Novel use of cervical sleeve in obstetrical trauma to preserve cervical function: A case of near complete cervical avulsion and multifactorial postpartum hemorrhage

Background: Clinically significant cervical lacerations are rare obstetric complications and repairs can be extensive. Cervical stenosis and sequelae such as hematometra, cyclic pelvic pain, arrest of dilation in subsequent pregnancies, and even infertility, are feared outcomes of severe cervical trauma. Currently there are no published surgical techniques beyond the use of cervical foley catheter to prevent stenosis in this setting. Here we describe the use of a smit sleeve to preserve cervical patency following a multifactorial postpartum hemorrhage with severe cervical trauma.

Case: A 19 year old gravida 1, para 1 female presented to our regional tertiary referral center by EMS for refractory postpartum hemorrhage from a rural hospital following an elective induction of labor and spontaneous vaginal delivery. Her postpartum course was immediately complicated by uterine atony which initially responded to uterotonics and an intrauterine balloon. Within 3 hours of delivery, she hemorrhaged an estimated 2 liters of blood with ongoing blood loss around the intrauterine balloon. She was resuscitated with fluids and blood products and taken to the operating room for examination under anesthesia. She continued bleeding heavily and the intrauterine balloon was exchanged for a Jada balloon. Labs returned consistent with severe coagulopathy. She was then transferred to our tertiary care center. She arrived at the trauma bay pale and difficult to arouse. Uterine tone was adequate. Bedside US showed well placed Jada and no obvious retained products of conception. She was taken to the operating room for examination under anesthesia that showed near complete cervical avulsion from the uterus. It was unclear whether normal anatomy could be restored or if peripartum hysterectomy was indicated. With intraoperative consultation to gynecologic oncology, a decision was made to attempt repair. The cervix was repaired with several figure-of-eight sutures and a cervical sleeve, traditionally used for pelvic radiation, was sutured into the cervical canal to promote

drainage and patency during recovery to prevent cervical stenosis and sequelae. She recovered in the surgical ICU and was discharged on POD#4. The sleeve remained in situ for approximately 8 weeks, after which her cervix appeared grossly normal.

Conclusion/Discussion: This case highlights the complexities of managing multifactorial postpartum hemorrhage, the importance of thorough obstetrical trauma assessment, and the value of a multispecialist team. A smit sleeve may offer benefits over conventional cervical foley as it can be sutured into the cervix, does not hang outside of the vagina, and can stay in situ for

prolonged periods of time, and may be generalized to any cervical trauma requiring extensive repair to preserve cervical funct