From the Research
Management for a pregnant patient at 22 weeks gestation with a history of D&C for retained placenta, current cerclage, and evidence of posterior uterine wall dehiscence with amniotic sac outpouching requires immediate hospitalization for close monitoring and specialized care. The patient should be transferred to a tertiary care center with maternal-fetal medicine specialists and a NICU. Bed rest with minimal activity is essential to reduce pressure on the weakened uterine wall. Corticosteroids (betamethasone 12 mg IM, two doses 24 hours apart) should be administered to accelerate fetal lung maturity in case of preterm delivery, as seen in similar cases 1. Magnesium sulfate for neuroprotection may be considered if delivery appears imminent. Serial ultrasounds should be performed to monitor the dehiscence, amniotic fluid volume, and fetal growth. Continuous fetal heart rate monitoring is necessary to detect signs of distress. The cerclage should not be removed unless there are signs of infection or labor. A multidisciplinary team including maternal-fetal medicine, neonatology, and obstetric surgery should develop a delivery plan, likely via classical cesarean section at 34-36 weeks if the pregnancy can be maintained safely until then, based on the most recent study 1. The patient should be counseled about the high risk of uterine rupture, preterm delivery, and potential fetal and maternal morbidity. This management approach aims to prolong the pregnancy while closely monitoring for complications that would necessitate immediate delivery, balancing the risks of prematurity against those of uterine rupture. Some key points to consider in the management of this patient include:
- The importance of close monitoring and specialized care in a tertiary care center 2, 1
- The need for bed rest and minimal activity to reduce pressure on the weakened uterine wall
- The administration of corticosteroids to accelerate fetal lung maturity in case of preterm delivery
- The consideration of magnesium sulfate for neuroprotection if delivery appears imminent
- The development of a delivery plan by a multidisciplinary team, including maternal-fetal medicine, neonatology, and obstetric surgery. It is also worth noting that, according to the most recent study 1, a delivery plan should include assessment of cesarean history and fetal macrosomia, judicious use of oxytocin, and intrapartum monitoring for nonreassuring fetal status. Additionally, the patient's history of D&C for retained placenta and current cerclage should be taken into account when developing the management plan, as seen in similar cases 3, 4.