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Transabdominal cervical cerclage

INTRODUCTION

Transabdominal placement of a cerclage at the cervicoisthmic junction appears to be a safe and effective procedure for reducing the incidence of spontaneous pregnancy loss in selected patients with cervical insufficiency [1-6]. Potential advantages of transabdominal over transvaginal cerclage are more proximal placement of the stitch (at the level of the internal os), decreased risk of suture migration, absence of a foreign body in the vagina that could promote infection, and the ability to leave the suture in place for future pregnancies [4]. A disadvantage of this approach is the potential need for two laparotomies during pregnancy (one to place the cerclage and potentially another to remove it).

INDICATIONS AND CONTRAINDICATIONS

There are no studies comparing the outcome of transabdominal and transvaginal cerclage in similar populations of patients. Transabdominal cerclage is a more morbid procedure than transvaginal cerclage. It usually requires a laparotomy for placement and delivery by cesarean. For these reasons, most experts recommend reserving the transabdominal approach for women with cervical insufficiency who have either failed two or more previous transvaginal cerclages or in whom a transvaginal cerclage is technically impossible to perform due to extreme shortening, scarring, or laceration of the cervix.

Contraindications to transabdominal cerclage are similar to those for transvaginal cervical cerclage. (See "Transvaginal cervical cerclage".)

TIMING

Transabdominal cerclage placement can be performed prior to conception [7] or in early pregnancy. Preconception placement provides optimum exposure and reduces risks of excessive bleeding and injury to the pregnancy. Placement of the cerclage after the first trimester is undesirable since the large size of the uterus makes the procedure difficult and thus may be associated with a higher risk of complications. No randomized trials have compared outcomes with preconception versus postconception cerclage. A review of 14 studies of abdominal cerclage published between 1990 and 2013 and involving a total of 678 patients reported live birth rates were similar whether abdominal cerclage was performed before or during pregnancy [8].

PROCEDURE

Open transabdominal approach — We use an open approach. It is usually performed with the patient in the supine position, but may be done with the woman in a modified lithotomy position if intraoperative transvaginal manipulation of the uterus or transvaginal ultrasound examination of the cervix is necessary [2].

          

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Literature review current through: Nov 2014. | This topic last updated: Nov 13, 2014.
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References
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