the procedure, combined with a cerclage after McDonald according to the procedure described above. This was performed under spinal anesthesia on the 4th day after rupture of the membranes (15 weeks and 2 days) without any complications. Intravenous antibiotics (3 x 1.5 g cephalosporin) were administered over 11 days. In contrast to the first patient, metronidazole was not administered i.v., but was applied as a vaginal suppository after removal of the tamponade. As in the first case, Lactobacillus preparations were subsequently administered to support the formation of normal vaginal flora. On the 3rd postoperative day the C-reactive protein increased from 0.4 to 1.3 mg/dl, sank to 0.8 mg/dl on the 3rd day and remained at this level until the patient was discharged”. After an inconspicuous exam and with sufficient amniotic fluid, the patient was discharged at 16 weeks and 6 days of pregnancy. The rest of the pregnancy was without any complications.
At 37 days and 0 days the cerclage tape was removed during a speculum examination and revealed a completely smooth-skinned portio uteri.
A spontaneous delivery was planned. The patient requested a primary c-section, which we performed at 38 weeks and 0 days under spinal anesthesia without complications. In the same session, the cervical canal was opened using a Hegar dilator. A boy (2890 g) was delivered from vertex presentation (Apgar 9/10/10, pH arterial 7.29). The boy showed a slight stridor, which did not regress and led to home monitoring by pulse oximetry at the age of three months. The cause of the stridor was diagnosed as unilateral vocal cord paralysis, the cause of which could not be found. An enquiry to the parents, six years after birth, showed that the vocal cord paralysis had worsened, so that a tracheotomy had had to be performed at the age of seven months. The operation was excluded as the cause of the stridor. Despite his handicap, the boy, now six and a half years old, has developed well. The mother would decide to have the operation again.