Tag Archives: incompetent cervix

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.

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

Stories of Strength: Colleen’s Story

My second Story of Strength is from Colleen. These are two posts from her blog, nvoutbackwoman.wordpress.com. Colleen is currently 16 weeks pregnant with her rainbow baby and doing well. Thanks for sharing, Colleen! I hope you have an uneventful pregnancy, and will look forward to an update when you have that baby!

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

Broken Hearts

Well, it’s been a while since I posted, and a lot has been going on in our lives since July. Shortly after my last post, and before we moved into the house, we found out we were pregnant. We were both so excited and a little bit nervous. Though my intuition told me earlier, at 18 weeks, we found out we were having a little girl. Besides a little nausea and some heartburn, my pregnancy was going well. We picked out the sweetest bedding at Pottery Barn, a neutral tan color with little owls, and planned a shower for February. I read about the best ways to prepare for a baby, and cut out anything remotely questionable out of my diet. I talked to her all the time, telling her how beautiful and smart she was and how much fun we would have together.

However, on December 8th when I was 23 weeks pregnant, I started not feeling well. I felt cramps, similar to menstrual pains, and saw a tiny bit of blood, so I decided to go to the hospital just to ease my fear. B was at work, so I drove myself. They told me everything looked good. The baby was kicking up a storm, and her heart rate was perfect. The nurse told me I was probably dehydrated, and they discharged me.

All that night the cramping continued, and started to become more painful. Around 6am I returned to the hospital, feeling like there was still so,etching wrong. The nurse finally checked my cervix, and ran out of the room. Another nurse came in and while she rapidly hooked me up to an IV, she told me I needed to call my husband and he needed to get there ASAP. With tears in my eyes I asked her if I was dilating. She told me I was completely dilated and was going to have the baby soon. I was not prepared for this.

After that, everything happened quite fast. B and a friend of mine arrived shortly after my OB, who gravely told me this was not good. He said he suspected that I had a condition called incompetent cervix, and would need a cerclage in future pregnancies. Basically my cervix could not handle the weight of a growing baby, and opened prematurely. He did an u/s to see how our baby was positioned. She was breech with the cord around her neck. The hospital called a special neonatal team to fly in from out of state, and they delayed her birth until after they arrived. Suddenly there were people everywhere, talking to me about viability, asking how much we wanted done. They said they would life flight her to Utah, but that I couldn’t go, though B could. I prayed that God would let me keep my baby.

He did not. After a few pushes, my beautiful baby girl was born. I remember the second they cut the cord and she was forever separated from me. B followed her to the room where they tried to get her to breathe. A few minutes later a solemn woman came in to talk to me. She didn’t have to say anything, but she told me they did all they could. My heart was ripped in two. I hated my body, my doctor, and the nurse that sent me home the night before.

They brought her in to us shortly after, I was not ready to see her and was crying hysterically. She was so perfect, I did not understand how this could be happening. Her skin was still so warm and she was bigger than I thought. She had long legs and fingers, downy hair, and her daddy’s ears. We named her Addison Grace.

The next several days were a blur. We learned how to make funeral arrangements, post an obituary, and how to tell people our daughter was dead.

She will always be our daughter, our firstborn child, and I will always think about the beautiful little girl, and then woman, she would have become. When we have more children, God willing, they will know about their sister.

Proud New Owner of a Bionic Cervix

We left for Chicago on April 12 and spent the weekend enjoying the city before my surgery Monday morning. We checked out the Bean, the Art Institute and had cocktails on the 96th floor of the Hancock Building after a cubs game.

Monday morning we took a cab to the hospital, driving by the incredible Museum of Science and Industry. We really need to go back, there’s so much to do there! The hospital itself was beautiful, brand new, and very modern. I checked-in at a huge white desk and the lady gave me a little buzzer…I joked we must have gone to the Cheesecake Factory by accident. They also had a large screen your loved ones could track your location with (like the airport arrivals board). Pretty cool, but a little impersonal too. We waited quite a while before my buzzer buzzed. Another lady’s had at the same time and as we walked back, she showed me pictured on her phone of her car, which had just been squished by a pile of bricks that randomly fell off of a building. “You never know when it’s your time,” she joked. Thanks….

Once they pulled me back, they made Brady wait in a smaller room while I was prepped. I had to change into the gown and stash all of my stuff into a garment bag. They took my vitals and placed my IV, then let Brady back in. The anesthesiologist came in and asked me a million questions and made me so much more nervous. I was terrified of going under general (thanks to an episode of Grey’s where Mandy Moore never wakes up) and we discussed a spinal instead. They explained the risks were comparable with both and I finally decided to go ahead with the general. The residents also came in and talked to me, and one, Dana, I think, was super sweet and helped me relax. The resident with the anesthesiologist was in ortho and I jokingly forbade him to touch my bones. He was kinda cute and I realized he (and everyone else) would see me naked and unconscious soon…. lovely. Dr. Haney came in there at some point and lightly chided the anesthesiologist (who was actually starting to grow on me) for making me nervous. He explained the whole procedure again and told Brady I wouldn’t remember much for a while after I woke up.

They then started to wheel me into the OR. Brady got to walk a little of the way before they shoo’d him away. Then they had me move to the table and “spread my arms like Jesus.” That part is a little hazy. Then the anesthesia resident put the mask over my face, but it was all weird, like crooked and over my eye. I was making faces so Dana was like, “No dummy, put it this way” and fixed it. Haha she didn’t say that exactly, but you could hear it in her voice. It was much more comfortable and I took a few deep breaths and next thing I know I’m waking up in recovery.

Everything was unbearably loud to me. The monitors beeping, other people talking, the enormous lady they wheeled by that kept hollering. The recovery nurse noticed I was wincing and apologized for how loud the lady was. She then started asking me how I was feeling and explained the PCA pump (push button pain meds). She told me to push it and let me know how it felt. It made me nauseous almost instantly so she unhooked it and called over the anesthesiologist. He was annoyed they gave me the drug they did (dilaudid) as I told them Vicodin makes me feel sick, and it usually reacts similarly. He also asked me if I’d heard about the Boston bombings (which happened while I was out). I was like “ummmmm no… I was unconscious?” It took forever to get a new PCA and then when it finally came, the nurse couldn’t get it to work. At this point poor Brady was wonder what the heck was happening to me. Dr. Haney had come and told him the procedure went well right after surgery, but no one told him why I was stuck in recovery for so long.

Finally they got me to my room. I was thrilled to be somewhere quiet, and Brady was finally called to come up with me. The room was quite large, and had a small room with a computer and a sink attached that made it even more private and insulated from the hallway. The view of the skyline was lovely. Nurses came in and out all evening and I slept most of the time while Brady watched movies. I was excited to eat as there was a Jamba Juice downstairs (we dont have one in our town), so he got me one and I drank a good deal of it. The next morning they said I should try and get up, and they removed my IV and catheter (super fun). The first time I sat up I thought I might throw up from the pain. It was intense

I was discharged that afternoon and we took a cab back to the hotel. There was a beautiful fruit arrangement waiting for me courtesy of my wonderful aunt. It tasted great to me, despite the crazy gas pains I started feeling. Apparently air builds up in your stomach when they open you up and it’s not so fun. We headed to bed early, as we had a flight early the next morning. I told the airport I needed assistance and popped a Percocet when we got there, so the airport is a bit of a blur.

I’ll post more regarding my recovery later, this is enough for now 🙂

Colleen

Colleen & Dr. Haney

Stories of Strength: Meghan’s Story

This is the first story of (hopefully) many I will share here, of how cervical insufficiency has affected women and their families. This story shows how important it is that doctors be aware that IC can be acquired through trauma – it doesn’t have to be congenital. Meghan, thank you so much for sharing your story. You’re one strong mama.

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

I am very “lucky.” My daughter and I survived ten weeks of unmonitored preeclampsia before it finally became severe enough that someone looked back at my labs and blood pressures and symptoms and induced me. My first child (second pregnancy after an early miscarriage) was born 51 hours later, after many intrapartum complications, on my 35th birthday.

My daughter got stuck in my pelvis at about 1.5 hours of pushing. This was after two episodes of severe drops in blood pressure after an epidural for me that rendered me unconscious, and my baby bradycardic (low heart rate). Despite a vacuum assist after 4 more hours of pushing after she crowned, (thanks to the fact I ran 20 miles a week until I got sick at 26 weeks gestation, I did have stamina), she was not coming out vaginally. This was a surprise to me because my mom birthed three 9.5 pounders and me, with her longest labor 4 hours!

So we went to csection, where a third OB gave a “push from below” in order to disengage my daughter’s head from my pelvic inlet, to deliver her. After my OB saw me post-op the next day, I knew I had a small tear (the lucky part), however at 6 months postpartum, I finally dared to feel it and discovered my cervix was ripped all the way through and still open at 9 o’clock longitudinally. So I knew I had a huge(!) problem – this was no “small tear.”

As a pediatric nurse practitioner working in family birthing/nicu, I know things happen. I see it every day – especially if the mother works in medicine – something invariably goes “wrong.” What pisses me off though is that 1) the OB made it sound like the tear was no big deal (watch and wait next time?), 2) by six months postpartum, she had already done two exams and had not found this, 3) she would have let me go ahead and get pregnant if I had not been one to feel my damage in the first place.

It turns out that my rip was from the lower uterine segment all the way down through, not a “small tear.” In my job I see the “push from below” all the time and I want to yell at the OB to put that in the OP note (thankfully mine was, but the extent of the damage was not accurate), and gently write a letter to the patient (to be opened 3-6 months postpartum when they have their feet under them again) to make sure they become aware that this could be an issue later on, but I cannot.

My husband and I were going to go ahead with another severely monitored pregnancy with only the preeclampsia over our heads. When I found my injury, I knew I would have an incompetent cervix and had already researched my options and had found Dr George Davis online, so when I was finally referred to him a year later, after discussions between the OB and MFM, I already knew what I wanted. I had a hysteroscopy and consult with him. As my OP note was unclear and my damage so severe, Dr Davis could not tell us exactly what was to happen, but theorized that I would need a transabdominal cerclage (TAC) for cervical competence and a transvaginal CervicoIsthmic cerclage (TVCIC) to keep a mucus plug in my open cervix to ward off ascending infection (the TVCIC is different than a normal transvaginal cerclage – TVC – in that it is much higher up the cervix and has no free strings that could allow an ascending infection). Dr Davis also recommended delivery early at 34 weeks, as my lower uterine segment was probably also going to be weak. I think the early delivery was the part I could not get over – an early delivery because of in-pregnancy issues is one thing in my mind because we are doing the best thing for the baby at that point, but planning for an early delivery was different – I was planning and choosing to put my child at a developmental disadvantage and it was a hard pill to swallow for me.

That was exactly two years ago, but my husband decided that between the early preeclampsia and my incompetent cervix, an attempt at a sibling for our daughter was not in the cards. I grieved this – I was not done. I was angry.

Fast forward to this summer and I was giving away my baby stuff (not just loaning out, as I had been doing), and my husband became concerned that this was the end of our possibility of having another child and mentioned another baby. He had always wanted another, but was too scared for my health and for our daughter potentially not having the same momma around if the preeclampsia was severe and early again, but me giving away our car seat was too permanent for him.

I called Dr Davis, who previously had been understanding and supportive of our decision to not go ahead and get the TAC. I told him we wanted to go ahead and get the TAC and investigate my actual damage. He was absolutely on board with this plan. I was TACed last month. Whether it was the 3.5 years since my delivery, or an incomplete and incorrect operative note, I don’t care – my body had done the best job of healing itself and my TAC went on beautifully, with a thick lower uterine segment and still approximated upper cervix – all this allowing no TVCIC needed and delivery at 39 weeks if we choose to get pregnant.

I am now awaiting my husband to digest all of this and come to his own conclusion that it is ok to get me pregnant with lots of monitoring for preeclampsia. My IC is now fixed. My broken heart will be fixed with another pregnancy and sibling for my beautiful daughter once my husband has battled his anxieties and fears. If my husband cannot come to that conclusion, I will most certainly grieve again, but will be thankful for my daughter and will continue to spread information about preeclampsia and IC.

For more information about preeclampsia, or to register as a woman or family member affected by preeclampsia for long term study, please see www.preeclampsia.org and for an IC support group and options, google Abbyloopers.

A Step in the Right Direction

Update: If you’d like to read the specifics of my surgery and recovery, see this post. If you have questions, or would like to contact me privately, please email tac.questions@gmail.com.

Okay, I was waiting until everything was planned to really discuss this, but now that everything’s been arranged, I’ve had a hard time working myself up to it. I want to explain the next step we’re taking to make sure that what happened to Lucy won’t happen to any of our other babies in the future. I also want this post to be a source of information for any women out there looking for an idea of what they should do next, because I know it can be hard to find. So before I really start, let me say that I am clearly not a doctor, and this is just my attempt to assemble the relevant information I’ve been able to gather. I’m not going to cite sources, although I may come back in the future and do that. Also, this post is going to be LONG and discuss lady parts in great detail and with diagrams, so that’s just a warning.

Before I get to the nitty-gritty, though, let me just break it down really simply for those who don’t want to know the details. David and I have decided that we’re going to do everything in our power to prevent my stupid dysfunctional cervix from hurting any more of our babies. Neither of us thinks we could live through another experience like we had with Lucy. What I’m doing is flying to New Jersey to have a surgery that will essentially permanently prevent my cervix from dilating. Technically, it’s reversible, but it’s meant to be left in place, and it will mean that I will be required to have a cesarean delivery for any future pregnancy. Not only that, but due to certain risks, I’m not even supposed to labor, so the C-section will be scheduled a little early. That’s the basic idea, and I know it sounds extreme (especially for someone who always wanted a natural delivery), but read on if you want to know more.

If you don’t know me, and you got to this post while searching for information about incompetent cervix/cervical insufficiency, then you’ve probably experienced a loss (or losses) like we did. I’m so sorry. I know the pain you’re feeling, the confusion, the anger, and the frustration with your body. I’m so terribly sorry you’ve had to go through this. If you’re like so many of us, your doctors have told you that your loss was a fluke, or maybe they are pretty sure it was IC. My case was pretty clear, although many times it’s difficult to diagnose IC. Other things can cause preterm labor – infection, problems with the baby, problems with the placenta or cord, etc. So if you have any of those things, it’s hard to know: did one of those things cause labor, which then caused your cervix to dilate, or did your cervix dilate first, causing labor to begin? In my case, there was no infection, nothing wrong, just a 3 cm dilated cervix, bulging bag of waters, and contractions. Anyway, my point is that some doctors are reluctant to diagnose IC. My advice to you, if you’re not sure, is to get enough opinions about your case that you feel comfortable in your own mind that you know what happened to you. Sometimes you just can’t know, and no doctor will be able to help you. You’ll just have to do your research and follow your heart.

The day that my sweet Lucy was born, while she was very much alive down the hall in the NICU, two different OBs told me what we were going to do next time. That’s how they say it. They say “here’s what we’re going to do,” and it is inferred that it will work. People trust their doctors, and when their doctors give them one option, and tell them it will work, they mostly put their faith in them. Doctors are, in general, wonderful knowledgeable people, whom I respect greatly. But they’re also people, and I’ve always thought it was my job as a patient to make sure I was well-informed about any course of treatment. That’s what started me doing research about this, and I assume that’s why you’re reading this. What my doctors told me was that I had an incompetent cervix, and that during my next pregnancy, we’d do a prophylactic TVC (trans-vaginal cerclage) at 11 weeks and I’d have progesterone shots starting at about 16 weeks. My guess is that, if you’ve had a loss, you’ve heard something similar from your doctor. The problem is, that’s all they say. There is a lot more information that they don’t give you, and you really need to have all that information to make an informed decision.

So, now to the diagrams, as I try to explain my understanding of the available procedures. There are essentially three types*:

1) TVC – transvaginal cerclage

a) Shirodkar stitch
b) McDonald stitch

2) TVCIC – transvaginal cervico-isthmic cerclage
3) TAC – transabdominal cerclage

a) Traditional open approach (laparotomy)
b) Laparascopy (through 5 small holes usually)
c) Robotic laparascopy (via da Vinci robot)

*It’s important to note that different doctors (and doctors in different parts of the world) may call these procedures different things. For example, a traditional Shirodkar stitch is somewhat complicated and placed high on the cervix. However, most doctors performing “Shirodkar” cerclages these days are really doing some variation, a modified Shirodkar. Similarly, any cerclage placed through an incision in the abdomen is technically a TAC (transabdominal cerclage). However, some surgeons placing a “TAC” are actually doing a modified McDonald or Shirodkar stitch through the top of the cervix via an abdominal incision. This is NOT recommended and is more likely to cause damage to the cervix and uterus during a normal pregnancy and any contractions. Make sure your doctor explains the procedure he or she plans to perform.

You’ve probably seen this before, but this is what the female reproductive system looks like:

uterus
This image is from MedlinePlus.

However, I’m simplifying it. Please forgive my extremely crude diagram. The important part for this discussion is that part of the cervix lies above the vagina, connecting to the uterus at the internal os, and the rest protrudes into the vagina, ending at the external os. Normally, and during a normal pregnancy, the cervix is long and closed (during pregnancy, you develop a mucous plug that prevents bacteria from entering your uterus). During labor, the cervix thins and opens (effaces and dilates), allowing the baby to pass through.

basic

So, what happens in a TVC is the doctor goes in through the vagina, reaches as high as they can on the visible part of the cervix, and stitches around the flesh of the cervix, pulling it tight like a purse-string. There are two main stitches used, although there are variants on each: the Shirodkar and the McDonald.

TVC copy

This is the procedure that most doctors recommend. Sometimes they will wait and watch your cervix for signs of funneling (when it starts to open at the top) or shortening. If it begins to funnel or shorten, they will then do an emergency/salvage/rescue TVC. Other times, they will do a prophylactic cerclage late in the first trimester or early in the second, then monitor the situation. The stitch is usually done with a spinal in place for anesthesia. When the pregnant woman reaches term, the stitch is cut and removed, allowing a vaginal delivery.

A TVCIC is relatively uncommon, although possibly becoming more common. (My doctor had never heard of it and accused me of using “chat room lingo.” As I said, doctors don’t know everything.) A TVCIC is an attempt to place a band made of mersilene (a very tough woven polyester fiber – you want it to be 5 mm) as high on the cervix as possible, still accessing it through the vagina. This is done by making two small cuts in the lining of the vagina in front of and behind the cervix. Then the band is inserted through the cuts, then tied around the cervix as high as possible. A TVCIC is usually placed during pregnancy (unless it is intended to be permanent), and can be done under general anesthesia or spinal, I believe. I have read some studies that report that a TVCIC should be intended to be permanent, but at least one doctor I’ve spoken with does it a little differently. He leaves the knot inside the vagina (instead of tucked away above) so that it can be snipped and removed to allow a vaginal delivery.

TVCIC copy

A TAC is a full-blown abdominal surgery. The surgeon places the woman under general anesthesia (often, although in my case, since I was pregnant, my doctor felt it would be better for the baby if I was awake using just a spinal block) and makes a bikini cut at the bottom of the abdomen (just like in a C-section). They then carefully move the bladder (which is in the way of the cervix). Spacers are placed in the cervix to make sure the mersilene band is not fitted too tightly. (Edit: No spacers were used in my surgery. Dr. Davis told us that during pregnancy, the cervix is swollen, so he ties the band as tightly as possible. Then, after delivery, the swelling goes down and leaves a functional cervical canal.) The band is then tied around the very top of the cervix, just below the internal os. If it is placed correctly, there is enough room left for all normal functions of the cervix (enough room for semen, menstrual blood, even enough room to have a D&C if that is necessary). The band simply prevents the cervix from dilating beyond its normal state. The TAC is always meant to be permanent, and can be used through multiple pregnancies without being redone. Also, a TAC can be placed laparoscopically, either by hand or by DaVinci robot. Outcomes vary from doctor to doctor, but in general, laparoscopic TACs have had slightly worse outcomes. The surgeons with whom I’ve spoken feel that that is because it’s hard to see and feel the exact place and the correct tension in the band. I think the DaVinci robot, in skilled hands, improves outcomes, but it still hasn’t been as well-tested as the traditional open placement. I will be having a traditional TAC, but here is a very succint discussion of the laparoscopic approach: Prophylactic laparoscopic abdominal cerclage: Tips for success

TAC copy

So those are your three basic options.

TAC, TVC, TVCIC copy

Edit: Dr. Davis, my surgeon, drew a much better diagram and has given me permission to share it here:

Dr. D

Pros and Cons

I think it’s pretty obvious how I’ve come down on this issue, but let me just lay out some of the basics.

My doctors didn’t give me any statistics about the TVC, so I went searching on my own. Statistics vary of course, but what I found is that they have a 75-85% chance of success. Sounds pretty good, right? But there are a few problems. The first is that those numbers very possibly include a lot of women who never would have had a problem a second time. Say you lost a baby in the second trimester because you developed an infection. That infection could have been caused by an opening cervix, or it could have been a complete fluke. If it was a fluke, you may very well not have any problems in the future, but you may receive a TVC nonetheless. The second, and much bigger, problem is that success for a TVC means getting a woman to viability, or 24 weeks. That’s right, let that sink in. So basically, if you really do have an incompetent cervix, your doctors are aiming for 24 weeks (or more, obviously, but 24 weeks is a success, remember), and you have a 3-in-4 or a 4-in-5 chance of getting there. I am here to tell you, having a baby at 24 weeks is NOT a successful pregnancy. Lucy was born at 23 weeks, but her case would not have been substantially different if she’d made it to 24. A baby is not meant to be born at 24 weeks. In the very best case, you’re looking at months in the NICU with the very real possibility of cerebral palsy, vision problems, breathing problems, and developmental delays. But that’s the BEST case at 24 weeks. Viability is no guarantee. Even with all the amazing medicine happening in NICUs, a 24 week baby has less than a 50% chance of living.

Whew, gotta catch my breath. There are benefits to TVCs, of course. They are the least invasive option – one quick outpatient procedure, and you’re done. Also important is that they are easily removed for a vaginal delivery. They do have to be redone for each pregnancy, but no big deal there. Overall, the biggest benefit is that they’re not very invasive. See here to read about the different types of TVC, and to see the difference between the Shirodkar and McDonald stitches. Also see here.

There are other important cons to consider about a TVC, though. Due to their placement in the part of the cervix inside the vagina, some believe that they can have a wicking effect, actually causing ascending infections that endanger a pregnancy. Also, for how simple the procedure, TVCs require a lot of a woman afterward. For example, my doctors wanted to place my prophylactic TVC at 11 weeks. Thereafter, I was to be on complete bed rest. Yep, you read that right. Complete bed rest from 11 weeks until I have the baby. IF I were to make it full-term, that means 29 weeks in bed. That wreaks complete havoc on your body, and I’m not sure why doctors don’t take that into account. I’m already overweight and at higher risk for embolisms and blood clots, and bed rest makes that risk so much higher. So that is definitely something I considered. Complete bed rest isn’t good for anybody.

But I truly believe that I wouldn’t make it full term with a TVC. As I said, success is measured by getting to 24 weeks, and you have a 75-85% chance of that. But one study I read suggested that you actually only have a 20% chance of carrying to term. Those are not good odds. As far as I can tell, this is because the cerclage is too low on the cervix. This means that if you have IC, your cervix can still funnel open from the top to the stitch. That means the baby, the amniotic sac, the umbilical cord – whatever – can sink down into the cervix, putting pressure on the cerclage. This is a problem for two reasons: 1) it makes your cervix functionally shorter, so you are more likely to lose your mucous plug and get an infection, and 2) the pressure, an infection, or a problem with the baby (say an umbilical cord prolapse, where the cord is pushed out ahead of the baby) can cause you to go into labor anyway. Once you’re in labor, it either has to be stopped or you have to deliver. In many cases I’ve read about, women with TVCs went into labor early, their stitch was not removed quickly enough, and the baby was delivered through the stitch. If this happens, it is very likely to tear or otherwise damage the cervix, making it even less likely to work in the future. Also, I know of at least one instance where a baby was delivered through a stitch and suffered severe head trauma because of it. These are real worries. I can’t count how many women I’ve talked to who have had failed TVCs that resulted in the loss of a baby and usually some damage to their bodies. And according to one surgeon I talked to, if you have true IC, it’s not a matter of if your cervix will funnel to the stitch, but when it will funnel, regardless of bed rest.

Now, the TVCIC. This one is tricky, as it’s not often done. The goal with a TVCIC is to get the band as close to the level of a TAC as possible while still going through the vagina for minimum invasiveness. If I understand it correctly, though, it’s otherwise like a TAC and not a TVC, in that the band is placed around the cervix, rather than a stitch being placed through the flesh of the cervix. I spoke with one well-known surgeon who thinks the TVCIC is not really an option. He thinks it is impossible to get the band as high on the cervix as the TAC. This is important because, as I mentioned above, the cervix will still funnel as much as it can. Any funneling at all can cause problems, although the less, the better. He also pointed out that during a TVCIC, the surgeon goes in blind essentially, and there are important things going on in that area (like your urethra and big blood vessels). So you would definitely want to make sure you were in the hands of a very skilled and experienced surgeon. That criticism makes sense to me, but it would be much less of an ordeal if the procedure could be done through the vagina (rather than through the abdomen, like a TAC). It would also be fantastic if it could be removed for a vaginal delivery, although this would mean that it would have to be redone for each subsequent pregnancy. The critical surgeon I talked to did not think it should be removed, but I spoke to another well-known surgeon who has done the procedure very successfully and who does think it’s a valid option. According to the somewhat limited data available on TVCIC, women with proven IC were able to carry their babies to term with the TVCIC about 90% of the time. That is a much better figure than for TVCs.

We’ve opted to go with the traditional TAC. The surgery can be done either during pregnancy or before pregnancy (something neither my OB nor my RE – reproductive endocrinologist – were aware of). Some surgeons will only do it during pregnancy, but the most experienced surgeons in the country (both of whom I’ve talked to by email and by phone) prefer to do it pre-pregnancy if at all possible, because there is no risk to the baby (as there is no baby, of course), it requires a smaller incision, and the recovery is faster. However, some insurance companies will not cover it prior to pregnancy (ugh, the insurance is another issue entirely – some insurances will not cover a TAC unless you’ve had TWO or MORE failed TVCs, meaning you’ve lost at least two babies.) Anyway, when the TAC is performed prior to pregnancy, it does not interfere with any attempts to get pregnant, or with IUI or IVF. As far as I know, the surgeons say you can start trying to conceive as soon as you’ve had one period.

Pros:

  • It’s permanent, and you should never have to worry about your cervix opening up again (although you will anyway). It shouldn’t get in the way of anything else, so even when you’re done having kids, you shouldn’t have to worry about it.
  • No bed rest is required by the surgeons, although your particular case may warrant some degree of bed rest. They do recommend taking it easy.
  • No pelvic rest necessary, unlike a TVC, unless your situation warrants. Have as much sex as you want, or don’t.
  • Since the TAC is placed just at the cervico-isthmic junction just below the internal os, if it is placed correctly, your cervix can’t really funnel at all.
  • If you are prone to premature labor for reasons other than IC (as many women with IC are), the TAC improves your chances regardless by improving the functionality of your cervix.
  • Again, statistics vary, and some doctors are better than others. But with a well-placed TAC, you have a 95-98% chance of carrying to term. I like those odds.

Cons:

  • It’s definitely a surgery. It’s pretty straightforward as surgeries go, but it has all the same risks as any other abdominal surgery: adhesions, blood loss, mistakes, etc.
  • If you have the TAC while you’re pregnant, there is a small risk to the baby. The surgeons I’ve talked with haven’t really had any losses to speak of, but there is something like a 1-2% chance of loss. It’s hard to determine what might be caused by the surgery and what might have been a first trimester miscarriage anyway.
  • Longer recovery.
  • Required C-section. The cut is made through the same incision (unless you’ve had your TAC placed laparoscopically, in which case you’ll have several small incisions, and a new larger one for the C-section).
  • No labor/chance of uterine/cervical rupture. If you are allowed to labor hard for a long time, there is a chance that your uterus or cervix could rupture. Some might see the fact that you aren’t allowed to labor as a pro, I guess. This small risk is the reason they usually schedule the C-section a week or two early.
  • You may have issues getting your insurance to cover the procedure. I didn’t, but if your insurance isn’t that great, you might have to fight them for it.
  • The TAC can be placed incorrectly, in which case it could fail. Research your doctor carefully.
  • Not that many doctors do it, and your OB may very well not support your decision.
  • It’s not a 100% guarantee. Women have lost babies with TACs in place, either because they had a badly placed TAC or because they had some other, unrelated problem. If you do go into labor early with the TAC, and the labor can’t be stopped, you will probably have to have an emergency C-section to deliver.

I feel like I’m forgetting a lot of stuff, so I may come back and add more information, but I think I’ve hit the main points. I’m really not looking forward to having the surgery. I’ve had surgery a couple times before, and it’s no fun. But losing my little girl was the worst thing that’s ever happened to me, and I could not bear a repeat of that. I listed more cons than pros for the TAC, but it’s the 95-98% chance of carrying to term that outweighs all the cons for me.

Again, I’m not a doctor. If you’re considering these options, I advise you to do your own research. The important thing is that you feel comfortable about your decision and you know why you made it. Don’t let doctors push you into any particular course of action, because they get it wrong, and the stakes just aren’t as high for them. You have to be an advocate for yourself, your baby, and your family. If you’d like to learn more, or hear from the doctors doing the TAC, or talk to a lot of women who have suffered losses like this (and have or would like to have a TAC), I’d suggest you head over to Abbyloopers for more info.