Tag Archives: TAC

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: An Incredibly Strong Mama

The amazing mama who shared this story wanted to tell it anonymously. It’s such a horrible shame that she KNEW she needed a TAC and couldn’t get one because of her insurance. It’s a story I hear way too often. No parents should have to lose a child – let alone TWO children! – to satisfy their insurance. Thanks for telling your story, mama. I can’t wait to hear about your rainbow baby.

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

 

On April, 2008, my husband and I welcomed a healthy baby girl at 40+5 weeks. It had been a fairly easy pregnancy. I was induced and she was born eight hours after the induction. I refused an epidural until the pain became unbearable. At that point, I was told it was too late to get it. I got a dose of narcotics, but that didn’t help much. Though I had an episiotomy, baby turned her shoulders on her way out and tore my perineum. It took about a month to heal, but things got better with time. Five years later, we decided to try for baby number two. I had my Mirena IUD removed and I conceived that month. Everything had been going well except for a couple of episodes of unexplained spotting. I had also been having some pressure in my lower abdomen. Each and every check and ultra sound had shown that baby was fine, but that he was low lying. My cervix was also said to be friable; nothing serious.

However, on 7/15/13, I went for an anatomy scan and no sooner had she started the scan than I noticed her tense. She asked if I have fibroids; I said no. She asked if I was having contractions; I said I had been having Braxton Hicks Contractions on and off but that my OB had said it was normal. By this point, I was beginning to get worried. I mean, why all these questions? The tech kept asking me to change position and also kept pressing my tummy so hard it was somewhat painful. Eventually, she mentioned that the baby was very low. So low that she couldn’t get a good view of his toes. She soon excused herself and came back with Dr. White, Maternal Fetal Medicine (MFM). He asked if I had been having any pain. I told him that I had spotting and bleeding 2 times in this pregnancy but ultrasounds showed that baby was fine. Each time, nevertheless, they didn’t check the cervix. 15 weeks was the 2nd ultra sound due to bleeding, and the tech had said that baby was fine. She did mention, however, that he lay a little low. Nothing to worry about. After that U/S, a nurse practitioner had done an internal check and said that my cervix seemed inflamed but also mentioned that some people just have a lot of blood during pregnancy. I told Dr. White that about two weeks after the nurse practitioner had checked me, I had started having some pain on my right hip and around my groin – right side only. They were about one to two minutes apart and about ten seconds long. They started about 10 pm and went on till the next afternoon. There was no bleeding / spotting. I called my OBGYN in the morning and she had no idea what that would be. She mentioned I may have kidney stones or round ligament pain, but asked me to give a urine sample to check for the kidney stones. I never heard from the doctor’s office, so I assumed that I was good to go.

Dr. White asked the tech to do a vaginal ultrasound. At that moment, Dr. White announced the bad news. My cervix was open. I was so naïve that I didn’t understand the implications of his news. He very gently explained that the cervix is supposed to remain closed until the baby is close to term. However, mine was already fully effaced and dilated at only 18 weeks. He said that this was very serious and that I would lose the baby as he wasn’t viable. He diagnosed me with an Incompetent Cervix and sent me to a hospital one hour away from home with hopes that I would be given an emergency cerclage. At the hospital, I was checked and was told that I was already 2cm dilated with bulging membranes. They kept me for observation. Luckily, I wasn’t having contractions. Later that night, one MFM came in to check me and she said that she might attempt a vaginal cerclage, but that she couldn’t do it that night. She said to wait until the next morning then the next doctor would do it for me.

The next morning, the MFM on duty checked me and said that he wouldn’t do anything at this point. It was too risky. My membranes had already been exposed to the vaginal bacteria for God knows how long. There was no way he was going to try to push back the membranes and attempt a suture. It was too late. I was definitely going to lose this baby. He told me to terminate the pregnancy or go home and wait for the baby to “fall out.” He tried to “console” me that I was still young and that I would be able to carry another baby to term with proper care. He even went ahead and narrated a story about a young woman who got a stitch after her membranes had bulged. How she got a bad infection that had her in the ICU for weeks before finally killing her. He said even if the infection didn’t kill me, it would definitely kill the baby and that I would possibly lose my uterus . . . meaning no more babies! I hated this doctor. I never ever wanted to see him again or be in the same room with him.

That midnight, my waters broke and the next day I was induced and delivered my sleeping son. He weighed 240 grams. He was so perfect and handsome. He looked just like his daddy. We were totally shattered. It’s as if our world came to an end. I had always heard of women miscarrying but I had never thought it would ever happen to me. I felt like a failure. My body had failed to do the one thing it was made to do. I felt so guilty. As if I had murdered our baby and destroyed my family. How could this be happening to us? Did we really deserve this? The MFM said that my next pregnancy would be high risk. That I would be followed closely and do a Trans Vaginal Cerclage (TVC) at around 16 weeks. We left the hospital empty handed and left our baby at the hospital, so cold and lonely.

I went back home and threw myself into research. I wanted to know what an Incompetent Cervix was. I wanted to know what my options were. I joined Facebook groups where I heard about other women who had been in my shoes. Though I felt relieved that I was not alone, the overwhelming sadness and guilt lingered. Through the Facebook group, I heard about Abbyloopers, an online group that advocates for a much better stitch than the TVC, the Trans Abdominal Cerclage (TAC). Needless to say, I joined Abbyloopers and delved into further research. As soon as I read about the TAC, how high it’s placed, its success rate, etc., I was sold. I immediately knew that a TAC was my antidote. I was going to get a TAC. I felt relieved and so very excited. Finally, I was going to have my rainbow. No bed rest needed. YAY!

A week after my loss, I saw my regular OBGYN. He told me he had no idea why my first pregnancy went well and this one didn’t. He also suggested doing a TVC at around 13 weeks of gestation and be closely monitored. He also mentioned possible bed rest. I told him I didn’t want a TVC. What I needed was a TAC. He was surprised I even knew what that was. He discouraged me saying it was overkill. It was too invasive, and that a TVC would work just as well. I wasn’t about to let him convince me otherwise. I had to get the TAC whether he liked it or not. He had no idea what I was going through, so to hell with him and his TVC ideas. I looked up a TAC doctor near me and found Dr. Ivar Einarsson at Brigham and Women’s. I scheduled a consult with him and I was so hopeful that this was it for me. Unfortunately, he told me that the kind of insurance I had would not cover the TAC until I tried a TVC and/or had a second loss. What? I almost went insane. How could this be? I was so sure I was going to get my TAC and now this man was telling me I couldn’t until I lost another baby! I called insurance but they refused to authorize a TAC saying it was not necessary at this point. I couldn’t afford to pay $20,000 out of pocket to pay this doctor. I also couldn’t afford the $5,000 needed to have this surgery done by Dr. Davis in New Jersey. This TAC route was looking bleak at this point. It was not going to be a possibility. We had run out of options. Due to this sad fact, my husband and I decided to try the TVC, our only option, and hope and pray for the best. Worst decision ever, needless to say!

In October, 2013, about three months after my loss, I got pregnant. Things started going downhill really early. I had bleeding at around 9 weeks. I went to the Emergency Room and baby was fine. My cervix was checked manually and it was said to be closed. That night, I had a lot of discharge that looked like my mucous plug. At this point, I was in the middle of changing OBGYN, so I had to wait about a week and a half to be seen by my new doctor. She checked my cervix and said that it was so low and open at the external os. She referred me to an MFM who was said to be the best at the area. The next day, I met this new MFM. Ultrasound showed that the cervix was indeed open at the external os but closed at the internal os. She also did a manual check and mentioned that my cervix was bad, that she could easily put a speculum through it. She put me out of work and on moderate bed rest until a week after my cerclage surgery. She also prescribed progesterone suppositories.

At exactly 13 weeks and one day, I had my TVC placed. I continued bed rest at home. A week after placement, I went in for my cervical length check and the doctor mentioned that she didn’t like how my cervix looked. It was tilted backward and she couldn’t see the cerclage too well. She told me not to go back to work until further notice. Each week I had vaginal ultrasounds, things kept looking better and better. My length was always between 4 and 5 cm. However, at 19 weeks, I was told that I was funneling past the stitch. I was given a pessary and put on hospital bed rest with bathroom privileges. Unfortunately, I continued funneling a week later and membranes budged. I was denied an emergency TVC due to slight fever; but was put on strict bed rest. The foot of my bed was elevated, trendelenburg position, and I had to eat, drink, pee, and poop in that position. I was miserable to say the least, but was very determined to do everything in my power to keep baby cooking. I religiously stayed in this position for about a week, but still, my membranes kept bulging to the point that I could feel them with my hand!

Unfortunately, my water broke and my pessary and cerclage had to be removed. My MFM explained that these were foreign objects and that she did not want to risk an infection. I was checked every few hours for infection. I was informed that as long as I did not develop an infection, then baby would stay in until 32 weeks. I had hopes. My doctor came in one morning and gave me important dates. Dates that included when steroids would be administered, when baby was viable, when baby would be 28 weeks, and finally, 32 weeks, delivery day. I was so hopeful. I prayed and prayed. Sadly, that same day, my cord prolapsed. The pregnancy had reached an end. I had to be induced. The next day, February 27, 2014 @ 21+4, we lost yet another perfect baby boy. We were beyond devastated, but then my husband and I decided not to lose hope; to look into the TAC once again.

I called up Dr. Einarsson, the TAC doctor I had met after my first loss and after consulting with him it was decided a TAC was my only option if I wanted to have more babies. My MFM was also 100% on board with this option. Luckily, or let me say ironically, my insurance covered my TAC, no questions asked. On 4/20/2014, while the Boston Marathon was taking place, I had my TAC done. It was bitter sweet that I finally had the one thing that I had needed from the word go. I felt relieved and hopeful that at last, our nightmare was at an end. My husband and I felt like we had another much safer chance at having our rainbow. We now have hope. Hope that eventually, we will put this TAC to work and that it will help us finally bring home a sweet and healthy, full term baby.

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

Stories of Strength: Tanesha’s Story

Tanesha’s story is so sadly familiar. After losing three beautiful babies, she’s got her TAC and is ready to try again. Thanks for sharing your experience, Tanesha.

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

I’m about 2 days post-op from my Dr. Davis pre-pregnancy TAC and decided to share my journey up to this point. I have not given up hope and I hope that you will not either. I’m 35 years old and I have 2 children from a prior marriage – a 16 year old daughter and 12 year old son. My husband and I married in January 2010. We conceived twin boys January 2013 on our 3 year wedding trip to NYC and were on top of the moon.

Vacation

Tanesha and her husband on vacation, when the twins were conceived.

At my 20 week anatomy scan it was discovered that my cervix was open and I had to be rushed to L&D. Long story short, I had an emergent cerclage, and since my membranes were already bulging, they then ruptured. After Pprom (preterm premature rupture of membranes) of baby A’s waters and 3.5 weeks on hospital bed rest, I had to deliver them due to infection and they were born too soon. After meeting with specialists and all, it was decided that due to my history, my issue was more related to the fact that I had twins and not my cervix. No one thought that I’d need a preventative cerclage and that it was more risky since it could cause infection. I would only have p17 (progesterone) shots and weekly cervical length checks.

Angels Tyler and Taylor

Tanesha’s beautiful boys, Tyler and Taylor. Photo by NowILayMeDownToSleep photographers.

Taylor and Tyler feet

Taylor’s and Tyler’s perfect tiny feet. Photo by NowILayMeDownToSleep photographers.

It didn’t take me long to get pregnant and I did so 4 months after my loss in October 2013, the same month my twin boys were due. I was so excited and thankful for another chance. I stayed positive. Had affirmations that I posted daily. I started a journal. I tried to drown out my fears with faith and hope. February 17th, I went and did a little shopping. When I got home I noticed some brown spotting. I was 17 weeks and had just had my first p17 injection about 5 days prior and my cervical length at that time was 5 cm. I decided to go to L&D as a precaution even though I felt that I was overreacting. Of course, as soon as I was checked out, the sonographer told me that my cervix was open and she could already see my baby girl’s hand. Heartbreak all over again! I had my baby girl within 24 hours and started the process of grief and disbelief all over again.

I started researching and found Dr. Davis and Dr. Haney. Since Dr. D was less than 2 hours away from me and I had such a good feeling about him I called, did a phone consult, and scheduled my appointment for a little more than 6 weeks from my loss. My husband had this week off already because my stepson is attending Duke this fall and on Monday we had to go down for Duke Blue Devil days in NC. Thankfully Dr. D had the same week open for my TAC. We went down on Thursday for pre-op. It took less than 2 hours and we checked into our hotel, the Hampton Inn on Blackhorse Road, before heading to his office since we were so early. The hospital rate for our stay was $99 and it was nice, clean, and in a good busy area with lots of restaurants. The hospital was about 5 minutes away and easy to find. Dr. D didn’t think we would get GPS coverage in our area, but we did and found it quickly. We used free valet parking and headed up to the 3rd floor for our appointment. We waited about 20 minutes and filled out some paperwork and Dr. D came and got us. We chatted, admired his collection of sodas, and I cracked up at his dry humor and multitasking skills. He asked me what I was going to have for my “last meal.” SMH. That didn’t help my nerves but it still cracked me up. He then walked us down to show us where to come in for surgery the next day. No food or drink after midnight. He gave us some restaurant suggestions and then we were free to go.

Fast forward to Friday. We checked in in the general same day surgery area around 11 am. Be prepared to wait an hour or 2 to actually go back for this part. I paid $100 copay and finally went back. The nurses were awesome in prepping me. They were really sweet and talked to me a lot. They were sweet even though my veins gave them problems (they give everyone problems). They went and got my husband and explained how everything would work, and then I finally went back around 2:30 or so for the surgery. I did not see Dr. D beforehand and I was knocked out almost immediately from general anesthesia. When I woke up, they wheeled me to recovery and I felt pretty good. I was not really loopy after getting to my room. I was a little hungry but not starving and I was on a liquid diet for 24 hours. My husband said that Dr. D came up to him and told him, “Piece of cake” and shook his hand. That was his post-surgery report in true Dr. D fashion. Lol. The next day after having the catheter removed I did some walking around, had a post-surgical ultrasound, and Dr. D gave me a summary of his reports and helped me with aftercare instructions. We then hit the road and came back home.

Post op selfie

Tanesha’s post-op selfie.

I am feeling a lot better than I thought I would. Besides having D&Cs after each loss, I had never had major surgery so I was pretty freaked out and worried. I felt in good hands and I am glad about my decision. I still have worries about conceiving after the TAC, etc., but I feel like this was necessary to move on. I’m 35 now and I would like to have to my rainbow as soon as possible. Dr. D gave us no restrictions. We can start TTC (trying to conceive) as soon as we feel up to it. I was actually ovulating when he did my ultrasound the day before the surgery (which I already knew) so hopefully things will stay intact and I will bounce back to my normal schedule soon. Sorry that this post was so long but I wanted to share my experience. Wish us luck on our new journey of TTC with the TAC and remember to stay strong and never give up on your dreams!

Thank you to Dr. D

Tanesha saying thank-you to Dr. Davis post-op.

The Big Three

Here’s the most basic contact information for the big three TAC doctors in the US. I’ll keep updating this post as I get new information. If you are specifically looking for a doctor in California, I keep a list of all of the doctors I know of who do TAC/TVCIC in the state, and everything I know about them. Email me at tac.questions@gmail.com for more information.

Arthur Haney
Pre-pregnancy and in-pregnancy TAC, placed traditionally (laparatomy, no laparoscopy)

Currently practicing in Chicago.

ahaney@babies.bsd.uchicago.edu

Center for Reproductive Medicine and Fertility
333 S. Desplaines Street
Suite 201
Chicago, IL 60661
Office: (773) 702-6127
Appointments: (773) 702-5161

The University of Chicago Medicine
5841 S. Maryland Avenue, MC 2050
Chicago, IL 60637

George Davis
Pre-pregnancy and in-pregnancy TAC, placed traditionally and laparoscopically via DaVinci robot; In-pregnancy TVCIC

Dr. Davis has retired, sadly, and is no longer practicing in either New Jersey or Tennessee.

askdrdavis@aol.com

 

 

James Sumners
Pre-pregnancy and in-pregnancy TAC, placed traditionally and laparoscopically via DaVinci robot; In-pregnancy TVCIC

Currently practicing in Indianapolis.

james_sumners@yahoo.com
FB: https://www.facebook.com/DrJamesSumners

Center for Prenatal Diagnosis
8081 Township Line Rd, Indianapolis, IN 46260
(317) 415-8070

Keep in mind, there are other very good surgeons who place the TAC and TVCIC. These three have the most experience of them all, but that doesn’t mean you have to see one of them. Also, please remember that all three of these surgeons are incredibly busy. I have no idea how they do all the work that they do, let alone have a life. They save hundreds of babies every year, so don’t get too frustrated if they don’t get back to you immediately, or even if you don’t get a response. It’s not because they don’t care. They care so much and they help such a huge number of women that sometimes emails or phone calls slip through the cracks. I promise you, they’re doing their best. If it’s critical that you reach them as soon as possible, usually calling is a better option.

Stories of Strength: Brittany’s Story

Brittany, whose cervical insufficiency was compounded by treatments for precancerous cells on her cervix, had her TAC placed as an emergency procedure late in her pregnancy. Unfortunately, the damage was already done. This is one way that a TAC can fail, and one option for how to proceed when it does. Thank you for sharing your story, Brittany. You’re a strong mama, and we wish you the very best.

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

My name is Brittany and this is my story. I was 19 when I found out I was pregnant and while I was happy to find out I was carrying twins, I also had found out I had pre-cancerous cells in my cervix. Due to a weak cervix, I had my twin boys at the gestational age of 24.5 weeks and they had to stay in the NICU for four months. I had to have two surgeries on my cervix and was only left with 9mm functional cervix and was told I am lucky to already have my kids.

Fast forward to 2013, my husband and I wanted to try for another baby because our kiddos are now 5. Remembering what the other doctors said about my cervix, I told my new doctor I would need a cerclage done. I was about 6-8 weeks pregnant when I started to have some bleeding on and off but my cervix was still shut. But I kept insisting bleeding is not normal and my cervix is barely there . . . Unfortunately, at 15 weeks I went into full on labor and that’s when the military doctors FINALLY believed me and my cervical issues. So they rushed me to a hospital in Savannah, GA. I stayed there over night and all contractions stopped. We were referred to Dr. Davis but had to drive up to NJ to be seen for the TAC (trans-abdominal cerclage). Two other doctors said I was too far along to have it done, but Dr. Davis had hope as long as we could get there.

We made it up there and had an amazing surgery. I got to see my baby, got the TAC, and Dr. Davis was amazed at how well it had gone. I went from 9mm to 3cm. He told me it looked great but we weren’t out of the woods yet. Mind you I had been bleeding and while Dr. Davis was doing my TAC, he couldn’t see why I was bleeding/clotting. Sadly, at 18 weeks my waters ruptured which is known as PPROM (preterm premature rupture of the membranes). The TAC did not fail – my cervix never opened – but since I was bleeding, the blood was like sandpaper and tore my membranes. I was told to abort our baby, but I had faith and had heard so many stories of fellow ladies going through the same thing, so I chose to be on strict bed rest. But, on week 19+6 I went into labor and had to go to the hospital. Since my daughter was not at a gestational age where she could survive, Dr. Davis told my doctor to just go in and cut the TAC instead of having a c-section since a c-section would further damage my uterus. I delivered the next day at 20 weeks. The nylon “string” he used is still around my cervix. I am currently trying to see Dr. Davis again to have it removed and get a pre-pregnancy TAC to eventually try again one day for our rainbow baby. It is not a guaranteed fix but I know it will hopefully help get me to a gestational age of a healthy baby. I hope my story can help in some way or give information on some questions you may have. Thank you for reading my story. Please keep your fingers crossed for us that everything goes well in the future and we get our rainbow we so desperately want.

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