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Contents: Operative Obstetrics: Original Research

Laparoscopic Transabdominal Cerclage and Subsequent Pregnancy Outcomes When Left In Situ

Ades, Alex PhD; Hawkins, Deborah P. MD

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doi: 10.1097/AOG.0000000000003263
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The global number of preterm births is estimated at 15 million per year, with nearly 1 in 10 neonates around the world born preterm.1 Cervical insufficiency is an important contributor to preterm birth and perinatal mortality. Many women with the condition suffer one or more mid-trimester losses or extreme preterm deliveries. The most common surgical treatment for cervical insufficiency is a cervical cerclage. The procedure was initially described as a purse string suture around the cervix performed using a vaginal approach. The most common techniques are the ones described by Shirodkar2 and McDonald.3 A transabdominal cerclage is used as an alternative for women in whom a transvaginal cerclage fails or for women who have had large portions of their cervix removed for treatment of oncologic conditions. Transabdominal cerclage via laparotomy was proposed by Benson in 1967.4 More recently, the procedure is being performed via laparoscopy.5

To date, publications on outcomes in subsequent pregnancies after the first completed pregnancy with transabdominal cerclage are limited to case reports or case series in women who had their transabdominal cerclages placed by laparotomy or are focused mainly on the first pregnancy after transabdominal cerclage (Airoldi J, Arvon R, Berghella V. Subsequent pregnancy outcomes after transabdominal cerclage [abstract]. Obstet Gynecol 2005;105:40S; and Windrim C, O'Dwyer V, Brennan D, O'Brien D, Higgins S. Pregnancy outcome after abdominal cerclage [abstract]. Am J Obstet Gynecol 2018;218:S319–320).6 There have been no publications on the outcomes of subsequent pregnancies in a group of women who have solely had laparoscopic transabdominal cerclage (as opposed to including women who have undergone laparotomy), hence there are no data to show whether it is safe for women to conceive again on the same suture. This study reviews the obstetric outcomes in a group of women who had their second or third pregnancies with a laparoscopic transabdominal cerclage in situ.

METHODS

We conducted a prospective observational study in a consecutive cohort of women who became pregnant again after undergoing laparoscopic transabdominal cerclage before or during a previous pregnancy. We keep a database of all the women who have a laparoscopic transabdominal cerclage in our center where information for all surgical procedures and pregnancies are recorded.

The main indications for laparoscopic transabdominal cerclage are either a previous failed transvaginal cerclage or oncologic surgery that removes significant portions of the cervix making it unsuitable for a transvaginal cerclage. We have previously published detailed indications for laparoscopic transabdominal cerclage, the surgical technique used, as well as the outcomes of pregnancies where the cerclage was placed before7 or during pregnancy.8

Women were referred from the Royal Women's Hospital in Melbourne as well as from other Australian and New Zealand hospitals. After insertion of the laparoscopic transabdominal cerclage, women went back to their referring doctor and were cared for by their obstetrician of choice when pregnant. Nineteen of the cerclages were placed prepregnancy as interval procedures and three were placed in the first trimester.

Patient demographics and medical, surgical, obstetric, and gynecologic history, as well as the indication for cerclage were recorded preoperatively. Pregnancy details and obstetric outcomes were collected directly from the obstetricians and pediatricians providing care, hospital charts, and telephone interviews with the women themselves. These interviews are conducted yearly; every patient in our database is contacted to ensure no deliveries are missed in our patient population. The questions are a standard set of basic obstetric questions (eg, gestational age at delivery, type of delivery, neonatal weight). Once details are gathered from the patient, corroboration is sought from the treating obstetrician and hospital records.

A total of 47 pregnancies in 22 women (19 women had one subsequent pregnancy and three had two) were recorded. Ethics approval was obtained from the Royal Women's Hospital, Melbourne, Human Research Ethics Committee. All women provided informed consent.

The primary study outcome was neonatal survival. This was defined as survival 30 days after discharge from the hospital. The secondary outcome was delivery at 34 weeks of gestation or more. The gestational ages are reported for first, second, and third deliveries after laparoscopic transabdominal cerclage (Table 1).

Table 1.
Table 1.:
Indication for Transabdominal Cerclage and Gestational Age at Delivery

RESULTS

Our center performed 295 laparoscopic transabdominal cerclages between August 2007 and May 2018, with almost 200 deliveries reported postlaparoscopic transabdominal cerclage to date. The study group for this publication is comprised of the 22 women who had more than one pregnancy with the same cerclage. Nineteen women had two pregnancies and three had three pregnancies (Table 1).

Before the cerclage, the mean gestational age at delivery for the same group was 21.5 weeks. Between them, the women in the study group lost 20 fetuses before the cerclage.

In the first pregnancies with the cerclage in situ, the neonatal survival rate was 100% (22/22) and 86% (19/22) of women delivered after 34 weeks of gestation. In the second pregnancies, the neonatal survival rate was 95% (21/22) and 86% (19/22) of women delivered after 34 weeks of gestation. In the third pregnancies, the neonatal survival rate was 100% (3/3) and 100% (3/3) of women delivered after 34 weeks of gestation (Table 2).

Table 2.
Table 2.:
Summary of Delivery Outcomes

DISCUSSION

When left in situ for subsequent pregnancies, laparoscopic transabdominal cerclage is associated with a high rate of neonatal survival. The three women who had three deliveries with their laparoscopic transabdominal cerclages made it as far in their third pregnancies as they did in their first and second pregnancies.

We realize that an observational cohort study of a small group of patients is not the strongest evidence on which to base practice. Obviously, owing to its nature, the condition being studied does not give much opportunity for blinding or randomization. Moreover, all of the women in our cohort had a successful first pregnancy with their cerclage in situ. This is likely because, if the first pregnancy is not successful, women would be unlikely to attempt a second pregnancy with the same cerclage in place; thus, we did not capture any such patients in our cohort.

In light of these limitations, we believe that, although not ideal, the prospective observation and report of all pregnancies after laparoscopic transabdominal cerclage performed at our center is the best information that we can provide at this stage. We maintain a very comprehensive database where all women who have laparoscopic transabdominal cerclages are included, and data are collected prospectively rather than retrospectively reviewing patient files. Our center is a tertiary referral site that has developed significant expertise with the procedure and the surgeon who performs the cerclages is very experienced. It is difficult to predict how the cerclage would behave if performed in different environments. Nevertheless, there is no reason to believe that adequately trained surgeons would not be able to replicate our results.

We encourage other groups to report their outcomes on subsequent pregnancies after laparoscopic transabdominal cerclage. Larger numbers of women may provide more information and eventually allow for a meta-analysis or systematic review. In addition, reporting of complications with prolonged retention of transabdominal cerclages, such as erosion into the vagina, would also help inform clinician and patient decision making about the potential risks and benefits of long-term transabdominal cerclage retention.9

In summary, based on our cohort, it is reasonable to give women some reassurance that they can have more than one pregnancy with the same laparoscopic transabdominal cerclage.

REFERENCES

1. Purisch SE, Gyamfi-Bannerman C. Epidemiology of preterm birth. Semin Perinatol 2017;41:387–91.
2. Shirodkar VN. A new method of operative treatment for habitual abortions in the second trimester of pregnancy. Antiseptic 1955;52:299–300.
3. McDonald IA. Suture of the cervix for inevitable miscarriage. J Obstet Gynaecol Br Emp 1957;64:346–50.
4. Benson RC, Durfee RB. Transabdominal cervico-uterine cerclage during pregnancy for the treatment of cervical incompetency. Obstet Gynecol 1965;25:145–55.
5. Norwitz E, Craigo S. Transabdominal and laparoscopic cervicoisthmic cerclage. UpToDate. Available at: https://www.uptodate.com/contents/transabdominal-and-laparoscopic-cervicoisthmic-cerclage. Retrieved July 23, 2018.
6. Duhig K, Chandiramani M, Shennan A. Failure of trans-abdominal cervical cerclage following successful term pregnancy with said cerclage. J Obstet Gynaecol 2008;28:348.
7. Ades A, Parghi S, Aref-Adib M. Laparoscopic transabdominal cerclage: outcomes of 121 pregnancies. Aust N Z J Obstet Gynaecol 2018;58:606–11.
8. Ades A, Parghi S, Aref-Adib M, Hong P. Laparoscopic transabdominal cerclage in pregnancy: a single centre experience. Aust N Z J Obstet Gynaecol 2008 Jul 9 [Epub ahead of print].
9. Hawkins E, Nimaroff M. Vaginal erosion of an abdominal cerclage 7 years after laparoscopic placement. Obstet Gynecol 2014;123:420–3.
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