Robert Atlas, MD, Chairman of OB/GYN at Mercy Medical Center, Maternal-Fetal Medicine Specialist, talks about cervical insufficiency and a minimally invasive procedure option for hopeful mothers-to-be.
Interview conducted by Ivanhoe Broadcast News in August 2017.
We are talking about cervical incompetence today; would you just give me an overview of what that is we’re talking about?
Dr. Atlas: Cervical incompetence is the old name; we are now using the term, insufficiency. Incompetence would suggest that it’s something that is always inadequate, despite the circumstance. Cervical insufficiency, suggests that depending on the situation, you could have a cervix that is sufficient one time, and then insufficient another time. It’s changed a little bit. Essentially it is a history of pregnancy loss. In a sense, a woman who is classically pregnant delivers a baby early, then the patients get pregnant again, and then it happens sooner. It’s a painless delivery, meaning all of a sudden you feel pressure, your water breaks, you deliver a baby. Now with the extent of what we’re using with ultrasound, we are able to identify women who have cervical insufficiency. In the past, we could only base it on the patient’s history with this condition. However, now we’re identifying this condition as early as the first pregnancy. We are able to find evidence of cervical shortening, effacement, and dilation that leads to preterm birth. There are also things that we can potentially do to prevent that from happening even in their first pregnancy.
How long has it been that you have been able to identify this in ultrasound so there was not that multiple loss?
Dr. Atlas: In actuality, researchers have been studying this condition for a long time. If you go back to the late 80’s, radiologists were doing most of the obstetrical ultrasound; they always did it transabdominally or through the mother’s belly and they were identifying something called a keyhole sign. It wasn’t until the early 90’s in which some researchers started to evaluate the cervix. However, the real studies came out in 2000-2001, but one of the primary studies announced in 2005 suggested that cerclage in the face of cervical shortening can be very useful. Especially in women who have had prior preterm births.
What are the treatments when radiologists identify this keyhole or identify this insufficiency?
Dr. Atlas: In the past, there wasn’t any treatment. It was an observation; someone looked retrospectively at what happened to those pregnancies. The therapy started to come back in the late 90’s, and the 2000’s when people began to do intervention studies assessing an intervention such as cerclage, versus no cerclage, and what were the outcomes.
Let’s talk about cerclage, what does it mean?
Dr. Atlas: Since this is a woman’s field, I will use the analogy of purses to demonstrate my point. Most women will remember there’s a type of bag that has a purse string. When the strings are pulled together, the bag closes, but you can also separate it as well. Well, that’s what we’re doing with our treatment. We’re going in and out of the cervix and then we tie it down tight, just like that purse string. We’re putting a suture in the cervix as high as we can to close the cervix off to give it some extra strength.
Can you describe for me how the surgery is performed, is it keyhole, is it minimally invasive?
Dr. Atlas: It is quite complex. There are different aspects to consider, the types of cerclages could determine the operations performed. There are vaginal approaches to cerclage, and then there are abdominal procedures. Classically, most people do vaginal cerclages in women who have just one history with this condition. The abdominal cerclages are used in cases where women had a type of surgery where there’s no cervix remaining, at least in the vagina. Typically, in women who have had a prior failed vaginal cerclage. However, it is a more intensive type of surgery. In a non-pregnant state, when you do an abdominal cerclage, it is minimally invasive. We do it here at Mercy, robotically, with the placement. But if it’s during a patient’s pregnancy, then it’s a more extensive abdominal surgery.
You said in non-pregnancy, is that in women and couples who are hoping to conceive? This is almost like a preventative measure?
Dr. Atlas: In women who have had losses, we like to do the abdominal procedure before a pregnancy because it’s easier to do in the non-pregnant state. One of the biggest concerns that have occurred in the past is that it can lead to some infertility. I think that many of the women who have done this surgery with us are currently undergoing infertility treatments. But going back to vaginal cerclages, those are used in the majority of patients who either have a short cervix by ultrasound or you’re doing a history indicated approach.
With the robotic cerclage, I know your colleague is the one who does the robotics?
Dr. Atlas: My colleague is an expert at robotic surgery. I could learn how to do it, sure, but I would still never be able to get to the talent level that he has and the expertise.
Is it a team approach then or are you monitoring and then your colleague takes over?
Dr. Atlas: When he is doing the surgery, I’m in the operating room with him. We discuss where he is going to place the suture and whether I feel comfortable with the location he is placing the suture. But he does the surgery because he is the expert at it.
How new is the robotic approach for this procedure and what is is the benefit of being able to do it this way?
Dr. Atlas: Well the benefit is it’s just a few small holes in the belly that multiplies. One, it’s minimally invasive; patients get to go home the same day. The recovery is much quicker; it’s about two weeks at most for recovery. I also think that patients tolerate it so much better than the old traditional approaches to abdominal cerclage. So we try and do them in the non-pregnant state if possible.
Can you talk to me a little bit about Jamie’s situation?
Dr. Atlas: Jamie has it, and it is very unfortunate. She had a couple of children, but then in the most recent couple of pregnancies, she had mid-trimester losses. She was devastated by those losses and was looking for an approach that would, in many respects, guarantee her ability to carry this pregnancy. I think that some women probably could have a vaginal cerclage, but because the outcomes and success rates are better with abdominal approaches, I think some women choose the abdominal approach because of that increased success rate in that approach. Jamie had many challenges in getting pregnant, and I think from her standpoint, she would tell you that this was worth the effort to get her beautiful daughter.
So she did indeed have the robotic?
Dr. Atlas: She did, she had the robotic before her pregnancy and before her infertility workup, or I should say evaluation.
How gratifying is it when the family comes back to see you?
Dr. Atlas: I mean for me, it’s why we do what we do. I mean to take a woman who is saddened by losses, but wants a child; to be able to give them that, it’s incredibly rewarding.
How long has the robotic approach been used, this is pretty cutting edge?
Dr. Atlas: Well, we’ve been doing it here for probably three years now. I think people were doing it a little bit before us around the country. However, there are not a lot of places in the country doing this. I know there’s an individual in Chicago. There used to be someone, whether it was New Jersey or in Tennessee, but he’s retired now. So there are not a lot of people who are known for doing this type of procedure.
You had mentioned that the success rate for the abdominal cerclage is much higher. Can you speak to that a little bit?
Dr. Atlas: Some reports suggest eighty, ninety percent success rates, but it is probably closer to ninety or ninety-five percent. I know Dr. Davis probably has one of the highest numbers of abdominal cerclages; he touts a ninety-five percent success rate. So it is incredibly successful. The issue that I think people need to understand is that it needs to be in patients who have cervical insufficiency. When someone has early deliveries because of preterm labor, this is not an approach that will make that successful.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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