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Abdallah W. Updates on laparoscopic cervical cerclage: obstetric outcomes and surgical techniques. Future Sci OA 2023; 9:FSO885. [PMID: 37621845 PMCID: PMC10445554 DOI: 10.2144/fsoa-2023-0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 07/03/2023] [Indexed: 08/26/2023] Open
Abstract
Aim Preterm birth is a worldwide health problem. After unsuccessful transvaginal cerclage, the transabdominal isthmo-cervical cerclage can be indicated. A laparoscopic approach has been described. Methods A search was performed including the combination of: "((cerclage) AND (laparoscopy)) AND (pregnancy)". A systematic review was performed to compare indications, outcomes, techniques, and safety. Results & discussion 42 articles were found through database search. 30 articles were included for review. By reviewing the literature, the transabdominal cervico-isthmic laparoscopic cerclage is highly effective in selected patients with a history of refractory cervical insufficiency. This technique has a high neonatal survival rate when placed in preconceptional or post conceptional patients. Moreover, laparoscopic cervical cerclage is a safe procedure when laparoscopic expertise is present.
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Affiliation(s)
- Wael Abdallah
- Department of Gynecology & Obstetrics, Hôtel-Dieu de France University Hospital, Saint Joseph University, Beirut, Lebanon
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Hirsch M, Reisel D, Saridogan E, David AL. Endoscopic transabdominal cervical cerclage replacement after recurrent late miscarriage. BMJ Case Rep 2022; 15:e247757. [PMID: 35228241 PMCID: PMC8886391 DOI: 10.1136/bcr-2021-247757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2022] [Indexed: 11/03/2022] Open
Abstract
Transabdominal cerclage (TAC) is a recognised treatment for recurrent spontaneous late miscarriage or preterm birth due to cervical weakness. This can be performed via an open procedure before and during pregnancy, or a laparoscopic technique preconception. Complications include cerclage failure and suture migration. We present a case highlighting these complications where laparoscopic removal of an open TAC and replacement led to two successful term deliveries. A woman in her thirties with a fibroid uterus, adenomyosis and a history of three spontaneous mid-trimester losses, had an open TAC at 13 weeks of gestation. Preterm premature rupture of the membranes occurred shortly after and at 18 weeks of gestation she underwent surgical evacuation of the uterus. Subsequent hysteroscopy confirmed migration of the cerclage through the cervical canal. We demonstrate the application of endoscopic gynaecological surgery to remove and replace the TAC with two successful term births by Caesarean section in the ensuing pregnancies.
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Affiliation(s)
- Martin Hirsch
- Oxford Endometriosis CaRe Centre, Oxford University, Oxford, UK
| | - Dan Reisel
- Reproductive Medicine Unit, University College London Hospitals NHS Foundation Trust, London, UK
- EGA Institute for Women's Health, University College London, London, UK
| | - Ertan Saridogan
- Reproductive Medicine Unit, University College London Hospitals NHS Foundation Trust, London, UK
- EGA Institute for Women's Health, University College London, London, UK
| | - Anna L David
- EGA Institute for Women's Health, University College London, London, UK
- NIHR University College London Hospitals Biomedical Research Centre, London, UK
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Tong S, Kaitu’u-Lino TJ, Hastie R, Brownfoot F, Cluver C, Hannan N. Pravastatin, proton-pump inhibitors, metformin, micronutrients, and biologics: new horizons for the prevention or treatment of preeclampsia. Am J Obstet Gynecol 2022; 226:S1157-S1170. [PMID: 32946849 DOI: 10.1016/j.ajog.2020.09.014] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/25/2020] [Accepted: 09/10/2020] [Indexed: 12/14/2022]
Abstract
There has been increasing research momentum to identify new therapeutic agents for the prevention or treatment of preeclampsia, drugs that can affect the underlying disease pathophysiology. Molecular targets of candidate treatments include oxidative stress, antiangiogenic factors, and the angiotensin, nitric oxide, and proinflammatory pathways. The proposed treatments undergoing preclinical and clinical trial evaluation are thought to act on placental or endothelial disease or both. Most have adopted the pragmatic strategy of repurposing drugs. Of all the therapeutic agents proposed, pravastatin has received the most interest. There are preclinical studies showing that it has pleiotropic actions that favorably impact on multiple molecular targets and can resolve a preeclampsia phenotype in many animal models. An early phase clinical trial suggests that it may have therapeutic activity. Several large prevention trials are planned or ongoing and, when completed, could definitively address whether pravastatin can prevent preeclampsia. Proton-pump inhibitors, metformin, and sulfasalazine are other drugs with preclinical evidence of multiple molecular actions that could resolve the pathophysiology of preeclampsia. These agents are also currently being evaluated in clinical trials. There have been many recent preclinical studies identifying the potential of numerous natural compounds to treat preeclampsia, such as plant extracts and micronutrients that have potent anti-inflammatory or antioxidant activity. Recent preclinical studies have also proposed novel molecular-targeted strategies, such as monoclonal antibodies targeting tumor necrosis factor alpha, placental growth factor, and short interfering RNA technology, to silence the gene expression of soluble fms-like tyrosine kinase-1 or angiotensinogen. Other treatment approaches that have transitioned to human trials (ranging from single-arm to phase III trials that have been completed or are ongoing) include folic acid, nitric oxide donors (such as L-arginine), recombinant antithrombin III, digoxin immune antigen-binding fragment, and melatonin. There have been case series showing the removal of circulating soluble fms-like tyrosine kinase-1 may help stabilize the disease and prolong pregnancy. Interestingly, there are case reports suggesting that monoclonal antibody eculizumab (complement inhibitor) may have therapeutic potential. If new agents are discovered that are proven to be effective in preventing or treating preeclampsia, the potential to improve global maternal and perinatal health will be significant.
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Marchand G, Taher Masoud A, Azadi A, Govindan M, Ware K, King A, Ruther S, Brazil G, Ulibarri H, Parise J, Arroyo A, Coriell C, Goetz S, Cook C, Sainz K. Efficacy of laparoscopic and trans-abdominal cerclage (TAC) in patients with cervical insufficiency: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2022; 270:111-125. [PMID: 35042177 DOI: 10.1016/j.ejogrb.2022.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cervical insufficiency (CI) may result in preterm delivery. We sought out to perform this review and analysis to compare the efficacy of laparoscopic and open transabdominal cerclage (TAC) in patients suffering with CI. METHODS Our search included PubMed, Scopus, MEDLINE, ClinicalTrials.Gov, Cochrane and Web of Science. We analyzed the data with Open Meta-Analyst Software as well as Review Manager Software. We included observational and randomized controlled trials that included patients with CI that underwent laparoscopic cerclage or TAC. RESULTS We included a total of 43 studies. Laparoscopic and TAC had a positive effect by increasing gestational age (GA); for the laparoscopic group (mean deviation (MD)) = 14.86 weeks (W), 95% CI [10.67, 19.05], P < 0.001) and TAC (MD = 12.79 W, 95% CI [10.97, 14.61], P < 0.001). Furthermore, improvements in all outcomes assessed (total fetal survival rate, neonatal weight, and prevention of delivery at a gestational age of<24 weeks) were all significant with the exception of the prevention of all preterm deliveries<37 weeks; for both laparoscopic at (RR = 0.116, 95% CI [-0.006, 0.238], P = 0.063) and TAC at (MD = 1, 95% CI [0.45, 2.24], P = 1), and for prevention of deliveries<34 weeks for the laparoscopic group (RR = 0.446, 95% CI [-0.323, 1.215], P = 0.256) only. CONCLUSIONS Although limited data prevented pregnancy and prepregnancy subgroups as well as a head-to-head comparison, we still found that in patients suffering from CI, both TAC and laparoscopic approaches to cerclage revealed a positive effect in preserving the pregnancy.
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Affiliation(s)
- Greg Marchand
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, USA.
| | - Ahmed Taher Masoud
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, USA; Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Ali Azadi
- Star Urogynecology, Department of Urogynecology, Peoria, AZ, USA
| | - Malini Govindan
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, USA
| | - Kelly Ware
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, USA
| | - Alexa King
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, USA
| | - Stacy Ruther
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, USA
| | - Giovanna Brazil
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, USA
| | - Hollie Ulibarri
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, USA
| | - Julia Parise
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, USA
| | - Amanda Arroyo
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, USA
| | | | - Sydnee Goetz
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, USA
| | - Chelsea Cook
- Star Urogynecology, Department of Urogynecology, Peoria, AZ, USA
| | - Katelyn Sainz
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ, USA
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Sunami R, Owada S, Yasuda G, Kasai M, Uchida Y, Takahashi H, Matsubara S. A modified transabdominal cervicoisthmic cerclage with the monofilament thread: Its efficacy and safety for women with extremely short cervix due to cervical conization. J Obstet Gynaecol Res 2021; 48:366-372. [PMID: 34806250 DOI: 10.1111/jog.15102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 10/31/2021] [Accepted: 11/07/2021] [Indexed: 12/01/2022]
Abstract
AIM The study aimed to examine the usefulness of modified transabdominal cervicoisthmic cerclage (TAC) using monofilament thread for the prevention of preterm delivery in women with an extremely short cervix after deep conization. METHODS We devised a monofilament thread for picking up the seromuscular layer of the site that is slightly cephalad to the internal ostium to prevent injury of the vessels around the uterine cervix. From 2017 to 2020, we performed this modified operation in eight women (nine pregnancies) at 12-16 weeks of gestation with a history of deep cervical conization. RESULTS A modified TAC was successfully performed in all patients. There was no measurable bleeding, and all patients were discharged without postoperative complications. Their pregnancy courses after the operation were uneventful. Of nine, one patient had premature uterine contractions and underwent cesarean section at 36 weeks (preterm delivery). In the other eight pregnancies, planned cesarean section was performed after 37 weeks of gestation. The median birth weight of the babies was 2996 g (range 2604-3374 g). All patients were discharged on the sixth postoperative day without complications. CONCLUSION A modified TAC can be safely performed and may prolong pregnancy without adverse events in patients with an extremely short cervix.
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Affiliation(s)
- Rei Sunami
- Department of Obstetrics and Gynecology, Yamanashi Prefectural Central Hospital, Kofu, Japan
| | - So Owada
- Department of Obstetrics and Gynecology, Yamanashi Prefectural Central Hospital, Kofu, Japan
| | - Genki Yasuda
- Department of Obstetrics and Gynecology, Yamanashi Prefectural Central Hospital, Kofu, Japan
| | - Mayuko Kasai
- Department of Obstetrics and Gynecology, Yamanashi Prefectural Central Hospital, Kofu, Japan
| | - Yuzo Uchida
- Department of Obstetrics and Gynecology, Yamanashi Prefectural Central Hospital, Kofu, Japan
| | - Hironori Takahashi
- Department of Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, Japan
| | - Shigeki Matsubara
- Department of Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, Japan
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Transabdominal cerclage in early pregnancy for cervical shortening after radical trachelectomy: A case report. Case Rep Womens Health 2021; 31:e00323. [PMID: 34094886 PMCID: PMC8150902 DOI: 10.1016/j.crwh.2021.e00323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/30/2021] [Accepted: 05/04/2021] [Indexed: 12/02/2022] Open
Abstract
Radical trachelectomy (RT) is a method of fertility preservation for patients with early invasive uterine cervical cancer stage IA2 or IB1 with a tumor diameter of ≤2 cm. However, women who have undergone RT have high risks of abortion and premature birth. To prevent premature birth, cervical cerclage is performed in patients with an ultra-short cervix, but the portio vaginalis is not visible in these patients, and transvaginal uterine cervical cerclage is almost impossible. In such cases, transabdominal cerclage (TAC) is considered. The patient reported here was a 39-year-old Japanese woman, gravida 2, para 0. At 37 years, she was diagnosed with cervical cancer, stage IB1 (according to the International Federation of Gynecology and Obstetrics [FIGO] classification), so abdominal modified RT was performed. One year after the operation, she became pregnant through in vitro fertilization and embryo transfer. The cervical length was 17 mm at 13 weeks of gestation but was shortened to 5 mm at 16 weeks of gestation, so TAC was performed. An emergency cesarean section was performed because of increased genital bleeding at 34 weeks of gestation and a live baby was delivered. Radical trachelectomy is used in women with early invasive uterine cervical cancer who wish to retain their fertility. Women who have undergone radical trachelectomy are at increased risk of pregnancy loss and premature birth. Transabdominal cerclage was undertaken at 16 weeks of gestation. Emergency cesarean section delivery of a live infant was undertaken at 34 weeks due to vaginal bleeding.
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Robotic Transabdominal Cerclage vs Laparotomy: A Comparison of Obstetric and Surgical Outcomes. J Minim Invasive Gynecol 2019; 27:1095-1102. [PMID: 31421250 DOI: 10.1016/j.jmig.2019.08.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/17/2019] [Accepted: 08/10/2019] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE To compare obstetric and surgical outcomes of transabdominal cerclage (TAC) via laparotomy (TAC-LAP) versus robotic-assisted (TAC-RA) approaches. DESIGN Retrospective cohort study. SETTING An academic medical center. PATIENTS Sixty-nine women with acquired or congenital cervical insufficiency. INTERVENTIONS All women underwent TAC either by laparotomy or robotic-assisted approaches by 2 primary surgeons between January 2003 and July 2018. Women with a preconceptional TAC without a subsequent pregnancy were excluded. MEASUREMENTS AND MAIN RESULTS A total of 69 women met inclusion criteria in the 15-year study period with 40 in the historical TAC-LAP group and 29 in the TAC-RA group. Gestational age at delivery was similar in the 2 groups (36 weeks 3 days vs 37 weeks; median difference -1 day, 95% confidence interval [CI] -6 to 2, p = .36). There were no differences in birth weight, Apgar scores, neonatal intensive care unit admission, or neonatal survival. Estimated blood loss and length of stay were significantly greater in the TAC-LAP group (50 mL vs 20 mL; median difference 25, 95% CI 5-40, p = .007 and 76 hours vs 3 hours; median difference 71, 95% CI 65-75, p <.001, respectively). Operative time was significantly shorter in the TAC-LAP group (65 minutes vs 132 minutes; median difference -64.7, 95% CI -79 to -49, p <.001). There was one intra-operative complication and 4 minor postoperative complications in the TAC-LAP group and none observed in the TAC-RA group. All outcomes were similar when comparing postconceptional TAC alone, except there was no longer a difference in blood loss. When comparing pre- versus postconceptional robotic TAC, there were no differences in surgical outcomes. CONCLUSION Robotic TAC has similar favorable obstetric outcomes to traditional laparotomy and is associated with reduced blood loss and shorter hospital stays. Despite longer operative times, the robotic group did not experience any intra-operative or postoperative complications, which speaks to the benefits of this minimally invasive approach to TAC.
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Moawad GN, Tyan P, Awad C, Abi Khalil ED. Surgical variance between postconceptional and preconceptional minimally invasive transabdominal cerclage placement. Am J Obstet Gynecol 2018; 219:414.e1-414.e2. [PMID: 30063900 DOI: 10.1016/j.ajog.2018.07.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/18/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022]
Abstract
Recent data show that transabdominal cerclage placement via laparoscopy carries better obstetrical outcomes in comparison to transabdominal cerclage placement via laparotomy. In this surgical tutorial, we review the technique for minimally invasive abdominal cerclage and highlight the surgical differences between preconceptional and conceptional cerclage.
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Ades A, Aref-Adib M, Parghi S, Hong P. Laparoscopic transabdominal cerclage in pregnancy: A single centre experience. Aust N Z J Obstet Gynaecol 2018; 59:351-355. [PMID: 29984840 DOI: 10.1111/ajo.12848] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 05/29/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Transabdominal cerclage can reduce the risk of preterm birth in women with cervical insufficiency. AIMS This study evaluated outcomes following insertion of a laparoscopic transabdominal cerclage in pregnant women. MATERIALS AND METHODS A retrospective observational study. PATIENTS pregnant women who underwent laparoscopic transabdominal cerclage from 2011 to 2017. Eligible women had cervical insufficiency and were not suitable for a transvaginal cerclage. INTERVENTION the insertion of a laparoscopic transabdominal cerclage in the pregnancy. MEASUREMENTS neonatal survival, delivery of an infant at ≥34 weeks gestation and surgical morbidity were evaluated. RESULTS Of 19 women who underwent laparoscopic transabdominal cerclage in pregnancy, at 6-11 weeks gestation, the perinatal survival rate was 100%. There were no complications. The average gestational age at delivery was 37.1 weeks. Sixteen women delivered after 34 weeks. CONCLUSIONS Laparoscopic transabdominal cerclage is a safe and effective procedure in women with poor obstetric histories. It requires the correct skill, expertise and patient selection.
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Affiliation(s)
- Alex Ades
- Department of Obstetrics and Gynaecology, Royal Women's Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Mehrnoosh Aref-Adib
- Agora Centre for Women's Health, Epworth Hospital, Melbourne, Victoria, Australia
| | - Sneha Parghi
- Agora Centre for Women's Health, Epworth Hospital, Melbourne, Victoria, Australia
| | - Phoebe Hong
- Agora Centre for Women's Health, Epworth Hospital, Melbourne, Victoria, Australia
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