Society for Maternal-Fetal Medicine Consult Series #65: Transabdominal cerclage

Cerclage is the mainstay of treatment for cervical insufficiency. While transabdominal cerclage (TAC) may have advantages over transvaginal cerclage, it is associated with increased morbidity and the need for cesarean delivery. In this consult, we review the current literature on the benefits and risks of TAC and provide recommendations based on the available evidence. The following are Society for Maternal-Fetal Medicine recommendations: (1) We recommend that TAC be offered to patients with a previous placement of transvaginal cerclage (history or ultrasound indicated) and subsequent singleton delivery before 28 weeks of gestation. (GRADE 1B); (2) We recommend maternal-fetal medicine consultation for counseling patients who may be candidates for TAC and those who have undergone TAC (Best Practice); (3) We suggest that both laparoscopic and open TAC are acceptable and the decision of approach may depend on gestational age, technical feasibility, available resources, and expertise (GRADE 2B); (4) We suggest that TAC can be performed preconceptionally or in the first trimester with similar fetal outcomes. If a patient with an indication for TAC presents after the first trimester, TAC can still be considered before 22 weeks (GRADE 2C); (5) We recommend that routine transvaginal cervical length screening not be performed for patients with transabdominal cerclage in situ (GRADE 1C); (6) We suggest that for individuals at risk of recurrent spontaneous preterm birth, including those with TAC in situ, a risk/benefit discussion of supplemental progesterone be undertaken with shared decision-making (GRADE 2C); (7) We suggest that pregnancy loss be managed with dilation and curettage or evacuation with transabdominal cerclage in situ or via usual obstetric management after laparoscopic removal of transabdominal cerclage, depending on gestational age and resources available (GRADE 2C); (8) We suggest cesarean delivery between 37 0/7 to 39 0/7 weeks for patients with transabdominal cerclage in situ (GRADE 2C).

Laparoscopic Cerclage as a Treatment Option for Cervical Insufficiency

Background: The traditional surgical treatment for cervical insufficiency is vaginal placement of a cervical cerclage. However, in a small number of cases a vaginal approach is not possible. A transabdominal approach can become an option for these patients. Laparoscopic cervical cerclage is associated with good pregnancy outcomes but comes at the cost of a higher risk of serious surgical complications. The aim of the present study was to evaluate intraoperative and long-term pregnancy outcomes after laparoscopic cervical cerclage, performed either as an interval procedure or during early pregnancy, using a new device with a blunt grasper and a flexible tip. Methods: All women who underwent laparoscopic cervical cerclage for cervical insufficiency in our institution using the Goldfinger® device (Ethicon Endo Surgery, Somerville, NJ, USA) between January 2008 and March 2014 were included in the study. Data were collected from the patients' medical records and included complications during and after the above-described procedure. Results: Eighteen women were included in the study. Of these, six were pregnant at the time of laparoscopic cervical cerclage. Mean duration of surgery was 55 ± 10 minutes. No serious intraoperative or postoperative complications occurred. All patients were discharged at 2.6 ± 0.9 days after surgery. One pregnancy ended in a miscarriage at 12 weeks of gestation. All other pregnancies ended at term (> 37 weeks of gestation) with good perinatal and maternal outcomes. Summary: Performing a laparoscopic cervical cerclage using a blunt grasper device with a flexible tip does not increase intraoperative complications, particularly in early pregnancy. We believe that use of this device, which is characterized by increased maneuverability, could be an important option to avoid intraoperative complications if surgical access is limited due to the anatomical situation. However, because of the small sample size, further studies are needed to confirm our findings.