Friday, August 3, 2012

Is it time to take the Cervical Pessary seriously?

So in the world of cervical insufficiency, there's a number of interventions that doctors use to try and stop the cervix from changing. We've witnessed cerclages and medicinal interventions first-hand (as Laurie had Progesterone injections and some tocolytic drugs like Indocin). One thing I came across in my research and actually mentioned to our Perinatologist as a possible option while we were in the hospital trying to save the twins that he more or less laughed off was the idea of using a cervical pessary either instead of or in addition to a cerclage as a way to help provide stability to the cervix.

What is a pessary? This picture more or less shows what it is:

It's basically a plastic donut-looking thing that is placed around the part of the cervix that protrudes into the vaginal canal. It seems that it mostly is used to help with cases of uterine or cervical prolapse to hold the cervix in place and prevent it from dropping into the vagina (I guess it's used more with bladder/incontinence issues resulting from prolapse), but some retrospective studies had mentioned about occasions of using a pessary to help stabilize the cervix in lieu of or in addition to a cerclage. In general, I don't think most doctors really considered them a normal intervention and didn't put much credence in the idea of a pessary to really make a difference in trying to help someone with CI. Our doctors certainly didn't think much of them.

Well, just in the last few months, a study was published out of Spain where the doctors actually did a randomized multi-center trial and demonstrated significantly reduced rates of delivery prior to 34 weeks with a pessary. The women in the trial were all diagnosed with possible cervical insufficiency based on ultrasound, with less than 2.5 centimeters of cervix between 20-23 weeks. In the women who did not have a pessary, 27% had delivery prior to 34 weeks. In the pessary group, only 6% delivered prior to 34 weeks. And there were no serious adverse effects reported. Certainly, more research needs to be done, but this study is the first really ringing endorsement of the pessary as a very low-impact, low-risk, inexpensive way to stabilize a weak cervix.

It just makes me wonder--if the doctors at our hospital had put a pessary in place to help stabilize Laurie's cervix until the cerclage could be placed, would that have made a difference for us? Would it have kept her stable for even an extra few days? Who else could benefit from this? What about a pessary for someone who has had PPROM and thus isn't a cerclage candidate due to infection risk? Certainly hoping that other doctors will take a cue from this Spanish study and give the pessary a closer look.