Transabdominal cervico-isthmic cerclage in the management of cervical incompetence

doi:10.1016/S0301-2115(96)02669-3

European Journal of Obstetrics & Gynecology and Reproductive Biology

Volume 72, Issue 2, April 1997, Pages 127-130

https://doi.org/10.1016/S0301-2115(96)02669-3 Get rights and content

Abstract

The use of transabdominal cervico-isthmic cerclage is described in 13 patients with a diagnosis of cervical incompetence. The patients were recruited from seven Scottish Maternity Units over a period of 10 years. The 13 patients have had a successful pregnancy in 86.6% of pregnancies with this procedure compared with a success rate of 16% in their previous pregnancies. In carefully selected cases transabdominal cervico-isthmic cerclage is a worthwhile procedure in patients with cervical incompetence when the cervix is so damaged that it would be impossible to insert a vaginal suture or when a vaginal suture has previously failed.

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Eur J Obstet Gynecol Reprod Biol
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There are more references available in the full text version of this article.

Cited by (48)

The effectiveness of transabdominal cerclage placement via laparoscopy or laparotomy: a systematic review and meta-analysis
2023, American Journal of Obstetrics and Gynecology MFM
Citation Excerpt :
Subsequently, based on our inclusion and exclusion criteria, 107 full-text articles were excluded. This left 83 eligible studies containing 3398 patients.14,15,17–22,34–107 Table 1 presents the baseline characteristics.
Failure or technical impossibility to place a prophylactic transvaginal cerclage in women with cervical insufficiency justifies the need for an abdominal cerclage. In this systematic review and meta-analysis, we studied the obstetrical and surgical outcomes of laparoscopic and open laparotomy abdominal cerclage approaches performed before (interval) or during pregnancy.
We performed a systematic literature search in PubMed, Embase, and the Cochrane Library for studies on laparoscopic and open laparotomy abdominal cerclage placement in February 2022.
All studies on laparoscopic or open laparotomy placement of an abdominal cerclage with at least 2 patients that reported on our primary outcomes were included.
All included studies were assessed for quality and risk of bias with an adjusted Quality in Prognosis Study tool. Random effects meta-analyses were performed for the primary outcomes, namely fetal survival and gestational age at delivery.
Our search yielded 83 studies with a total of 3398 patients; 1869 of those underwent laparoscopic cerclage placement and 1529 underwent open laparotomy placements. No studies directly compared the 2 cerclage approaches. The survival (overall, 91.2%) and gestational age at delivery (overall, 36.6 weeks) were not statistically different between the approaches. For the procedure during pregnancy, the laparoscopic group showed significantly less blood loss >400 mL (0% vs 3%), a slightly lower procedure-related fetal loss (0% vs 1%), a shorter hospital stay but a longer operation duration than the open laparotomy group. For the interval cerclages, the laparoscopic group showed significantly fewer wound infections (0% vs 3%) and a shorter hospital stay than the open laparotomy group, but showed comparable offspring preterm birth and survival rates.
Based on indirect comparisons, the laparoscopic and open laparotomy abdominal cerclage placements at interval or during pregnancy produced similar outcomes in terms of survival and gestational age at delivery. There are some small differences in perioperative care, surgical complications, interventions, and complications during pregnancy. This implies that both methods of abdominal cerclage placement have high success rates and thus we cannot conclude that one of the methods is superior for the placement of an abdominal cerclage.
Efficacy of laparoscopic and trans-abdominal cerclage (TAC) in patients with cervical insufficiency: A systematic review and meta-analysis
2022, European Journal of Obstetrics and Gynecology and Reproductive Biology
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.
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.
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.
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.
Fertility outcomes after preconceptional laparoscopic abdominal cerclage for second-trimester pregnancy losses
2021, European Journal of Obstetrics and Gynecology and Reproductive Biology
Cervical incompetence is an important cause of recurrent pregnancy loss, typically presenting in the second trimester with silent cervical dilation and premature delivery of the fetus. We aimed to evaluate the conception rate and time to conception or failure to conceive after preconceptional laparoscopic abdominal cerclage (LAC).
We conducted this retrospective observational cohort study at a tertiary referral center. Patients who underwent LAC in the nonpregnant state for a second-trimester pregnancy loss between June 2012 and February 2020 were included.
The subjects were 40 patients with a history of one or more second-trimester pregnancy losses despite the placement of vaginal cerclage, who had undergone LAC before contemplating a future pregnancy. The mean number of second-trimester pregnancy losses before LAC was two per woman. The ages of the women at the time of cerclage ranged from 21 to 42 years. The time to pregnancy, which was the primary outcome of the study, was determined as the number of menstrual cycles before the patient became pregnant after LAC and the number of cycles needed for the patient to achieve her latest pregnancy before LAC. Of the 40 women, 22.5 % were noted during the LAC operation to have a pelvic peritoneal pathology that might have affected fertility, and all such pathologies were treated concomitantly during the procedure. Spontaneous pregnancy rates before and after LAC were 96.4 % and 89.3 % (p = 0.299), and times to pregnancy before and after LAC were 6.3 ± 8.4 and 6.6 ± 8.1 cycles (p = 0.897). Neither difference was statistically significant. In more than 84 % of patients who became pregnant after LAC, pregnancy was sustained to the stage of viability.
In patients with cervical incompetence, LAC is a very effective intervention to sustain pregnancy to the stage of viability. If placed during the preconceptional period, it does not delay achieving pregnancy and does not have a negative impact on the chances of conception. This may be reassuring to women undergoing this procedure before they achieve a pregnancy.
Evaluation of a new technique of prophylactic cervical cerclage simplified from the Shirodkar cerclage: A pilot study
2017, Journal of Gynecology Obstetrics and Human Reproduction
Citation Excerpt :
However, while certain data support the effectiveness of cerclage in cases of repeated history of premature birth [7], few studies have compared different cerclage techniques. Cervical cerclage techniques are less binding [6,8–10], but may be less effective than cervico-isthmic cerclage techniques [8,11–13]. The most commonly used cervical cerclage technique used is the one described by McDonald [3,14].
In terms of prophylactic cerclage, the simplest and most commonly used technique is the McDonald cervical cerclage. Cervico-isthmic cerclage techniques may have better results, but are more difficult to achieve. A simplified Shirodkar technique would have the advantage of being “cervical high” while remaining easy to achieve.
To compare the results of high cervical cerclage, according to a simplified Shirodkar technique, with those of a classic McDonald cerclage, in the case of women at high risk of prematurity in an exploratory study.
A comparative, retrospective study of prophylactic cerclage was conducted according to one or the other technique performed in a university hospital from 2006 to 2013. Women were included only if they had a history of at least two late miscarriages and/or premature delivery before 33 weeks. The primary outcome was the rate of delivery before 35 weeks.
Our study involved 38 women: 24 in the McDonald cerclage group and 14 in the simplified Shirodkar cerclage group. The two groups were comparable for their obstetric and general characteristics. The percentage of preterm deliveries before 35 weeks was similar in both groups (7.1% and 25.0% in the Shirodkar and McDonald groups respectively; P = 0.17). No significant difference was observed in the rate of surgical complications or hospitalizations during the pregnancies.
In this study, we were unable to demonstrate an advantage to using the simplified Shirodkar technique – high cervical cerclage – compared with use of the McDonald technique – classical cerclage.
Cerclaje cervical
2013, Progresos de Obstetricia y Ginecologia
Transabdominal cervico-isthmic cerclage: 13 cases at Rouen University Hospital
2012, Gynecologie Obstetrique et Fertilite
L’objectif de ce travail est de rapporter notre expérience du cerclage du col par voie abdominale et d’évaluer son efficacité selon la technique chirurgicale.
Étude unicentrique rétrospective de 13 cas de cerclage cervico-isthmique par voie abdominale (huit par laparotomie et cinq par cœlioscopie), sept cas effectués hors grossesse et six cas entre 12 et 14 SA, entre 2004 et 2009. Nous avons analysé les antécédents obstétricaux, les étiologies de béance cervicale, les différentes stratégies thérapeutiques mises en œuvre pour leur prise en charge et le devenir obstétrical de ces patientes après cerclage.
L’âge moyen des patientes au moment du cerclage était de 35 ans [27–42 ans]. Les patientes avaient une gestité moyenne avant la mise en place du cerclage abdominal de 4,2 [1–7] avec une moyenne de 3,3 antécédents de fausses couches tardives ou d’accouchements prématurés. Quatre-vingt pourcent des patientes présentaient un ou plusieurs épisodes d’échec au cerclage par voie vaginale de type Mac Donald-Hervet ou Shirodkar. La durée opératoire moyenne des cerclages a été de 100 minutes par voie laparotomique contre 94 minutes par voie cœlioscopique avec une durée moyenne d’hospitalisation respectivement de sept et 2,5 jours. Aucune complication grave per- et postopératoire n’a été observée quelle que soit la voie d’abord. Parmi les 13 cerclages réalisés chez ces patientes, onze ont obtenu une grossesse. Neuf grossesses (82 %) ont été menées à terme avec naissance d’enfants vivants et deux ont accouché prématurément à 34SA + 5j et 36SA + 4j. Deux patientes souhaitent actuellement une grossesse dont une est prise en charge dans notre centre d’assistance médicale à la procréation dans le cadre d’une FIV.
Le cerclage cervico-isthmique par voie abdominale qu’il soit réalisé par laparotomie ou par cœlioscopie est une alternative au cerclage vaginal pour la prise en charge des incompétences cervicales après échec de cerclage vaginal et/ou absence de relief cervical. La cœlioscopie semble alors représenter une voie d’abord simple, efficace avec un risque de complication opératoire faible chez ces patientes au parcours obstétrical souvent dramatique.
The aim of this study was to describe our experience with cervico-isthmic cerclage by abdominal approach and to assess this efficacy.
A retrospective analysis of 13 transabdominal cerclages (eight by laparotomy and five by laparoscopy), seven cases performed before pregnancy and six cases between 12 and 14 weeks of gestation, between 2004 and 2009. We analyzed the previous obstetric accidents, the etiology of cervical incompetence and the patient outcome after cerclage.
Median age of the patients was 35 years [27–42 years]. Patients had an average of pregnancy 4,2 [1–7], with 3,3 previous fetal losses or preterm delivery. Eighty percent had a prior failed transvaginal cerclage. The mean operative time of laparotomic cerclage was 100 minutes and 94 minutes by laparoscopy, with a mean hospitalization time respectively of seven and 2,5 days. No operative complication was reported. Eleven women were pregnant after cervico-isthmic cerclage: nine deliveries by caesarean section at term, and two preterm births between 34 and 37 weeks of gestation. Two patients are looking for being pregnant and one of those is currently doing a procedure of IVF.
Transabdominal cervico-isthmic cerclage is an alternative technique for the management of cervical incompetence after failed vaginal cerclage. Our data indicated that the cervico-isthmic cerclage placed laparoscopically compares favorably with the laparotomy approach in regard to operative technique and risk of complications.

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Transabdominal cervico-isthmic cerclage in the management of cervical incompetence

Abstract

Am J Obstet Gynecol

Transabdominal cervico-uterine cerclage during pregnancy for the treatment of cervical incompetence

Obstet Gynecol

Cervical resistance in patients with previous spontaneous mid-trimester abortion

Br J Obstet Gynaecol

Successful use of transabdominal isthmic cerclage in the management of cervical incompetence

Eur J Obstet Gynecol Reprod Biol