Transabdominal Cerclage for Managing Recurrent Pregnancy Loss

SURGICAL technique Transabdominal cerclage for managing recurrent pregnancy loss Among women in whom prior transvaginal cerclage has failed, transabdominal cerclage has a high rate of success in providing a good pregnancy outcome Eric G. Crihfield, MD; Renae Shibata, MD; Olivia Moskowitz, MD; Gianni Rodriguez-Ayala, MD; and Michael L. Nimaroff, MD CASE A woman with recurrent pregnancy loss Cervical insufficiency describes the inabil- A 38-year-old woman (G4P0221) presents to ity of the cervix to retain a pregnancy in the your office for preconception counseling. Her absence of the signs and symptoms of clini- history is significant for the following: a spon- cal contractions, labor, or both in the second taneous pregnancy loss at 15 weeks’ gesta- trimester.1 This condition affects an estimated tion; a pregnancy loss at 17 weeks secondary 1% of obstetric patients and 8% of women IN THIS to preterm premature rupture of membranes with recurrent losses who have experienced ARTICLE (PPROM); a cesarean delivery at 30 weeks and a second-trimester loss.2 6 days’ gestation after placement of a trans- Diagnosis of cervical insufficiency is Transvaginal vaginal cerclage at 20 weeks for cervical dila- based on a history of painless cervical dila- cerclage tion noted on physical exam (the child now tion after the first trimester with expulsion of decision tree has developmental delays); and most recently the pregnancy in the second trimester before a delivery at 24 weeks and 4 days due to pre- 24 weeks of gestation without contractions page 37 term labor with subsequent neonatal demise and in the absence of other pathology, such as (this followed a transvaginal cerclage placed at bleeding, infection, or ruptured membranes.1 Suture 13 weeks and 6 days). Diagnosis also can be made by noting cervical placement How would you counsel this patient? dilation on physical exam during the second page 38 trimester; more recently, short cervical length on transvaginal ultrasonography in the second Dr. Crihfield is a Resident in Obstetrics and Gynecology Transabdominal at Northwell Health, Manhasset, New York. trimester has been used to try to predict when cerclage a cervical cerclage may be indicated, although Dr. Shibata is a Resident in Obstetrics and Gynecology sonographic cervical length is more a marker technique at Northwell Health, Manhasset. for risk of preterm birth than for cervical insuf- page 40 Dr. Moskowitz is a Fellow in Minimally Invasive ficiency specifically.1,3 Gynecologic Surgery at Northwell Health, Manhasset. Given the considerable emotional and Dr. Rodriguez-Ayala is a Minimally Invasive Gynecologic physical distress that patients experience Surgeon in the Department of Obstetrics and Gynecology at Northwell Health Huntington Hospital, Huntington, New York. with recurrent second-trimester losses and the significant neonatal morbidity and mor- Dr. Nimaroff is Chairman, Department of Obstetrics tality that can occur with preterm deliv- and Gynecology, North Shore University Hospital and Long Island Jewish Medical Center, Manhasset. ery, substantial efforts are made to prevent these outcomes by treating patients with The authors report no financial relationships relevant to this cervical insufficiency and those at risk for article. preterm delivery. 36 OBG Management | May 2020 | Vol. 32 No. 5 mdedge.com/obgyn 1 FIGURE 1 Decision tree for placement of transvaginal cerclage History of second- trimester delivery or viable preterm delivery Cerclage placed in prior pregnancy? Yes No History-indicated Acceptable alternative: cerclage should be Preferred managment: History-indicated placed between 12 Measure cervical length transvaginal cerclage and 14 weeks’ gestation from 16-24 weeks placementa Cervix dilated Cervical length > 25 mm Cervical length < 25 mm on physical exam Continue to monitor Place ultrasonography- Place physical exam- cervical lengths indicated cerclage indicated cerclage aAccording to the American College of Obstetricians and Gynecologists, history-indicated transvaginal cerclage can be placed in the case of a history of 1 or more second-trimester pregnancy losses related to painless cervical dilation even if no cerclage was placed in a prior pregnancy; however, more recently, tracking cervical length has become preferred management as it avoids unnecessary cerclage in one-half of patients.1 Transvaginal cerclage: Indications for transvaginal cerclage. The A treatment mainstay indication for transvaginal cerclage is based Standard treatment options for cervical insuf- on history, physical exam, or ultrasonography. ficiency depend on the patient’s history. One A physical-exam indication is the most of the treatment mainstays for women with straightforward of the 3. Transvaginal cerclage prior second-trimester losses or preterm placement is indicated if on physical exam deliveries is transvaginal cervical cerclage. in the second trimester a patient has cervical A transvaginal cerclage can be placed using dilation without contractions or infection.1,7 either a Shirodkar technique, in which the ves- A history-indicated cerclage (typically icocervical mucosa is dissected and a suture placed between 12 and 14 weeks’ gestation) is placed as close to the internal cervical os as is based on a cerclage having been placed in a possible, or a McDonald technique, in which prior pregnancy due to painless cervical dila- a purse-string suture is placed around the tion in the second trimester (either ultraso- cervicovaginal junction. No randomized tri- nography- or physical-exam indicated), and als have compared the effectiveness of these it also can be considered in the case of a his- 2 methods, but most observational studies tory of 1 or more second-trimester pregnancy show no difference, and one suggests that the losses related to painless cervical dilation.1 Shirodkar technique may be more effective in More recent evidence suggests that in obese women specifically.4-6 patients with 1 prior second-trimester loss or mdedge.com/obgyn Vol. 32 No. 5 | May 2020 | OBG Management 37 SURGICAL technique Transabdominal cerclage for managing recurrent pregnancy loss FIGURE 2 Suture placement in transvaginal gestation for a history-indicated cerclage and transabdominal cerclage procedures in patients with 2 or more prior second- trimester losses. Success rates, especially for ultrasonography- and history-indicated cerclage, are Uterus thus high. For the 14% who still fail these methods, however, a different management strategy is needed, which is where transabdominal cerclage comes into play. Abdominal Abdominal cavity cavity Transabdominal cerclage is an option for certain patients Transabdominal cerclage In transabdominal cerclage, an abdominal approach is used to place a stitch at the cer- vicouterine junction. With this approach, Transvaginal Shirodkar the cerclage can reach a closer proximity to cerclage cerclage the internal os compared with the vaginal McDonald approach, providing better support of the cerclage cervical tissue (FIGURE 2).11 Whether per- formed via laparotomy or laparoscopy, the transabdominal cerclage procedure likely carries higher morbidity than a transvaginal Vagina approach, and cesarean delivery is required after placement. Since transvaginal cerclage often is successful, in most cases the transabdominal approach should not be viewed as the preterm delivery, serial sonographic cervical first-line treatment for cervical insufficiency length can be measured safely from 16 to 24 if a history-indicated transvaginal cerclage weeks, with a cerclage being placed only if has not been attempted. For women who cervical length decreases to less than 25 mm. fail a history-indicated transvaginal cer- By using the ultrasonography-based indica- clage, however, a transabdominal cerclage tion, unnecessary history-indicated cerclages has been proven to decrease the rate of for 1 prior second-trimester or preterm birth preterm delivery and PPROM compared can be avoided in more than one-half of with attempting another history-indicated patients (FIGURE 1, page 37).1,7 transvaginal cerclage.11,12 Efficacy. The effectiveness of transvaginal A recent systematic review of preg- cerclage varies by the indication. Authors nancy outcomes after transabdominal cer- of a 2017 Cochrane review found an overall clage placement reported neonatal survival reduced risk of giving birth before 34 weeks’ of 96.5% and an 83% delivery rate after gestation for any indication, with an aver- 34 weeks’ gestation.13 Thus, even among a age relative risk of 0.77.2 Other recent studies population that failed transvaginal cerclage, showed the following8-10: a transabdominal cerclage has a high success • a 63% delivery rate after 28 weeks’ gestation rate in providing a good pregnancy outcome for physical-exam indicated cerclages in the (TABLE, page 40). Transabdominal cerclage presence of bulging amniotic membranes also can be considered as first-line treatment • an 86.2% delivery rate after 32 weeks’ gesta- in patients who had prior cervical surgery or tion for ultrasonography-indicated cerclages cervical deformities that might preclude the • an 86% delivery rate after 32 weeks’ ability to place a cerclage transvaginally. CONTINUED ON PAGE 40 38 OBG Management | May 2020 | Vol. 32 No. 5 mdedge.com/obgyn SURGICAL technique Transabdominal cerclage for managing recurrent pregnancy loss CONTINUED FROM PAGE 38 TABLE Cerclage indications and success rates8-10,13 Type of cerclage Success rates History-indicated transvaginal cerclage 86% delivery rate after

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