Questions From Readers about the Cerclage

I have gotten a lot of questions since being featured on the Faces of Loss site. Some I will not answer yet because I haven't gotten to that point in the story, but today I am focusing on the cerclage so I can answer them.

What kind of cerclage did you have?

I had the double McDonald stitch. It was done by a perinatologist at 15 weeks. I had an epidural for the procedure.

Did the cerclage hurt?

The actual procedure did not hurt. The epidural did, but it was bearable. The procedure is uncomfortable, but mostly for the fears that go along with it.

Were you worried about the risks of the cerclage?

I was terrified. There is a risk of infection and a risk of them breaking your water during the procedure and the pregnancy ending right there. However, to go without the cerclage meant certain death for my babies so there was really no choice.

Who was your OB/GYN and would you recommend them?

I had a fabulous OB who took my case very seriously seeing me every week through the first and second trimester. I do not want to post his name on here because it reveals where I live to the internet world, but if you send me a message with your e-mail I will send it to you.

Was there any pain after the procedure?

The was some cramping and occasional sharp pains, nothing too bad though.

How about pain long term after the removal?

I did have sharp pains afterwards that continued until my hysterectomy. The were mainly sharp stabbing pains if I sat wrong, or during intimate times. I think maybe it was from scar tissue. Because they took my cervix as well during the hysterectomy there is no more pain.

Do you think bedrest was necessary?

I 100% think it was! I was dilated to the stitch at 22 weeks with funneling when they applied pressure to my abdomen. Funneling is where the cervix tries to open up when pressure is place. Bedrest took a lot of pressure off of my stitch and my cervix. Although it was miserable, I truly believe it saved my babies.

That is all for this round, if you have further questions about anything feel free to send them to me and I will try to get them answered in future blog posts. Have a great weekend!

Blogs I Love

Here is another blog I love to read. The blog is called "My Expected End". Marie is a teacher who has lost two babies due to Incompetent Cervix. She is trying to get the abdominal cerclage which should help her to carry closer to term. Not all doctors are willing to do this and she is facing difficulty. She tells her journey through infertility, grief, hope, and tears in a poignant way that hits very close to home for me. She through it all retains her faith and you can literally seem to feel her need for Jesus through her struggles. I hope you will all find it as dear as I do. I highly recommend it for those of you with IC. Here is the link.

http://myexpectedend.blogspot.com/

The TAC

Before I start this post I this post I want to make a few points clear. I am not in the medical field. All of the information I post is based on my own experiences, information from my doctors, and my own private research. It is not intended to be medical advice, nor to replace your own research. It is simply just for the sake of knowledge.

After we lost Mason there was numerous opinions on what route would be best to proceed for us in the event of another pregnancy. My OB that I had at the time we lost Mason was very blunt and said that he felt that if I had a trans-vaginal cerclage I would just break through it and lose another pregnancy. Just as a refresher, the TVC (trans-vaginal cerclage) is a band or a stitch placed at the top of the cervix during the pregnancy through the vagina and is in most cases removed before labor begins. There are many studies on the TVC that show varying success rates from 75-85% for a singleton pregnancy. The rate is even less for twins. There are many possible complications from infection causing pre-term labor to the cervix dilating through the stitch tearing the cervix. This is what my OB was afraid of in my case. He referred me to the fertility clinic that we had used to concieve in for a consult on the TAC(trans-abdominal cerclage).

At the consultation, the Fertility specialist said that they don't usually do a TAC until a TVC has failed. In my case I was so dilated with Mason that a cerclage was not possible. He also stated that he did not feel that I needed to go as extreme as the TAC and referred me on to a perinatologist. The peri I saw happened to be the same specialist that was called in to consult when I was in the hospital with Mason. She is the woman who told me my cervix was too dilated to do an emergency cerclage and held my hand and cried with me when she told me there was nothing that could be done to save Mason.

I went to my appointment with her to gain more information. She is a very by the book person. She told me that she would not do a TAC without having a TVC first except in cases where part of the cervix had been removed for cancer. She went on to tell me that she was not even sure that I had IC, she was wondering if my clotting disorder caused the loss of Mason. I left feeling very frustrated and went home to do my own research.

In case you are wondering what the big deal is about the TAC I will explain it. Basically, it is major abdominal surgery with recovery compared to a c-section. In layman's terms they make an incision and then using a stitch or a band, they permanently attach the bottom of your uterus to your cervix. That way there is essentially no way for the cervix to dilate. For those of you wanting more medical explanation here is a copy of some of my research.

All procedures are performed with the type of abdominal incision decided based upon the size of the uterus and maternal body habitus. The uterus is usually pulled out of the mother's body and maintained moist with warmed saline. The procedure requires removing the bladder from the cervical area while tunnels are created near the uterine artery on each side. A mersilene band (a polyester suture) is placed around the upper portion of the cervix and tied in a square knot tightly enclosing the cervix which is not removed after the pregnancy. Because many fragile uterine veins are in this area, the most common complication is bleeding. Methods of stabilizing this bleeding depend on the situation and anatomy, while avoiding compromise of the supply of blood to the uterus. In recent years, perioperative treatment with indomethacin has been used for a total of 48 hours, as a uterine relaxant. Indomethacin is a drug that belongs to the family of drugs called nonsteroidal anti-inflammatory drugs (NSAIDs). Indomethacin reduces pain, fever, swelling, and redness.

Prenatal care following the procedure would also include cervical exams every two weeks, careful attention to signs and symptoms of preterm labor (with aggressive use of tocolysis if labor persists) and planned delivery by cesarean as soon after 37 weeks as fetal lung maturity can be documented. Because of the latter intervention tactic, 37 week delivery is considered “term” for the purpose of our follow-up information.

As you can see the TAC means an automatic c-section as the stitch is intended to permanently stay in place. It is usually done before pregnancy, but can be done early in the pregnancy as well. Doctors only like to do it as a last resort because it is such major surgery. It is very frustrating to the women involved because often times the woman has to have multiple losses before a doctor will go to this length.

I did go on to have a twin pregnancy with a TVC and I made it to 35 weeks. They are healthy now, but I also did full bedrest from 11 weeks on and I still was dilated to the stitch at 22 weeks. It almost went south and it has done so for many of my IC sisters.

If you want more information on the TAC here is a link to a yahoo group devoted to it. It is called Abby Loopers and it is a great place for information and support.

http://health.groups.yahoo.com/group/Abbyloopers/

Noah and Mina's Story-The Cerclage-Open content warning

Ok, so we got through the first trimester in the last post. I must admit at this point we were all unsure whether or not this pregnancy would make it. The major bleed that I had at 12 weeks was continuing. No doctor would do a cerclage while the woman is bleeding. A cerclage is a purse string style stitch through the cervix that is pulled tight to keep the cervix from being able to dilate. If a woman is bleeding, there is a big chance she is miscarrying and the cervix will need to be open in order for her to do so. I was told that a cerclage would have to wait until the bleeding stopped.

This news was devastating because we knew I could not carry the pregnancy without the cerclage. The problem is that the further along you do a cerclage, the higher the risk of losing the pregnancy because of complications from the procedure. The optimal time is between 12 and 13 weeks. They won't do it earlier because most miscarriages occur in the first trimester. Any later and complications occur such as your water being broken during the surgery and causing you to lose the pregnancy because of the procedure being do to save it. My scheduled cerclage was put on hold and that was scary.

We had known that I would do bed rest in the last trimester. However, with the loss of blood and no end in sight, my OB put me on strict bedrest effective immediatly. I could lay in bed or on the couch, but that was it. I was alloted a 10 minute shower every other day, and allowed to microwave meals. That was it. After a week of bedrest the bleeding began to slow. It took three weeks, but it finally stopped. Finally at 15 weeks and 3 days the cerclage could be put in.

It was a nerve wracking day. The risks to the babies had been put to me in a open, but terrifying format. I was so afraid that the cerclage would hurt them and I would lose my babies that day. I was not ready to say goodbye. Also, the would be giving me an epidural for the procedure which was just daunting. An epidural when you are in massive pain from labor does not sound that bad, but getting one when you feel totally fine just seemed more scary.

I was prepped for the OR. Apparently not a lot of these procedures are done each year as this condition only affects 1% of women. This made me the freak of the day and everyone wanted to see this. I had interns, nurses, residents, and other OB's that wanted to watch this procedure. When I agreed to let them observe, I had no idea what I was going to be allowing them to see.

I was wheeled back for the procedure and Jake was left to worry in the hallway. The epidural was given-Owww!!!! and I was laid on the table. Once it was established that I was numb, my legs were strapped into stirrups that were hanging from the ceiling and spread wider that I have ever been able to do without an epidural.

At this point I am flat on my back with my legs open for what felt like the whole world to see. I remember hoping I did not have any underwear fuzzies anywhere embarrasing. Then the nurse takes the cover off the tools that they would be using. It looked like midevil torture devises. There was one tool in paticular that looked like a hooked spatula with a metal ball on the end. I made the mistake of asking what it was for and I was told it was a weighted speculum. Basically they insert the hook part into your vagina and the weighted metal ball pulls down opening you up for the doctor to get in there. I thought that's it, I will never be the same after this and felt a little sick to my stomach. After that I did not ask any more questions.

The instruments were in place and the procedure began. I held my breath the whole time, praying that my water would not be broken. At one point I heard dripping, but was reassured that it was just blood. I have never been so relieved to be told "Don't worry, you are just bleeding.". After the longest 30 minutes, they announced that it was done. A sonogram maching was brought over to make sure the babies heartbeats were still good. They were. I was wheeled back to a pale Jake to begin recovery.

Not begin the part where the epidural wears off. I began to have the worst itching imaginable, but I couldn't feel the scratching. So I would itch, I would scratch and no relief. Then I began to have terrible cramping, but I was told this was normal. After several hours I was told everything was fine and released to go home back on bedrest. I was not totally out of the woods because of infection causing labor, or the stitch being broken, but the babies were as close to lockdown as they could get. Next time..more about the second trimester.