Tag Archives: abdominal cerclage

A Note on “Funneling”

This is just a really quick note on a topic that is confusing for a lot of women: funneling. Many of us hear the word “funneling” and start to panic, but it’s a word that has some very different meanings.

What we women with cervical insufficiency need to worry about is funneling of the cervix, which often precedes premature dilation. You can funnel from the top down, or from the bottom up. With a TAC, it is possible to have a narrow funnel through the TAC (narrow because you should only be able to dilate up to about one centimeter with a properly placed TAC), but not common. It also doesn’t necessarily mean that your TAC will fail or that anything will happen to your baby; it’s just something that your doctor will have to keep an eye on.

A lot of times, you might hear a woman say that she “funneled to the TAC,” but not below. This is something that some doctors or ultrasound techs say, but it’s confusing. There is NO cervix above a TAC, just uterus. When a doctor tells a woman that she has funneled to her TAC, it’s a terminology problem, not an anatomy problem. It simply means that the lower uterine segment is beginning to expand, which always happens as the baby gains weight, and is a normal part of any pregnancy.* By itself, it is NOT a concern in a TAC pregnancy or any other pregnancy, although it’s possible that it might happen earlier in a woman with cervical insufficiency (I don’t know, and I’m not a doctor, that’s just a guess). Sometimes doctors say that means that you really did need a TAC, which I feel adds to the confusion, as the expansion of the lower uterine segment is only an indication that the baby is growing.

So if you hear that you, or any woman, has funneled “to the TAC,” know that it’s normal and probably not something to worry about. We have plenty to worry about already. Your doctor should be on the lookout for funneling through or below the TAC, which certainly can indicate a potential problem.

*This is also the reason that c-sections done before mid-late second trimester usually require a classical vertical incision. The lower uterine segment has not expanded enough for a low-transverse incision between the uterine arteries.

TAC Variations

When you think of a procedure like the TAC (transabdominal cerclage), you may think that it is a standardized operation. In fact, each surgeon has his or her own techniques, informed by their teachers and developed over their years of experience. So while there are some basics that are common to all TACs, the procedure itself can actually vary quite a bit.

So what are the defining characteristics of a TAC? What makes a TAC a TAC? Technically, there’s only one:

A TAC must be placed via an abdominal incision. If a surgeon tells you a TAC can be placed vaginally, he/she is either misleading you or very much mistaken. Either way, steer clear. A TAC is a transABDOMINAL cerclage, and can only be placed through an abdominal incision.

For the record, when I say “TAC” throughout this blog, I mean a cerclage that is placed via an abdominal incision and tied as a band around the internal os of the cervix at the cervicoisthmic junction. This has been proven to be the most effective form of TAC so far, although any cerclage that is placed through an abdominal incision is technically a TAC.

There are several areas where TACs differ:

Incision

Remember, this incision is NOT on your uterus, only on the outside. We’ve established that all TACs must be placed abdominally. Traditionally, this has meant through an open incision in the abdomen (laparotomy). Most of the time the incision is a low transverse incision — a horizontal line at about the level of your pubic hairline. Sometimes, however, there might be a reason for a vertical incision. If a surgeon does all of his placements vertically by default, I personally might consider seeing somebody else, as that type of incision makes recovery more difficult (in addition to creating a nasty scar). Sometimes a Pfannenstiel type incision has been used, but that is not as popular these days. Alternately, many surgeons now place TACs laparoscopically, or via several tiny incisions in the abdomen. This can be done with or without the DaVinci robot, but the incisions should be about the same regardless.

Here are a few examples of incisions:

Jill Donald Davis in-preg traditional almost 3 yrs

This is my scar, on my soft, stretch-marked 3 pregnancy belly. Dr. Davis in-pregnancy traditional TAC, September 2012. This scar has been used for TAC placement and 2 c-sections. 3 years post-TAC, 2.5 years post c-section #1, and 6 months post c-section #2.

Haney pre preg almost 2 months

This is a Dr. Haney traditional pre-pregnancy TAC at about 2 months post-op.

Haney 4 weeks

This is a traditional Dr. Haney TAC at 4 weeks post-op. Dr. Haney is able to make a very small incision for pre-pregnancy TACs and TACs on smaller women, but keep in mind that your OB will very likely use the same incision for your c-section, so it will be bigger anyway.

Davis pre preg traditional 1 month

This is a traditional Dr. Davis TAC at 1 month post-op.

Paraiso RoboTAC 3 months

This is a Dr. Paraiso RoboTAC, 3 months post-op. She has older scars as well; the arrows point to the TAC scars.

Scibetta in-preg lap TAC 3 yrs

Dr. Scibetta lap TAC, 3 years post-op. After 3 years and 2 c-sections, she says this scar on her right side is the only incision you can still see.

Material

There are three possibilities here:

    • 5 mm mersilene tape. This is probably the most common option. Mersilene is a nonabsorbable braided polyester suture. It is sterile, inert, and nonreactive, so it should be able to stay in your body indefinitely without causing any problems. It’s incredibly strong, and could essentially support the weight of a grown man jumping on it.
Mersilene Tape In Situ

5 mm mersilene tape in situ. From http://www.kjkhospital.com/CaseStudyDetails.aspx?nid=24

    • Neonatal/IV tubing. I only know of this being used in Australia. Tubing — either neonatal tubing or IV tubing — is used the same way as mersilene tape. As far as I know, success rates are similar.
Dr. Alexander Neonatal Tubing TAC

A TAC placed by Dr. Alexander in Brisbane using neonatal tubing.

  • Nylon suture material. This is not recommended. It is strong, but much more likely to erode into the tissue of your cervix.

Suture Type/ Knot Placement

Some surgeons use curved needles to thread the band behind the cervix, but some prefer to use a more blunt instrument like clamps. Most surgeons placing a TAC traditionally tie the knot posteriorly (behind the cervix), I believe, to avoid problems with bladder adhesions and irritation. (One paper I read said tying the knot posteriorly allows the TAC to be removed, theoretically, through the vagina in a procedure called a culdotomy, in which the vaginal wall is cut in order to access the knot via the rectouterine pouch. I have never heard of this being done.) However, the knot is sometimes anterior (in front of the cervix) when placed laparoscopically without the DaVinci robot. The knot is usually a square knot, but surgeons may have their own variations.

Most variations here are minor and don’t make a lot of difference. There are a couple, though, that potentially make a big difference.

  • I have heard of surgeons tying the band lateral to the uterine arteries, instead of medial to them, but that is a mistake (as opposed to a preference), and can lead to erosion into the arteries and bleeding.
  • Some surgeons don’t tie a band around the cervix at all, but instead stitch through the cervix. One example is a surgeon who makes an abdominal incision and places a modified Shirodkar stitch at the internal os. This, in my opinion, should not be done, as it is more susceptible to problems with erosion and more likely to cause damage to the cervix, and ultimately, more likely to fail. If you’re going to undergo major surgery, you might as well have the best, safest solution, which is a band tied around the internal os of your cervix.

Method

This encompasses all the other variations that might exist between surgeons. Some prefer only in-pregnancy, while some only do pre-pregnancy. Some have a strong preference for traditional, laparoscopic, or robotic laparoscopic. There are a lot of different approaches to anesthesia and pain management. Some doctors prefer spinal anesthesia in pregnancy, some always place the TAC under general anesthesia. Some prescribe ibuprofen for pain management, while others tell you never to take ibuprofen in pregnancy. There isn’t a clearly right way to do most of these things, and very experienced, very successful doctors have different opinions. Do your own research and decide who you want to trust based on that.

A Note About TAC Surgeons

When you start looking into a TAC, you will quickly realize that there are a few surgeons who are much more frequently mentioned than others. In the US, those are Dr. Haney, Dr. Davis, and Dr. Sumners (see The Big Three for contact info). When I got my TAC in 2012, all three were equally popular. Since then, Dr. Davis has semi-retired, and more women are seeing Dr. Haney, so the commentary is very much skewed toward Dr. Haney at the moment. While these three doctors have some differing opinions, they are all essentially equally experienced, and all have the same very high success rates. As far as the Big Three go, you’re in good hands all around, but I’ve been hearing some disturbing comments to the effect that Dr. Davis (or Dr. Sumners, or any other doctor) does it “wrong,” and therefore their TACs fail more often. That’s pure nonsense, so if you hear such a thing, don’t let it worry you.

My real point here is that there is no “right” or “best” surgeon, only the best one for you. If you have time, shop around. See who your insurance covers, and figure out if you can or want to travel. There are a lot of things to consider when you choose your surgeon. Here are a few:

  • How far are you willing to travel?
  • Does he or she accept your insurance?
  • How much experience does he or she have?
  • Does he or she prefer laparoscopic, traditional, or robotic assisted laparoscopic? (If you have a preference.)
  • What type of material does he or she prefer to use?
  • What are his or her stats? Success rate?
  • How comfortable are you with him or her?
  • Will he or she be available to answer questions after surgery/during pregnancy? Will he or she consult with your OB/MFM/perinatologist?
  • Does he or she offer an out-of-pocket rate? (if your insurance will not cover the procedure, you may save money by traveling cross country or even out of country to a doctor who offers an at-cost option)

These are all questions you’ll need to ask yourself and your doctor. As far as experience goes, you’ll have to remember that not all doctors can have 20+ years of experience placing TACs. Some of them will be less experienced, and that’s okay. With several of our beloved TAC doctors nearing retirement, more and more women will have to see these less experienced surgeons, which, of course, is how they gain experience. Also, no two doctors do any procedure the exact same way. They each put their own spin on it, and are constantly trying to improve their own performance. Some use mersilene, some use neonatal tubing. Some place one band, some place more. There are a hundred variations, and no “right” version. We all want the very best doctor when our baby’s lives are at risk, but placing a TAC is actually a relatively simple procedure. If you find yourself in a situation where it makes sense to you to see a surgeon with less experience, there might be some additional things to think about. Personally, if I were going to have my TAC placed by a newer surgeon, I would want 1) a traditional open placement, and 2) an in-pregnancy placement. Here’s my reasoning: 1) a traditional placement allows an inexperienced surgeon a more open field and better visualization. He or she can feel the tension of the band and the knot. 2) This one seems counter-intuitive, but according to at least one study, it’s more difficult to get the correct tension on the band when placing it on a non-pregnant cervix. Since the cervix swells during pregnancy, placing it in-pregnancy means that you already know what size it will be. Placing it before than can lead to the band being too loose or too tight, both of which can cause the TAC to fail. These are probably more cautious than necessary, and if your convenient local doctor only does pre-pregnancy lap-TACs, you will do just fine. Going with the method your doctor feels most comfortable performing is probably more important than any specific type of placement. If you have any questions, please feel free to email me (Jill) at tac.questions@gmail.com.

A Note on Contractions and Preterm Labor

This is just a brief post to mention a tip that I hope will be helpful to anyone suffering from contractions or irritable uterus during pregnancy. I have had contractions/irritable uterus/preterm labor in all of my three pregnancies. In the last two, with my TAC I was able to endure the contractions and make it to full term, despite starting to contract at 22 weeks and 16 weeks respectively. There are many ways of dealing with preterm contractions that have varying degrees of success. I will go over all of those methods in more detail later, but there’s one method that helped me immensely, and it’s one that I haven’t read about anywhere else. Ready for this?

A maternity support belt.

That’s it. It’s simple, cheap, and (for me at least), incredibly effective. Wearing a basic maternity support belt helped control my contractions more than any other method I have tried. Once I started contracting, I wore it 24 hours a day, 7 days a week, only taking it off to wash it or to bathe. When I did take it off, my contractions immediately worsened, and they immediately calmed when I put it back on. It’s a big part of the reason I was able to stay pregnant to term, in my opinion.

I have no medical basis for this, and I can only make educated guesses about why it works. I know it probably won’t work for everyone. I just wanted to put this trick out there in case it might help anyone else the way it helped me. I’d love to know if you try it and whether it helps you.

Belt up, ladies.

Stories of Strength: Felicity’s Story

Felicity is an Australian TAC mama! She has written from the other side of this whole TAC experience – from over the rainbow, I guess you could say. She has two gorgeous, healthy girls. Note that her TAC is not mersilene, but IV tubing; an interesting variation from most TACs placed in the US. Thanks so much for sharing your story, Felicity!

If you’d like to share your story, please send it and any pictures to tac.questions@gmail.com.

 

The Delight a Cervical Cerclage Promises
The story of Australian mum, Felicity, and two very different pregnancies.

Pregnancy One: Baby girl, Allegra, born by c-section on 09/09/09 at 39.5 weeks.

“What if I sneeze?” I asked.
“Yes, that could bring on labour” my obstetrician noted with that calm bedside manner you expect.

And after spending a few nights at the Gold Coast’s John Flynn Private Hospital he then said “it’s best if we transfer you to the Mater. If you deliver now we can’t look after the baby anyway – you’d have to go there.”

That was the third precautionary advice I’d been given in a matter of days. The first was at the scheduled ‘growth scan’ when the sonographer said “I think the doctor will admit you immediately. You may not be going home.” The second, that really stunned me, delivered by the resident obstetrician at the scan sounded much like this – “you really need to get to 28 weeks.” My thoughts immediately jumped to how I was going to control my ‘incompetent cervix’ and ensure it didn’t reduce in length anymore. I couldn’t come up with a plan. After all, I hadn’t even felt it shorten – no contractions, no indication whatsoever.

For a first pregnancy, the detection of a single umbilical artery and a baby with only one kidney at 12 weeks, an amniocentesis at 20 weeks, identification of an incompetent cervix at 25.5 weeks and diagnosis of gestational diabetes at 29.5 was making for an eventful 2009.

By far, the most significant statement though, made on 10 June 2009 read like this: “There is funnelling of the membranes down the internal os of the cervix which is now only 10 mm in length. This may remain like this for several weeks or may result in early PPROM or PTL. In view of the high risk for preterm delivery suggest administration of steroids and bed rest.”

With a new obstetrician, I was to become a patient of Brisbane’s Mater Mothers’ Hospital, the Queensland hospital of choice for high quality maternity services with an unmatched neonatal intensive care unit.

And so it was true. I was administered steroids, prescribed progesterone and nifedipine, hospitalised for 60 days and ordered to total bed rest (with a further 30 days of bed rest at home). Total bed rest meant I was allowed to stand to walk to the bathroom – only. Yet one week earlier I was delivering a large arena event for the Queensland Government which incorporated thousands of students and teachers. In fact, the results of one scan at 25.5 weeks meant life slowed down to the pace of a snail!

At 34 weeks my care was transferred back to my original obstetrician at John Flynn Private Hospital, I was released from hospital and awaited the planned delivery of my baby by elective caesarean at 39.5 weeks.

Finally, she was greeted by two passing statements from that same obstetrician who was so calm many weeks before – “Felicity, you have a girl” and “your cervix is completely blown out.” And so it was, the distress, worry, sadness and anxiety turned to glee, with just one moment of calm to punctuate the crisp, sterile air of the operating suite.

Felicity

Felicity 2

Pregnancy Two: Baby girl, Ilaria, born by c-section on 28/03/14 at 37.5 weeks.

Prior to even falling pregnant with baby number two I set a precedent for this experience by doing the research, followed by the advising. I wasn’t going to put myself in the anxious position of reactive reasoning as I had with my first pregnancy. To my obstetrician at the Gold Coast’s John Flynn Private Hospital I asked what he would do. The reply – a trans vaginal stitch. I knew it only had a success rate around 60%. I wasn’t satisfied.

To Laurie Brunello, a Brisbane-based doctor I had found through extensive online research – “I’m here to find out about a trans abdominal cerclage, and it’s success rate for incompetent cervix.” He replied “a cerclage will enable you to maintain your normal activity level throughout your pregnancy. Just don’t go sky diving.” He added that he’d been doing cerclages since the mid-1970’s, is one of a few obstetricians who do the surgery in Australia, can claim a 90 – 95%+ success rate and believes no woman should have to lose a baby to request the procedure. Dr Laurie Brunello was to be my saving grace.

In February 2012, under general anaesthetic at Brisbane’s Mater Private Hospital he lassoed my cervix with a ring of plastic IV line. I remained in hospital for five days post-surgery as the healing process started for the second cut along my previous c-section scar.

With some sadness, albeit great trust and admiration for Dr Brunello’s specialty, I had to take his advice to have my future pregnancy monitored by Dr Alexander Alexander. The time had come for Dr Brunello to retire. My confidence remained steadfast though – Dr Alexander had been trained in the cerclage procedure by Dr Brunello.

By July 2013 I was expecting baby number two and by September I had seen Dr Alexander for the first time. To my new obstetrician I explained that while I hadn’t lost any children, a shortening of my cervix to 10 mm with baby number one was unexplained by no family history, no previous pregnancies and no surgery. What I did know though was that I simply did not have the emotional strength to go through another pregnancy with forced bed rest from 25 weeks. Sensing my concern and noting my past history his advice was to reduce activity from 18 – 26 weeks. At this point I was reminded of Dr Brunello’s humorous storytelling of sky diving, or lack thereof. I shared this with Dr Alexander and told him I had grate faith in the cerclage, had chosen the pioneer and best specialist in Australia for the procedure, and felt positively able to continue my pregnant life along the same vein as my pre-pregnant days.

Unlike pregnancy one in 2009, 2013 and 2014 presented as a very uneventful ante-natal period. I walked each morning up until 18 weeks gestation then remained relatively sedate until 26 weeks. I did however swim most days during months five and six of the pregnancy, undertook light gym activity post-26 weeks up until 34 weeks and continued working fulltime until 36.5 weeks.

Control would be one way to describe this pregnancy. I felt in control. But also, health, excitement, and energy are words that spring to mind. I was doing this! And with complete elation I heard correctly when Dr Alexander announced he would bring Dr Brunello out of retirement to assist delivery of this beautiful baby on 28 March 2014 at Brisbane’s Mater Mothers’ Private Hospital.

When the day arrived and our bundle of joy cried out for the first time, “Ilaria!” we replied after Dr Brunello asked what her name would be. With a gentle Italian lilt he spelt “I .. L .. A .. R .. I .. A..” and announced “my father is Ilario – names ending in ‘a’ signal the female variant. In Italian it means happy, cheerful.”

Not only were we happy and cheerful, but in the same room for the first time was the complete team that made this pregnancy stress-free, joyful and successful. What a delight!

Felicity 3