Cervical insufficiency is defined as the repeated inability of the cervix to maintain an intrauterine pregnancy until term.1 The clinical course is classically described as painless dilation in at 16 to 28 weeks leading to premature delivery or pregnancy loss. Cervical insufficiency is estimated to complicate up to 1% of all pregnancies and up to 8% of the pregnancies that end in midtrimester loss.2
Presently a variety of effective medical and surgical interventions exist to treat patients with a history of cervical insufficiency. However, patients with multiple losses have traditionally been offered placement of a cerclage, or cervical stitch, during subsequent pregnancies. Cerclage placement has typically been performed transvaginally and this has been effective for many patients. However, in 1965 Benson and Durfee3 first described cerclage placement via an abdominal approach. The transabdominal approach offers several advantages to the transvaginal route: higher placement relative to the level of the internal os, lack of slippage, and lack of foreign body material in the vagina. The transabdominal approach is usually reserved for women with structurally abnormal cervices, typically secondary to cervical surgery, or for those women who have suffered a pregnancy loss secondary to cervical insufficiency despite placement of a transvaginal cerclage.4
Transabdominal cerclage placement has been reported in the literature to carry a very high success rate, with neonatal survival rates estimated at greater than 90%.5,6 The main drawback to the transabdominal approach, however, has been increased maternal morbidity5 as transabdominal placement has traditionally been performed via laparotomy. However, recent advances in minimally invasive surgery have made the placement of a transabdominal cerclage possible via laparoscopy.7 A recent comprehensive review indicates similar efficacy of an abdominal cerclage placed laparoscopically or via a laparotomy.8
At Brigham and Women’s Hospital we have been performing abdominal cerclage for over 20 years. We have over 100 cases treated via laparotomy and continue to offer this surgical option for abdominal cerclage placement. More recently, however, we were among the first centers in the United States to offer cerclage placement via laparoscopy. We have successfully performed over 50 laparoscopic cerclage procedures since 2007. In comparison to our cases placed via laparotomy, we have not had any significant complications and we have demonstrated significant improvement in patient morbidity as well as similar pregnancy success rates. All of our laparoscopic patients are able to go home the same day and most have resumed their normal activities within a week.
We strongly prefer to place the cerclage prior to pregnancy since placement is easier and less risky since there is no risk of fetal compromise. However we can also perform these procedures during pregnancy.
We have a unique team approach to these procedures with close collaboration between Dr. Einarsson from Minimally Invasive Gynecologic Surgery and Dr. McElrath from the Maternal Fetal Medicine Service. This way, the patients benefit from the respective expertise since the placement of the cerclage laparoscopically requires expert laparoscopic skills and the subsequent management of the pregnancy is optimally managed by a very experienced expert in maternal fetal medicine and cervical incompetence. The Brigham & Women’s Hospital is the only major center performing abdominal cerclage that also cares for its patients in entirety from cerclage placement to ultimate delivery. As such, we have amassed an internationally unique fund of institutional experience in not only the surgery of cerclage placement, but also the high risk management of pregnancies in women treated with abdominal cerclage. Our ultrasonographers, nurses, physicians and labor floor staff all have extensive experience in the specific needs of patients whose pregnancies include treatment with abdominal cerclage.
We have had excellent pregnancy outcomes in our patients, both before and after the implementation of placement of a laparoscopic cerclage, with an estimated success rate of over 95%.
1 Vyas NA, Vink JS, Ghidini A et al. Risk factors for cervical insufficiency after term delivery. Am J Obstet Gynecol 2006;195:787-91.
2 Drakely AJ, Quenhy S, Farquharson RC. Midtreimster loss-appraisal of the screening protocol. Hum Reprod 1998;13:1975-80.
3 Benson RC, Durfee RB. Transabdominal cervico-uterine cerclage during pregnancy for the treatment of cervical incompetence. Obstet Gynecol 1965;25:145-55.
4 Novy MJ. Transabdominal cervicoisthmic cerclage for the management of repetitive abortion and premature delivery. Am J Obstet Gynecol 1982;143:44-54.
5 Zaveri V, Aghajafari F, Amankwah K, Hannah M. Abdominal versus vaginal cerclage after a failed transvaginal cerclage: A systematic review. Am J Obstet Gyncol 2002;187:868-72.
6 Lotgering F, Gaugler-Senden IPM, Lotgering SF, Wallenburg HCS. Outcome after transabdominal cervicoisthmic cerclage. Obstet Gynecol 2006;107:779-84.
7 Scibetta JJ, Sanko SR, Phipps WR. Laparoscopic transabdominal cervicoisthmic cerclage. Fertil Steril 1998;69:161-3.
8 Burger NB, Brölmann HA, Einarsson JI, Langebrekke A, Huirne JA. Effectiveness of Abdominal Cerclage Placed via Laparotomy or Laparoscopy: Systematic Review. J Minim Invasive Gynecol 2011 Nov;18(6):696-704.
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