Abstract
Cervical ligation in early pregnancy is the first choice for the treatment of cervical dysfunction. It can significantly prolong gestational weeks, improve the success rate of pregnancy, and improve the outcome of mother and child. And the incidence of complications of this operation is low, serious complications are very rare, the most common complications include premature rupture of membranes, chorioamnionitis, endometritis, perioperative bleeding, cervical laceration and so on, rare complications include bladder cervical fistula, ureteral cervical fistula and so on. This paper reports a case of severe soft birth canal laceration after cervical ligation, and reviews the relevant literature, summarizes the relevant experience, and provides some suggestions for the diagnosis and treatment of this kind of pregnant women.
Case Report
Clinical Information
Li Yue, Family instead of narration: second child, After 37 weeks
of pregnancy, Paroxysmal lower abdominal pain 2 hours into our
hospital “. The patient is mentally retarded from childhood, can’t live
alone, Regular menstruation. The last menstruation is unknown.
Family member v. According to early pregnancy ultrasound, the
last menstruation is February 29,2020. There was no obvious
abnormality in early pregnancy. About 20 weeks after menopause,
Establishment of birth check cards in local communities at 12
weeks of gestation. But irregular birth tests during pregnancy.
The whole pregnancy prenatal examination was 3 times. Current
pregnancy Four weeks, Paroxysmal lower abdominal pain. For 30
to 60 seconds, between two and three minutes, with vaginal fluid,
Clear color, about 300ml, Vaginal examination suggests gluteal
exposure, the palace has been opened. In the last 3 days, no bath
history, In our hospital, Emergency plan “
1) G6P1 pregnancy Four weeks,
2) Buttock,
3) Mental retardation “income my department.
The general condition of pregnancy is fine, Diet, sleep, Normal
defecation. There was no significant loss of weight in the near
future. Past history: denial of heart, Liver, brain, Kidney, diabetes,
History of hypertension. The patient is mentally retarded, the
answer is not relevant. Denial of blood transfusions, Allergies,
Surgery, Smoking, A history of drinking, etc. History of pregnancy
and childbirth :1-0-4-1(her daughter’s intelligence is normal).
After admission: T:36.5°, P:90 beats/min, R:20 times per minute,
mmHg; BP:136/87 There was no obvious abnormality in the
remaining related physical examination. Obstetric examination
:30cm, high Abdominal cm,95 LSA, of birth orientation Fetal heart
140 beats/min. The contractions lasted 30 to 60 seconds, between
two and three minutes, show your hips, S 3, The membranes are
broken, Amniotic fluid, open your mouth, estimated fetal weight
about 2800+-200g. Auxiliary examination: ultrasound and other
examinations are not available.
After admission, the emergency department improved the
relevant hematological examination, informed the family of the
current situation of pregnant women, suggested vaginal delivery,
the family expressed understanding. After 8 minutes, hip traction
assisted delivery of a baby girl, weight 2800g, the delivery process
is smooth. After placenta stripping, vaginal bleeding is less. Routine
examination of soft birth canal, exploration of cervical mouth
integrity, did not touch obvious laceration, in the external mouth
of the cervix touch a similar birth control ring object, consider with device pregnancy, touch the ring back outward pull, pull failure.
After using vaginal retractor to open vagina, silk thread and fine
rubber strip were fixed on cervix, and the family history was asked
again to the pregnant woman’s family. The family carefully recalled
that pregnant women in other hospitals about 20 weeks due to
cervical dysfunction, cervical ligation, and no follow-up. When the
cervical suture was removed, vaginal bleeding began to increase,
and the soft birth canal was carefully examined again. A laceration
was seen about 3cm above the cervix, extending upward, about 6 to
7cm, deep into the posterior fornix, the posterior fornix was intact,
the uterine contractility was normal after routine suture with
absorbable suture No .2.
The vaginal discharge was still seen in the vagina, the vagina
was opened again, and the suture continued observation showed
that there was still a small stream-like bright red blood outflow,
considering that the soft birth canal laceration reached the
posterior fornix, the possibility of incomplete rupture of the uterus
was not ruled out, and further difficulty in exploring the vagina
was considered, And the suture is difficult, inform the pregnant
woman’s family situation, suggest to carry on the laparotomy
exploration, after the doctor-patient communication carries on the
laparotomy exploration operation, at this time the total amount
of vaginal bleeding is estimated to be about 800ml, to prepare the
blood transfusion, parallel emergency laparotomy exploration.
Preoperative Diagnosis
1) Soft birth canal laceration
2) Postpartum hemorrhage
3) Pregnancy with cervical ligation
4) Cervical insufficiency
5) Hip position
6) G6P2 pregnancy 37 4 weeks
7) Mental retardation.
To explore the uterus, Lower uterine segment, Bilateral appendages, there was no abnormality in the appearance of the retroperitoneal and posterior domes of the bladder, at this point the contractions are poor, A 250- ug. injection the posterior vault was full, about 6cm, diameter from the abdominal compression of the posterior fornix, about300 ml of blood clots came out of the vagina, the fullness of the posterior vault disappears, At the same time, there is active bleeding between the vagina and the posterior vault, Vaginal suture is difficult, Under vaginal instructions, Transabdominal No .0 absorbable suture at the posterior fornix under the cervix continuous spiral suture. Re-exploration of the vagina without significant bleeding, Suture the perineal incision, Sterile gauze 2 fast compression of vaginal wall. To explore the abdominal cavity again, the palace, Lower uterine segment, Bilateral appendages, no hematoma at the retroreflective peritoneum and posterior vault, no significant bleeding at the suture, Ornidazole to flush the abdominal cavity, close your belly, about 1,500ml, of bleeding to correct anemia and symptomatic treatment, Six days after surgery, Good recovery.
Discussion
Cervical dysfunction refers to pregnancy, At the time of full
term pregnancy, the cervical canal was flattened, thinned, dilated
and widened, which eventually leads to an abortion, Cervical
dysfunction is the most common cause of habitual abortion in
mid-term pregnancy. Related literature reports that 20% to 25%
of mid-pregnancy abortion is due to cervical dysfunction. Cervical
dysfunction is a clinical diagnosis, the diagnosis is vague, Lack
of objective gold standards. Most scholars believe that cervical
laceration induced by labor and induced labor, cervical conization,
cervical ring resection, congenital mallet tube dysplasia, lack of
cervical collagen and elastin, exposureene female phenol exposure
and cervical tissue structure defects are the high risk factors. The
main diagnostic basis :1,1 or 2 times during the same gestational
week, and no obvious abdominal pain or contractions, (a) Abortion
that is progressing rapidly during the birth process; During
pregnancy, the length of the cervical canal was found to last less than
25 mm; 2. others such as uterine fallopian tube shadowing, Cervical
balloon traction camera, during luteal phase, cervical dilatation
was evaluated by cervical dilator 7 or 8 [1]. The main treatment
methods are non-surgical treatment and surgical treatment. Most
researchers believe that non-surgical treatments such as restricted
mobility, bed rest, and pelvic support devices are not effective. So
far, Cervical ligation is still the only effective [2] for the treatment
of cervical dysfunction. Most scholars believe that cervical ligation
strengthens the tension of the cervical canal to the greatest extent
possible.
And prevent the extension of the lower uterine segment and
cervical dilatation; Increased the cervical intratumoral bearing
late pregnancy fetal and fetal appendages gravity; Meanwhile,
after surgery, fetal preservation may reduce the tension of uterine
muscle and lower uterine load; Cervical ligation weakens the
defects of the cervix itself, Maintain cervical length and retain
cervical mucus suppository. There are corresponding complications
in any operation. Although the operation of cervical ligation is
simple, after decades of development, its technology has been
continuously improved, making the incidence of complications
low, and serious complications are very rare. At present, the most
common complications are premature rupture of membranes,
chorioamnionitis, endometritis, perioperative bleeding, cervical
laceration, circumferential or circumferential band displacement,
etc. The rare complications include bladder cervical fistula, ureteral
cervical fistula and so on. Uterine rupture, septicemia is extremely
rare, but there is still a possibility of [3]. Either complication is
fatal to pregnant women and may cause adverse maternal and infant pregnancy outcomes. The incidence of various complications
varies with the timing, indication, operation and timing of cervical
ligation. In this case, cervical ligation causes severe soft birth canal
laceration and postpartum hemorrhage and requires laparotomy to
repair soft birth canal laceration.
Looking back on the pregnancy management process of the
patient, the whole pregnant woman did not carry out a standardized
prenatal examination throughout the pregnancy, and the pregnant
woman and the family of the pregnant woman could not provide
the corresponding medical history after hospitalization. After
placental dissection, the routine exploration of soft birth canal
found that the cervix was intact and not torn, but the cervical orifice
touched a circular object similar to the birth control ring, and only
after the failure was taken out was the silk thread and rubber strip
of cervical ligation. Ask the patient’s family history and provide a
history of surgery. At this time we realize the seriousness of the
problem, the cervix after cervical ligation is complete, then the fetus
is from which part of the soft birth canal delivery. After the vaginal
retractor opened the vagina, the soft birth canal laceration was
found, the posterior cervix was torn upward, the posterior fornix
was deep, postpartum hemorrhage occurred after vaginal suture,
and the suture of soft birth canal laceration was performed after
vaginal suture failed. Smooth repair of soft birth canal laceration,
avoid hysterectomy. As far as the patient is concerned, even if we
know before the birth of the cervical ring ligation, as far as the
situation is concerned, the opening of the uterine mouth, first
exposed buttocks, S 3, we cannot remove the cervical ring line in
time to avoid soft birth canal laceration.
Traditional McDonald and Shirodkar surgery is performed
through the vagina, using non-absorbable thick silk thread or nylon
thread suture, and the fetus can be delivered through the vagina
after removing the suture. Abdominal cervical isthmus ligation
can use polypropylene ring ligation, generally do not remove [4].
For pregnant women without complications and planning vaginal
delivery of McDonald surgery, it is generally recommended to
remove the ligation line at 36-37 weeks of pregnancy. Here we
should understand that removing the pointer of the ligation
line is not delivery, so as not to cause serious consequences. For
elective cesarean section, it is recommended to remove sutures
at the same time. Pregnant women after transabdominal cervical
isthmus ligation suggest elective cesarean section to terminate
pregnancy, generally do not remove the ring ligation line. If
obstetric complications require early termination of pregnancy,
if vaginal delivery is allowed, the circumferential ligation line can
be removed. If not, cesarean section terminates the pregnancy
[5]. The opinion of immediate removal (<24h) or delayed
removal (>24h) is not uniform for patients with premature
rupture of membranes. It is necessary to consider the timing [6]
of suture removal combined with gestational weeks and possible
complications. For patients with premature birth symptoms after
ligation, the removal of sutures should be careful, and those with
threatened premature birth symptoms should be treated with
routine treatment, such as exacerbation of symptoms, changes in
cervical canal dilatation, and regular uterine contraction. Remove
the [7] of ligation when vaginal bleeding increases. As far as this
patient is concerned, the main cause of complications is the serious
consequences of improper removal of cervical ligation, warning us
to pay attention to the timing of removal of ligation in such patients.
Cervical ligation is the most effective method to treat cervical
dysfunction. Although its complications are few, the consequences
of various complications are serious. We should pay attention to the
monitoring and management of pregnancy after ligation: according
to the management of high-risk pregnancy; the operator should pay
attention to the matters needing attention, preferably follow up this
kind of pregnant women regularly; pay attention to the length of
cervix and the shape of cervix; pay attention to the screening and
treatment of vaginal infection.
References
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- American College of Obstetricians and Gynecologists (2014) ACOG Practice Bulletin No.142: Cerclage for the management of cervical insufficiency. Obstet Gynecol 123(2 Pt 1): 372-379.
- Burger NB, Brölmann HA, Einarsson JL, A Langebrekke, J A F Huirne (2011) Effectiveness of abdominal cerclage placed via laparotomy or laparoscopy: systematic review. J Minim Invasive Gynecol 18(6): 696-704.
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