Cerclage this time after incompetent cervix/30 weeker last time?

takmjs · April 2014

Hi everyone! I'm sorry, but I can already tell you this is going to be long.

I am currently 9 weeks pregnant and was just told by my new MFM that doing a cerclage is not the protocol with previous preterm birth moms. I had a pre-pregnancy consultation with a different MFM in the same office (who, of course, became a stay-at-home mom 3 weeks ago), and she understood and respected my wishes to get a cerclage this pregnancy--even after explaining the normal protocol and the risks of a cerclage to me. I have to go to a different hospital and see different doctors this pregnancy, because my employer switched insurance and no longer covers the last MFM I had (who I completely loved and trusted 100%).

I also did a pre-pregnancy consult with my MFM from my last pregnancy, before I knew how much I'd have to pay out-of-pocket to go to him with our new insurance. He told me that he normally doesn't think about doing a cerclage until there are 3 preterm losses, or 2 preterm losses and another risk factor. He said, though, that I had every risk factor (5 different ones) in the book happen to me in my first pregnancy, so that's why he would recommend a cerclage.

Here's my history of my last pregnancy (2+ years ago).

1. Spotting at 5 weeks, ultrasound at 5w5d, discovered I have a bicornuate uterus (heart-shaped) with a complete split down the middle--basically, I have 2 half-uteruses. Was told I would probably have a breech baby, and there's a slightly higher risk for incompetent cervix, preterm labor, etc.

2. Referred to a MFM at 16 weeks for a consult. He was extremely informative and positive about BU's and said they'd start doing biweekly cervical length checks.

3. Started a cycle of cervix shortening, then the same measurement, then shortened a little more, then the same....very stressful.

4. At 24w2d, I was around 1.5cm and put on modified, home bed rest (too late for a cerclage). Started progesterone suppositories, I think--I may have started them sooner? Also got a round of steroid shots for baby's lungs.

5. At 24w6d, woke up soaked in blood, so went to the hospital (90 min away). Baby was fine, and I was dilated 1 cm. Was put on hospital bed rest for the remainder of the pregnancy.

6. At 29w6d, starting having contractions and my water broke. Had me on magnesium for 42 hours before they decided baby's heart rate wasn't variable enough and did an emergency C-section at 30w.

7. My daughter was in the NICU 7 weeks exactly and is a tiny little peanut still, but growing appropriately at 2 years, 3 months old.

What I'd like to know is:

1. Should I trust the new MFM's opinion, since he's the expert on high-risk pregnancies, even though the other MFM in his own office would have done a cerclage on me?

2. Is it possible to ask for a doctor who's more willing to do cerclages, and see him/her the rest of the pregnancy? I didn't really like this doctor's demeanor or explanations in general, so I think either way, I'd like a different MFM, but I don't know if doctor's offices will let you pick a doctor based on whether they believe in certain procedures more than others. Anyone with experience in that?

3. If there's anyone who has anything remotely similar to my history, I would love to hear if you got (or didn't get) a preventive cerclage for baby 2 (or 3), did you need an emergency cerclage, how things worked out, what your doctors said was the protocol, etc.?

I hate to question doctors, but I don't want it to be too late for a cerclage again this time and think "what if I had a cerclage?" I'm mostly mad that someone in the same office said she was willing to do a cerclage (which completely eased my mind), and now--3 weeks before I thought I was going to get the cerclage--I'm told "that's not the protocol--not just at this hospital, but nationally." I'm so not confrontational, so I didn't say a lot, but I told him I would feel more comfortable with a cerclage. He told me the same info over again about why it's the protocol. Ugh!

Thanks so much, and I'm really sorry it's so long!

Whales124 · April 2014

I have a septate uterus which carries some if the same risks. I had a cerclage placed at 17w when my cervix started shortening. My MFM is amazing and has this sixth sense I can't explain, he was expecting shortening, therefore was more than willing to place the cerclage. I carried to term.
I was told by his office that when/if we decide to have another I will have the cerclage placed in the first trimester. If I were you I would find someone you are comfortable with. You have been through a lot and the few people I know that have had preterm once have had it again. I would also ask about p17 shots too.
Good luck! I hope you can find a doctor that will understand your concerns!

bluebird0521 · April 2014

I would get a doctor that you are comfortable with.

With that said, I had a pre-term loss at 22 weeks and I did not get a cerclage this time around because there was not enough evidence to support it. They did place me on weekly 17P injections though starting at 16 weeks with bi-weekly ultrasounds to measure my cervical length. I actually preferred to not get the cerclage, but I was a little worried I would shorten when it was too late. Well at 24 weeks I started having shortening but it was too late for a cerclage, which was exactly what I was worried about. I am now on bed rest and I maintain my 17P injections, but they also added progesterone vaginally each night as well. Now the next pregnancy I will have a preventative cerclage placed because there is more evidence to support that course of action.

takmjs · April 2014

Thank you so much for your responses! It reassures me that I'm not just being paranoid and overly cautious and naggy. I called the MFM's office today, and talked to a nurse about how I'd like a different doctor, but she wouldn't tell me if one was more willing to do cerclages than others. Since the hospital I have to go to is a teaching hospital, we are assigned a fellow (has completed residency, but is working on the extra 2-3 years of MFM fellowship before they become a full MFM). I really wish I could go to someone with more experience, so they could not only give me research backing but also their own experiences with bicornuate uteruses and incompetent cervixes.

Anyway, I told her I want a cerclage and that that was part of my plan with the original MFM I saw at their practice. She said ok, and she would talk to the head MFM about it, and then he and the other MFM's (not the fellows) would discuss it at their Thursday meeting, and she'd get back to me Thursday afternoon. I guess I just pray now that they'll agree with me and let me have the cerclage. If they don't, I honestly don't know what I'll do. I'd have to pay out of pocket to go to my old MFM, and the next closest hospital with a high-level NICU is 2.5 hours away.

takmjs · April 2014

A follow-up:

My actual doctor from Monday called and left a message for me to call him back. Luckily when I called back, he wasn't available and I got to talk to the wonderful nurse to I talked to the other day. She told me that all the higher-level doctors agreed that they don't think I need a cerclage for this pregnancy and none of them would have advised me to get one this time. However, since the pre-pregnancy consultation doctor had it in my plan and I still want it, they will do it for me. Hallelujah! The nurse did repeat to me that she wants me to know that none of the doctors agree with it, so I should be aware of that.

I don't like that I'm going to have to go to a clinic where none of the doctors believe in my decision--that my previous MFM and this hospital's previous doctor (the MFM that is now a stay-at-home mom) agreed on. It's so frustrating to deal with that, and that I have no other option with my insurance. I know they're the experts, and they probably don't like to be questioned, but I didn't just guess at it and say I want a cerclage on a whim. It's from the advice of my previous MFM--who is the only doctor who knows my pregnancy history b/c he was the one there--and checked on me every other day of my 5+ week hospital bed rest stay, plus all the appts before that. He knows my body during pregnancy better than these doctors.

Part of me wants to say fine, let's not do it, and let's just do the cervical length checks and I'll prove to you that my cervix is incompetent--which would require a cerclage anyway. But then, it would be an emergency cerclage and have higher risks and doesn't seem to have the same outcomes as a preventive. Also, I don't want to look back after having a preterm baby earlier than last time, and think "I should've fought harder to get a cerclage." I feel like I did my part, and I'm doing the best I can for this baby now.

What I'm wondering now is: since it's kind of against doctor's advice, will insurance cover it? Or will that be an issue? I know on my pre-preg consult notes, it said "an elective cerclage." It didn't say "preventive," it said elective. I did ask at the time if that meant insurance would cover it, and she said they would, but again--that was apparently a doctor that none of these agree with. Has anyone with an "elective" cerclage ever had an issue with insurance?

takmjs · April 2014

nola78 said: Do you have to go through MFM?
@nola78, I would love to go to my local OB, because it's 25 minutes from my house (and 10 minutes from my work). I have to go to an MFM dr, and I want to. I went to an OB and MFM for my first pregnancy, and I completely transferred my care to an MFM once I was put on bed rest at 24 weeks. I want to be seen by an MFM dr solely this time, because our local OB clinic is not equipped to deal with high-risk pregnancies. The main OB there is a hot-head and told me last pregnancy (I only saw him once when my dr wasn't in the office) that I don't need to go to the high-risk clinic, because they're just trying to get my money. Yeah, and if I would've stuck with them, I never would've been checked for cervical length, and I worry what would've happened with a dr like him caring for me and baby. I'm pretty sure they wouldn't know how to do cerclages, if they even do them. I think they'd just send a person up to one of the hospitals I've gone to if they actually noticed someone needed a cerclage before it was too late.

Good question, though. Thanks for looking out for me!

TabithaRyan26 · April 2014

This is my story. .. I went into preterm labor at 24 weeks with my last child. This was also my first... with him beingso premature he had a massive hemmorage in his brain and SO and I decided that he would be taken off of the ventilator. This being said I am currently pregnant with #2... went to the mfm Tuesday and they found that my cervix was already opening... at only 12 weeks 5 days. I was scheduled for a cerclage Thursday and I am currently on bed rest. I wasn't even a candidate for the procedure. .. I guess it just depends on the mfm.

angelsnight · April 2014

I lost my daughter due to an IC so with this last pregnancy (my rainbow) I had a preventative cerclage placed. Two of the four doctors in my practice are pro-cerclage, the other two are not. Had I gone to the other two they would have told me "it probably won't happen again".

My doctor that suggested I get the cerclage said many doctors won't do one until you've experienced multiple losses/preterm births but she thinks (and I completely agree) that it's inhumane. That's like saying you need to survive three serious car crashes without a belt before you decide a belt is a good idea.

It's still not concrete that I had IC (it could have also been due to an infection) as my cervix never shortened with this pregnancy. So it's hard to say if it is because I do not have IC, or if it is because the cerclage just did its job. In fact she was so snug in there I had to have a C section because she wouldn't come out. But my doctor said she wouldn't let me go through any future pregnancies without a cerclage, there is just too much at stake to risk it. If I were you I would shop around to find a doctor who will do one. The risks are very minimal for a preventative one, and not all doctors are right. I truly believe if I had been under the care of one of the other doctors in my practice, there is a good chance my daughter wouldn't be here right now.

takmjs · May 2014

@angelsnight, thank you for your response. I love that your doctor is/was such an advocate for you to get a cerclage, and her explanation of the car accident thing makes perfect sense. I don't understand why some doctors think it's ok for you to have 2-3 losses before they'll give you a cerclage, when you clearly had issues in your last pregnancy. I just want to shake them and ask them if they've ever dealt with any women who've just had a preterm loss. I honestly don't understand it, and I'm glad my consult doctor agreed to it, and that I pushed for it this time.

Thanks again! I just feel more and more happy with my decision, even though I don't have a choice in being at this hospital. The next closest is 2.5 hours away.

JackieP1023 · May 2014

I know I am late to the game, but I wanted to share my story.

Our first pregnancy was a complete surprise (I have PCOS and just getting pregnant on our own was highly unlikely). My mom has IC-she was (luckily) diagnosed with her first loss, my older brother-who was born alive at 21 weeks, and lived only about an hour. (In 1982). She went on to have 5 successful pregnancies, all with cerclage. All 5 were c-sections.

I asked if this could be genetic, I was told there is no evidence that it is. At 19 weeks, I went to the ER for spotting, and I was 2-3cm dilated. I was admitted, and an emergency cerclage was attempted the next day. It was not successful, as during the procedure my water broke. Our daughter was born still 1 week later.

We decided to try again, and ended up seeing a RE, and finally conceiving after about a year of treatment. I had a preventative cerclage placed at 13 weeks, started procardia (preventative measure) at 15 weeks, modified rest at 15 weeks, weekly p17 shots weeks 20-35. Cerclage was taken out at 36 weeks, and I ended up being induced due to GD at 39+2. Our healthy daughter was born 7lb 13oz on Feb 3.

Without the cerclage and other measures that were taken, we wouldnt have made it. Definitely push for whatever care you are comfortable with!

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Cerclage this time after incompetent cervix/30 weeker last time?

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