Rescue cerclage at 13 weeks’ gestation

Case report A 36-year-old woman presented 7 weeks into her fi ft h pregnancy, having suff ered four miscarriages; three in the 2nd trimester at 17, 15 and 13 weeks ’ gestation. A transvaginal ultrasound scan confi rmed viability and a cervical length of 30 mm with no funnelling. Due to a past obstetric history strongly suggestive of cervical insuffi ciency, involving painless dilatation of the cervix, an elective suture was planned, but at 13 weeks ’ gestation immediately prior to the suture, a scan revealed no measurable cervix and visible bulging fetal membranes were confi rmed on speculum examination. A McDonald ’ s cerclage was performed. Cyclogest, indomethacin and bed-rest were commenced post operatively. A routine anomaly scan at 20 weeks revealed borderline ventriculomegaly, which had resolved on a subsequent scan 1 month later. Weekly cervical surveillance demonstrated a cervical length of 32 mm at 14 weeks, shortening to 12 mm at 15 weeks and remaining static until premature pre-labour rupture of the membranes occurred at 25 4 weeks. Steroids were administered and the cerclage removed due to onset of labour . At 25 6 weeks, a male infant weighing 850 g was born by spontaneous vaginal delivery. At the age of 3 years, the boy has only mild developmental delay. Discussion We report the fi rst case of a rescue cerclage before 14 weeks ’ gestation that resulted in a viable pregnancy. Cervical insuffi ciency is a recognised cause of mid-trimester loss and pre-term delivery. Th ere is no diagnostic test for cervical insuffi ciency and the diagnosis is usually retrospective, based on past obstetric history. Th ere is confl icting evidence regarding the success of cervical cerclage and even less certainty regarding the benefi t of emergency cerclage, which remains a poorly researched area (Drakeley et al. 2003). However, as exposed membranes are associated with a very poor prognosis, the procedure is argued to be justifi ed. An elective suture, as initially planned in this case, is usually inserted early in the 2nd trimester once fetal viability is confi rmed and the risk of 1st trimester miscarriage commonly due to chromosomal abnormalities has passed. An emergency cerclage would not normally be anticipated at such an early gestation. However, in this case, the repeated history of 2nd trimester losses with ultrasonographical evidence of cervical shortening in the index pregnancy suggested a very early presentation of cervical insuffi ciency and with no intervention, a miscarriage was likely to be inevitable. Th e rescue cerclage gained a further 13 weeks of the pregnancy. Th is case demonstrates that bulging membranes, even occurring before 14 weeks ’ gestation, can be managed successfully with a rescue cerclage. We would suggest that in women at such high risk of mid-trimester loss, a diagnosis of cervical insuffi ciency should not be excluded due to presentation at such an early gestation. Ultrasonographical cervical length assessment could be considered as early as 13 weeks. For those women with a strong history of such early cervical insuffi ciency, the suture could be placed once a fetal heart is detected or prior to conception.