Mail fra Dr. Lotgering (Nederland)

Nå har jeg fått e-post fra han fyren i Nederland også, men må sende videre forespørsler vedr kostnader der.
Det er litt frustrerende at alle har så forskjellige oppfatninger om når det er best å legge TAC'en, før eller etter man er blitt gravid. Og i vårt tilfelle så er det jo ingen garantier for at man faktisk blir gravid, selv om (eller nettopp fordi) vi har hatt flaks de gangene vi har hatt IVF tidligere. Selvfølgelig så er det jo ingenting som sier at vi ikke kommer til å bli gravide igjen, men det er noe med det å liksom skulle "forvente" å være så heldig en gang til. Det greier jeg bare ikke.

Ellers er jeg i Trondheim for tia, koser meg hos Mamma og Pappa.
På fredag var jeg og besøkte en studievenninne i Kristiansund, og det var også veldig koselig. I går feiret vi 2-årsdag til den eldste nevøen min, så da falt jeg ut av lavkarbo-opplegget mitt også. Men i dag er det tilbake på samme kjøret. Har gått ned 3,5 kg siden 18. mai, men det er da jeg veide meg i dag morges. Så håper at noe vann kommer av igjen nå som jeg er i gang igjen ;D
I dag har jeg vært i byen, truffet en venninne til lunsj. Veldig koselig. Det er godt å komme litt bort, altså.

Her er altså den siste e-posten, min var som til de andre.

Dear esmeralda,

My apologies for answering your mail a little late, I was on vacation.

In answer to your questions:

Your history seems compatible with classical cervical insufficiency, which means that prophylactic cerclage is indicated. Given the findings at cerclage in your third pregnancy TAC may be the best solution.

Bicornuate uterus is associated with an increased risk of preterm birth, this may be related to a short cervix (as in DES daughters and/ or a "capacity"problem. In your case the deliveries were very early indeed, which suggests that a short or weak cervix may not be the only problem. Ideally, a cerclage should be > 25 mm from the external ostium in order to be optimally effective both mechanically and as barrier against ascending infections (the cervical canal being lined with white blood cells). However, even with a very short cervix TAC is usually succesful. Our reported overall success rate is 93%.

Gravity is not likely to play a major role and the effectiveness of bedrest has not been proven. I generally do not recommend bedrest if the cerclage is well in place and complaints are absent. A cerclage acts as an early warning system. The cervix without cerclage may open at the internal ostium (funneling) without being noticed, with a well positioned cerclage the internal ostium may not dilate much before being noticed as discomfort. In case uterine contractions are noticed, I recommend a tocolytic (nifedipine OROS) to restore uterine quiescence, independent of gestational age - generally without admission.

As with all surgical procedures, experience with transabdominal cerclage improves both the effectiveness and complication rate. Most gynecologists are not confident in operating close to the major arteries and veins in pregnancy. It is difficult to state a minimal number, as it depends also on general skills and general experience to deal with potential complications.

For several reasons, I prefer to perform TAC in pregnancy. First, in case of infertility after TAC prior to gestation the procedure was unnecessary and the infertility may be blamed on the procedure. Second, the cervix swells in pregnancy and complications of TAC prior to pregnancy may occur because the cerclage is too tight or too loose (migrating through tissue if too tight, ineffective if too loose). When performed in pregnancy through laparotomy, the gynecologist can most accurately determine the right tension on the knot. There are gynecologists, however, who prefer to perform TAC prior to pregnancy by laparoscopy. They have not reported large series, but argue that operative blood loss is less in the nonpregnant state and that minimally invasive surgery improves recovery.

Short inter-pregnancy interval is associated with a slightly increased risk of prematurity. The reasons for it are unknown. I would recommend at least a 3 months interval.

I generally perform TAC at about 14 weeks, but given your very early deliveries I would recommend to perform it in your case soon after 12.0 wk.

Costs, infortunately, are in issue. The system in the Netherlands is rather confusing, the hospital charges an all-in fee. Please contact m.waas-schraven@.......... for further information.

Progesterone is the natural uterine relaxant. There has been one large RCT that suggests a beneficial effect of 17-OH-P in case of a history of unexplained preterm labor. In the USA where the study was performed, the FDA has not approved its use. I do not know of any country where it has been registered for this indication. Further studies are underway. In the meantime I do not object to its use, but seldom prescribe it - only on the explicit request of the patient. I prefer to keep the uterus relaxed, if needed, with the calcium channel blocker nifedipine. That also is off-label use, but our national society nonetheless considers it a first choice tocolytic.

I hope this information is helpful to you. Please find enclosed 2 articles on cerclage that may also be of interest.

Sincerely yours,

Fred K. Lotgering