Tag Archives: cervical incompetence

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.

Stories of Strength: Polly’s Story, Part 1

This week’s story of strength is the first part of Polly’s experience with cervical insufficiency. Polly, like most of us, was blindsided by her incompetent cervix. Thank you for sharing, Polly.

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

 

After 6 ½ years, the morning of February 2nd, 2012 would change our lives forever. We got our first positive pregnancy test. Excited as mess, I called Robby to rush home just to make sure I wasn’t seeing things! Coming home, I sprung the test on him. All he could do was smile, a smile that you could tell had fear in it. After confirming through a local place, we were on the hunt for an OB. Sadly the OB that we were using was too far for us to travel. So we decided to search for one where we lived. A friend I had met in school told me about this OB that was really good; she listened, and cared. Excited, I booked the first appointment. I wasn’t sure what to expect, as it was too early for an ultrasound. Instead all my levels were checked. My progesterone was low and dropping, my body was not producing enough. Easy fix, progesterone suppositories. The next appointment I was far enough along to finally get an ultrasound. I was so scared; what if there wasn’t a heartbeat? What if I was wrong? Thankfully there it was, a heartbeat. 152 bpm! Perfect! Things were perfect, no problems for the next few weeks.

Around 13/14 weeks I started having really bad back pains, bad enough that when one struck it literally brought me to the floor. I was not able to stand, I would fall every time. Going back to my OB, I explained what was going on. It was the first time she told me to stop being paranoid. This pain continued for another 2 weeks then magically stopped. At 17 weeks I started to spot red blood. Not a lot, but enough to notice on tissue. I called again, and again was told to stop being paranoid. All first time moms “see” things. After this I decided that since I was out of school I would take it easy. I just had a feeling that I needed to.

At my 20 week scan we discovered that we were having a boy. Gabriel would be his name. We were both so happy, that is what we were hoping for. We wanted the perfect family, a first born son then a second born girl. You know to have that big brother protection when she gets older. That was our dream, and this was the start of it! The next 6 weeks I rested, relaxed, didn’t do much of anything. At 26 weeks I woke up with the most intense pain I ever felt! I literally screamed waking my husband up from a deep sleep. It felt like something was ripping my insides apart. The pain did not let up until a few hours later. I again called my OB, told her exactly what happened. She told me it was normal to feel pain and that I needed to get used to it. But this kind of pain? Yes that kind of pain she told me. Stop being paranoid! After that I laid around even more. At 28 weeks 2 days I started to spot red again, and I started freaking out yet again. I call her, and again, “stop being paranoid! It’s probably from sex,” but I hadn’t had sex since 26 weeks after the pain I had. “Oh well you’re just stressed/paranoid for nothing.”

That Thursday night, at 28 weeks 3 days, I felt funny, just a feeling that was jerking me. This feeling wouldn’t go away, it just kept growing. I decided that night just to go to bed, maybe I am just being paranoid. I started to believe that I was being a pest, and I was paranoid enough to make myself feel/see these past things. I woke up around 1 am Friday morning hungry as normal. That feeling was still there, but I ignored it. After I drank some milk, I started to vomit. Why was I vomiting? My morning sickness stopped around 16 weeks. Every time I would vomit, that feeling got intense and I felt something weird. After about the 5th time, I decided to hell with my OB. I’m going to the hospital. So I woke Robby up and told him we gotta go now. On the way to the hospital that feeling, it grew so intense my anxiety started to rise. I was close to having an anxiety attack, even though I didn’t know what the feeling was.

After we arrived at the hospital, they wheeled me up to L&D. Since I was up walking, joking, cutting up, they didn’t check me right away. They went ahead and hooked my belly up to the contraction monitor, but no contractions were shown. They thought Gabriel was just swimming around, and that was the reason they couldn’t keep his heartbeat on the screen. It was actually an hour before they checked me. The nurse and I were joking about something keeping a smile on her face. She told me she had to check my cervix, that it was required, and that was fine by me. The smile on her face turned into the most lost, afraid look I’ve seen. After taking off her gloves, she literally ran out of the room. My heart sank, and I knew then that those feelings were telling me something was wrong with Gabriel. Oh my god, the first thought was he died. Next thing I know, a doctor and a slew of nurses rushed in. All talking to and over one another, next brought an ultrasound machine in. I couldn’t breathe; I just knew something was wrong. When I was able to hear his heartbeat on it, I could breathe again.

That is when we got the news, he was head down engaged in my birth canal, and I was 7 cm dilated fully effaced bag bulging out. There was no time left, he was coming that morning. My baby boy would be here within hours. NO I can’t believe this. He’s not ready, I’m not ready. They told me there was nothing they can do, I was too far along. The fear I felt before was nothing compared to what was in my heart then. After breaking my water, he told me they were putting me on Pitocin to speed things up. After it was started, a new OB walked in. It was my OB, the one who kept telling me I was paranoid. The one who made me feel like I was being a pest to them. She looked shocked that I was there. After everyone left, all I could do was cry. I cried for myself, I cried for Gabriel, I cried for Robby, I even cried for the nurse who said she was hungry! I was so upset, I was not ready for him to be out.

At 11:15am, Gabriel Aiden Marion Swafford was born at 2 pounds 10 ounces, 16 inches long. My perfect baby boy, but he wasn’t crying. I didn’t hear him, “what is wrong with him” I kept screaming. Why is he not making noise? He was rushed away shortly after, and I was wheeled into my room. I didn’t know if he survived, if he was alive or not. When I got into my room, the nurse would not tell me anything about Gabriel. She acted as if he didn’t exist. At 1 pm my OB came in to ask me what hospital I wanted to send him to. Finally at 2 pm, I got to see my son for the first time. After 3 hours, there he was. There was the baby that was growing inside me. He was so small, but oh he had some of the longest legs I’ve ever seen. The nurse and the lady from the hospital kept hounding me about paperwork. Every time I tried to look at him or ask about him, they would redirect my focus back into filling out form after form after form. Finally when I was done filling out forms they took him away. I wasn’t even fully introduced to him and they took him away! I begged them not to, just another 5 minutes. No they told me, that I can see him when I’m discharged out of the hospital. He was transferred 70 miles away from me.

That night was one of the worst nights of my life. Not knowing what was going on, not knowing what was wrong with him. The only reason I could sleep that night was narcotics. Finally it was sunlight, it was morning. Time to get out of here and haul butt to Tupelo! At first my OB refused, she wanted to keep me an extra day. I told her bluntly and rudely, either discharge me or I’m walking out. I WILL GO SEE MY SON! Finally she agreed, and I was discharged around 12 pm. We went home, packed what we could and left to Tupelo. When we got there a new set of fears came over me. What if he died over the night? What if he’s so sick that he won’t make it? Did I fail him? Why did my body fail him? So many questions came in my head as I walked through the lobby into the elevator. Second floor, NICU. A place I had never been, nor did I ever want to be. Front desk clerk said more paperwork before we went back there. Finally done signing our life away, he gave us the tour. Instructed on what we needed to do every visit, where we needed to go. He escorted us to his room. There he was . . . in a weird box looking thing. I was so scared to go into the room. Tears came pouring down violently. It was so hard to breathe, but I went in. There he was. My perfect baby boy.

Gabriel - Polly's Story