Transabdominal cervicoisthmic cerclage: a review

Preconception laparoscopic cervical cerclage for prevention of mid-trimester pregnancy loss and preterm birth: A 6-year study

Objective

To evaluate surgical results and pregnancy outcomes of preconception laparoscopic cervical cerclage (LCC) in women with cervical insufficiency.

Study design

We conducted an observational study in consecutive women who had preconception LCC. Data was prospectively collected from 55 women at high risk of second trimester miscarriage and extreme preterm delivery due to cervical insufficiency who underwent pre-conception LCC between January 2017 - December 2021. This included patient demographics and relevant obstetric & gynaecological history, previous cervical cerclage, operative complications and subsequent pregnancy outcomes. All women included in study had at least one previous unsuccessful transvaginal cervical cerclage. The surgeries were conducted in private tertiary hospital in Hyderabad, India. The follow-up was until December 2022. The primary outcome was neonatal survival. Surgical morbidity and complications were also recorded.

Results

There were 49 pregnancies of which 46 progressed beyond first trimester. 4.34 % (2/46) were delivered between 28 and 33 weeks due to preterm premature rupture of membranes (PPROM). 13.04 % (6/46) including 5 women with pregnancy complications and one with unicornuate uterus needed delivery between 34 and 36 weeks. 82.60 % (38/46) women were delivered at or beyond 37 weeks of pregnancy. In those who carried pregnancy beyond first trimester, live-birth rate and neonatal survival rate were 100 %. All neonates had favourable outcome with no long-term morbidity. There were no intraoperative or immediate postoperative complications. Two women had long-term complication in the form of tape erosion needing further surgery.

Conclusions

This study provides evidence that LCC improves pregnancy outcomes significantly in those with cervical weakness, without increasing the safety risk.

Translocation of a cerclage band into the endocervical canal after preconception transabdominal cervico-isthmic cerclage

A 34-year-old woman, who had a history of five spontaneous losses and failures of two McDonald purse-string cerclages, underwent a transabdominal cervico-isthmic cerclage (TCC). She became pregnant 17 months after TCC. At 35 weeks of gestation, she was admitted to our hospital due to preterm labor and delivered a healthy female baby (2270 g) by cesarean section. After delivery of the newborn infant, we found a migration of about one third of the cerclage band into the endocervical canal. Two years later, she had one further pregnancy, reached 33 weeks of gestation, and delivered a 1450 g male baby by cesarean section due to a preterm labor without any signs of infection. Although it could have been a case of pure coincidence, we take a chance to speculate that the migration of the cerclage band into the endocervical canal might have been the reason for the preterm labor, and it must have been removed at her first cesarean section and replaced by a new cerclage band for her next pregnancy.

Abdominal versus vaginal cerclage after a failed transvaginal cerclage: a systematic review

OBJECTIVE

The purpose of this study was to compare the outcomes of pregnancy after transabdominal cerclage versus after transvaginal cerclage in patients with a failed transvaginal cerclage during a previous pregnancy.

STUDY DESIGN

MEDLINE and EMBASE were searched in English. We included studies that reported perinatal and/or maternal outcomes in women who had a transabdominal cerclage or a transvaginal cerclage placed at or before 20 weeks of gestation, after having had a failed nonemergent transvaginal cerclage in a previous pregnancy. Data were included for individual patients if they met the inclusion criteria, and their outcomes were reported separately. We excluded patients with cervical amputation because transvaginal cerclage is not an option for these women because of technical difficulty.

RESULTS

Fourteen studies met the inclusion criteria. Thirteen of the studies were case series (12 retrospective and 1 prospective), and one study was a retrospective cohort study. In total, 157 women in the studies had a failed vaginal cerclage in a previous pregnancy; 117 women had a subsequent transabdominal cerclage; 40 women had a subsequent transvaginal cerclage. The likelihood of perinatal death or delivery at <24 weeks was 6.0% (95% CI, 3.8%-8.2%) after transabdominal cerclage and 12.5% (95% CI, 2.7%-22.7%) after transvaginal cerclage. The likelihood of serious operative complications after transabdominal cerclage was 3.4% (95% CI, 0.01%, 6.8%). There were no serious operative complications after transvaginal cerclage.

CONCLUSION

Transabdominal cerclage may be associated with a lower risk of perinatal death or delivery at <24 weeks of gestation, but it may be associated with a higher risk of serious operative complications. A multicenter randomized controlled trial should be conducted to address this question.

Transvaginal cervicoisthmic cerclage as an alternative to the transabdominal technique

OBJECTIVES

To analyse the foetal outcome after transvaginal cervicoisthmic cerclage, to determine whether it is a valid alternative to the reference transabdominal technique.

STUDY DESIGN

Description of the vaginal operative technique, retrospective review of 20 cervicoisthmic cerclage patients from 1990 to 2000.

RESULTS

In the curative group of women with a history of late pregnancy losses or premature deliveries and usually previous failed classical cervical cerclage, the foetal survival rate improved from 18% before cerclage to 79% after cerclage. No operative complications were reported. In the prophylactic group, typically characterised by the absence of the cervix as a consequence of surgery for invasive cervical cancers, the foetal survival rate was 83% after cerclage.

CONCLUSIONS

The transvaginal cervicoisthmic cerclage allows a high foetal survival rate without complications in highly selected patients with poor obstetrical history. Because of its simplicity, this technique should replace the transabdominal route for surgeons experienced in vaginal surgery.

Transabdominal cervicoisthmic cerclage: the Riyadh Armed Forces Hospital experience

Between 1985 and 1996, 17 transabdominal cervicoisthmic cerclage procedures were performed and followed up through 28 pregnancies at Riyadh Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia. Fourteen procedures were carried out during pregnancy and three preconceptionally. Twenty-four pregnancies continued beyond 36 weeks of gestation and three were premature deliveries. The material used was an infant feeding tube size 6 and the knot was tied posteriorly. The sole miscarriage was at 6 weeks' gestation. All deliveries were by caesarean section. Fetal survival was 92%. In conclusion, abdominal cerclage is an effective and safe operation which helped the pattern of pregnancy wastage to be restored to normal in selected patients.

Transabdominal cerclage

The procedure of the transabdominal cerclage (TAC) is outlined. Sixteen cases of TAC are described in detail. The fetal salvage rate increased from 36% before to 96% after the operation. Caesarean section has to be performed at term after TAC has been applied. The transabdominal method of cerclage seems to be very promising, especially for women with severely damaged or practically absent cervices.

Transabdominal cervicoisthmic cerclage: a reappraisal 25 years after its introduction

Most cerclage operations for cervical insufficiency are performed transvaginally. The transabdominal route is beneficial in treating patients with cervices that are either extremely short, congenitally deformed, deeply lacerated, or markedly scarred because of previously failed transvaginal cerclage procedures. The average gestational age at surgery was 11.5 weeks and the operation was performed after early ultrasonographic verification of fetal viability. Patients with advanced cervical effacement or dilatation in the second trimester were excluded. A 5 mm wide Mersilene band was applied in an avascular space above the junction of the cervix and the uterine isthmus without dissection or tunneling among broad ligament vessels. This simplified surgical approach resulted in little operative blood loss (mean, 75 ml; range, 50 to 200 ml). After transabdominal cervicoisthmic cerclage, 21 pregnancies in 20 patients resulted in 18 term births, one premature birth with favorable outcome, and two early fetal deaths (90% salvage rate). A review of the world literature indicated 130 pregnancies with transabdominal cervicoisthmic cerclage during pregnancy and a cumulative success rate of 89%. Preconceptional transabdominal cervicoisthmic cerclage was reported in 30 pregnancies with an overall fetal survival rate of 81%. A survey of specialists in maternal-fetal medicine indicated an increasing interest and familiarity with transabdominal cervicoisthmic cerclage since its introduction more than two decades ago although this procedure is still not widely applied in obstetric practice.