You are on page 1of 7

Research

www. AJOG .org

OBSTETRICS

Laparoscopic cervico-isthmic cerclage: surgical technique and obstetric outcomes

Wendy L. Whittle, MD, PhD; Sukhbir S. Singh, MD; Lisa Allen, MD; Louise Glaude, RN; Jacqueline Thomas, MD; Rory Windrim, MD; Nicholas Leyland, MD

OBJECTIVE: The purpose of the study is to review the surgical tech- nique, complication rate and obstetric outcome associated with the laparoscopic approach to the placement of the cervico-isthmic cerclage.

STUDY DESIGN: A prospective cohort study was conducted from 2003-2008 and compared with previously reported cases of cervico- isthmic cerclage by laparotomy and laparoscopy.

RESULTS: Thirty-one patients underwent cerclage placement during pregnancy and 34 patients were not pregnant at the time of the surgery. Seven cases were converted to laparotomy due to complications arising

from uterine vessel bleeding or impaired surgical visibility; 2 pregnan- cies were lost perioperatively. No other complications occurred. The fe- tal salvage rate (n 67 pregnancies) was 89% with a mean gestational age of 35.8 2.9 weeks. Six pregnancies were lost in the second tri- mester due to the consequences of acute or subacute chorioamnionitis.

CONCLUSION: Our findings suggest that the cervico-isthmic cerclage placed laparoscopically compares favorably with the traditional laparot- omy approach.

Key words: abdominal cerclage, cervico-isthmic cerclage, laparoscopy, laparotomy

Cite this article as: Whittle WL, Singh SS, Allen L, et al. Laparoscopic cervicoisthmic cerclage: surgical technique and obstetric outcomes. Am J Obstet Gynecol

2009;201:364.e1-7.

C ervical incompetence occurs in 0.5-1% of all pregnancies, has a re-

currence risk of 30% and typically pre- sents in the second trimester as pelvic pressure and cervical dilation in the ab- sence of uterine activity or ruptured membranes. 1 The etiology of cervical in- competence can be classified as (1) a me- chanical failure of the cervix to remain

From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital (Drs Whittle and Windrim and Ms Glaude); the Department of Obstetrics and Gynaecology, St. Joseph’s Health Care Centre (Drs Singh and Leyland); and the Department of Obstetrics and Gynaecology, Mount Sinai Hospital (Drs Allen and Thomas), University of Toronto, Toronto, ON, Canada.

Received Nov. 10, 2008; revised Feb. 25, 2009; accepted July 14, 2009.

Reprints not available from the authors.

0002-9378/free

© 2009 Published by Mosby, Inc. doi: 10.1016/j.ajog.2009.07.018

Published by Mosby, Inc. doi: 10.1016/j.ajog.2009.07.018 For Editors’ Commentary, see Table of Contents closed

For Editors’ Commentary, see Table of Contents

For Editors’ Commentary, see Table of Contents closed against the increasing uterine dis- tention pressure,

closed against the increasing uterine dis- tention pressure, or (2) a functional fail- ure due to premature cervical ripening. 1 The cervical cerclage through a vaginal approach was introduced as a mecha- nism to reinforce the cervical integrity. In 1965, Benson and Durfee 2 introduced an alternative to the vaginal approach— the placement of a cerclage at the cervical isthmus: a noose-like suture positioned around the isthmus in the avascular space above the cardinal and uterosacral ligaments placed by laparotomy. 3 This technique was intended when the vagi- nal approach was not feasible due to al- tered cervical anatomy (ie, congenital anomaly, scarring due to cone biopsy, or laceration at delivery); the indication was extended by Novy 4 to include a failed transvaginal cerclage in a previous pregnancy. Cervico-isthmic cerclage re- views quote a successful pregnancy out- come rate from 76.5-100%; however, the morbidity associated with the surgical procedure is significant. 5 In an era when endoscopic surgery provides a mini- mally invasive alternative with docu- mented benefit over the traditional lap- arotomy approach, it has been proposed

364.e1 American Journal of Obstetrics & Gynecology OCTOBER 2009

that the cervico-isthmic cerclage could be completed laparoscopically. 6 The ob- jective of the present study is to review the surgical technique, morbidity, and obstetric outcome associated with the laparoscopic approach to placement of the cervico-isthmic cerclage. Our find- ings will be compared with reports of the traditional cervico-isthmic cerclage placed by laparotomy and more recently laparoscopy. 7-30

M ATERIALS AND M ETHODS

A prospective observational cohort

study was conducted from January 2003 to June 2008 at Mount Sinai Hospital (Toronto, Canada) with institutional

ethics board approval (MSH REB no. 06- 0149-E). The indication for cerclage placement was a presumptive diagnosis

of mechanical cervical incompetence

based on the Novy criteria. 4 Pregnant patients underwent pelvic ultrasound to confirm viability, and were offered first trimester aneuploidy screening or diag- nostic chorionic villi sampling prior to cerclage placement. After surgery, preg- nant patients underwent routine cervi- cal/vaginal swabs and urine culture. All infections were treated with routine an- tibiotic therapy; if the test of cure indi-

www.AJOG.org

Obstetrics Research

TABLE 1

Patient demographics

Demographic

n

Mean maternal age at cerclage, y Mean gravidity No. of live children/patient Patients with previous term pregnancy T1 loss, % (mean no. T1 loss/patient) T2 loss, % (mean no. T2 loss/patient) Patient with prior TA Patients with prior failed cerclage Patients with previous cervical surgery (cone, LEEP) Patient with DES exposure Nulligravid/primigravid patients with insufficient cervical tissue

32.6 4.6 (range, 22–42) 3.4 2.3 (range, 0–14) 0.43 (range, 0–2)

27.60%

38.5% (0.8 1.8) 92.3% (1.6 1.1)

13.8%

58.0%

68.7%

0%

5 (7.6%)

DES, diethylstilbestrol; LEEP , loop electrosurgical excision procedure; T1 , first trimester; T2 , second trimester. Whittle. Laparoscopic cervicoisthmic cerclage. Am J Obstet Gynecol 2009.

cated ongoing infection, suppressive an- tibiotic therapy was prescribed for the remainder of the pregnancy.

Surgical preparation

The patient was prepared in the dorsal lithotomy position with a urinary cathe- ter in situ. If the patient was not preg- nant, a transcervical uterine manipula- tor was used; for the pregnant patient, a sponge on ring forcep was placed into the vaginal fornix to facilitate uterine manipulation. A traditional 4 puncture operative laparoscopy set up is used. Ini- tial abdominal entry is achieved through the closed Veress technique at the umbi- licus. 16 For cases done during preg- nancy, the gravid uterus was avoided through entry in the left upper quadrant by the closed Veress technique or through an open Hassan technique at the umbilicus. Abdominal insufflation was maintained at 12-15 mmHg using CO 2 .

Step 1: development of the paravesical and vesico- uterine spaces

The vesicouterine peritoneum was in- cised using the CO 2 laser (Coherent Inc., Santa Clara, CA) or monopolar scissors across the lower uterine segment, and a combination of sharp and blunt dissec- tion was used to reflect the bladder from the lower uterine segment and anterior cervix. Paravesical spaces were devel-

oped bilaterally through a combination

of blunt and sharp dissection.

Step 2: creation of broad ligament peritoneal windows

Anteversion of the uterus revealed a transparent posterior leaf of the broad ligament, an avascular space to create a window in the broad ligament on each side of the uterus. Fluid placement in the anterior cul-de-sac facilitated identifica- tion of the avascular space. The opening was created by a “push and spread” tech- nique through the peritoneum with a laparoscopic grasper and enlarged by stretching the opening parallel and lat- eral to the uterine vessels. Creating this window allowed for caudal displacement

of the ureters and identified the uterine

vessels at the cervico-isthmic junction.

Step 3: placement of suture material through broad ligament peritoneal window

A no. 1 Prolene (Ethicon Inc., Somer-

ville, NJ) suture on a CT-1 needle was passed into the abdomen through a 10-12 mm port on a laparoscopic needle

holder. It is critical that the needle be set

to pass from the posterior aspect of the

right broad ligament window through anteriorly to prepare the trailing suture length for the final step; in this step the needle and suture sit lateral to the right sided uterine vessels.

Steps 4 and 5: right and left sided placement of cerclage at the cervico-isthmic junction

The needle was introduced medial and posterior to the uterine vessels, a small pur- chase of cervical tissue at the level of the cervico-isthmic junction is taken, and the needle is followed through anteriorly with the distal end of the suture in the cul-de- sac behind the uterus. This step anchored the suture on the right side of the uterus. The suture material and needle was passed anteriorly across the lower segment to the left side of the uterus. In a similar fashion, the needle is placed medial to the left sided uterine vessels and a small purchase of cer- vical tissue at the level of the left sided cer- vico-isthmicjunctionwas taken as the nee- dle was passed through posteriorly through the broad ligament window leav- ing the needle in the cul-de-sac and secur- ing the suture to the left side of the uterus (Figure, A and B).

Step 6: the cerclage knot secured

The cerclagewas tied by either an extracor- poreal or intracorporeal knot at the poste- rior aspect of the uterus. The tension of the suture can be adjusted over a transcervical 5 mm Hegar dilator in the nonpregnant patient. The suture placement should sit at the level of the internal cervical os, above the uterosacral ligaments, the knot at the posterior aspect of the uterus (Figure, C and D). At the conclusion of the procedure, the laparoscopic ports are removed, the gas evacuated, and the abdominal wall and skin are repaired in the usual fash- ion. No tocolytic agents were adminis- tered during or post procedurefor gravid patients. Perioperative antibiotics were administered at the discretion of the pri- mary surgeon. Nonpregnant patients were discharged home from the postop- erative recovery area; pregnant patients were admitted overnight for observation and a pelvic ultrasound to confirm fetal viability.

R ESULTS

Sixty-five patients underwentlaparoscopic cervico-isthmic cerclage during the study period; patient demographics are pre- sented in Table 1. Thirty-one patients un- derwent cerclage placement in the first or

OCTOBER 2009 American Journal of Obstetrics & Gynecology 364.e2

Research Obstetrics

www.AJOG.org

TABLE 2

 

Pregnancy outcomes following laparoscopic cervico-isthmic cerclage placement

 

Outcome

n

Perioperative pregnancy loss

n 2

 

T1 SA

n 1

T1 TA

n 1

IUFD

n 1

Delivery 24 wk with NND

n 6

Delivery 24 wk

n 54

Mean GA if pregnancy lasted 12 wk

34.4 5.4 wk (17-39 wk)

Mean GA if pregnancy lasted 24 wk

35.8 2.9 wk (24.5-39 wk)

Distribution of GA at delivery

24 28 wk

n 2

28

32 wk

n 5

32

36 wk

n 10

36

wk

n 53

NND with delivery 24 wk

n 1

 

No. of NICU admissions

n 12

No. with long-term sequelae of prematurity

n 0

Weeks of pregnancy gained: 13.2

Mean GA at delivery in last pregnancy

prior to cerclage:

19.7 8.0 wk

Mean GA at first delivery

 

postcerclage:

32.9 8.8 wk

Fetal salvage rate 6.5-fold improvement

No. of liveborn children at last pregnancy prior to cerclage:

8/67

(11.9%)

No. of liveborn children at first pregnancy 12 wk postcerclage 53/60 (88.3%)

GA , gestational age; IUFD , intrauterine fetal demise; NICU , neonatal intensive care unit; NND , neonatal death; T1 SA , first trimester spontaneous abortion; T1 TA , first trimester therapeutic abortion.

Whittle. Laparoscopic cervico-isthmic cerclage. Am J Obstet Gynecol 2009.

 

second trimester ( 16 weeks’ gestation) and 34 patients were not pregnant at the time of the surgery. Seven cases were con- verted to laparotomy due to either compli- cations arisingfrom uterine vessel bleeding (n 5) or impaired surgical visibility (n 2) due to morbid obesity; 6 of these pa-

tients were pregnant. Two patients experi- enced a perioperative pregnancy loss; both cases had been converted to laparotomy due to bleeding requiring uterine vessel li- gation and 1 of the cases was 16 weeks’ gestation. No other immediate surgical complications related to laparoscopy oc-

TABLE 3

Details of pregnancy failure

No. of cerclage failures

6

Mean GA at failure

20.7 / 2.9w (17–23)

 

Reason for failure

PPROM

n 3

Cervical dilatation clinical chorioamnionitis

n 2

Preterm labor

n 2

Placental pathology

Acute stage II/III chorioamnionitis

n 6

PPROM , premature preterm ruptured membranes

Whittle. Laparoscopic cervico-isthmic cerclage. Am J Obstet Gynecol 2009.

 

364.e3 American Journal of Obstetrics & Gynecology OCTOBER 2009

curred. All patients delivering after 24 weeks of gestation underwent cesarean section with the cerclage left intact; no op- erative complications of this surgery oc- curred. Six patients had the cerclage re- moved at the time of delivery and a tubal ligation performed. The cerclage was re- movedin 1 patient at the time of delivery at term as it was no longer intact, and 1 pa- tient had the cerclage removed postpar- tum through a posterior colpotomy as it had eroded through the posterior fornix into the vagina. Sixty-seven pregnancies have occurred in this study cohort and 8 patients remain nonpregnant. The overall pregnancy suc-

cess rate defined as number of live births

per number of pregnancies is 80.6%; de- tails of pregnancy outcomes are presented in Table 2. Three pregnancieswere aborted in the first trimester (1 patient had a termi- nation due to fetal trisomy 21); all 3 cases were managed by dilatation and curettage through the cerclage.Themean gestational age at delivery for all remaining pregnan- cieswas34.4 5.4weeks (17.0 –39.0wk);1 patient experienced an intrauterine fetal demise unrelated to the indication for the cerclage. Cerclage failure was defined as delivery prior to neonatal viability between 13 and23 6weeks of gestation;6 patients experienced a cerclage failure with a mean gestational age at presentation of 20.7 2.9 weeks (range, 17.0 –23.0 wk). Details of the clinical presentations are presented in Table 3; all failures were attributed to the clinical consequences of acute or subacute chorioamnionitis and occurred in women with a history of recurrent second trimes- ter loss. Each patient was managed with a posterior colpotomy for cerclage removal followed by a vaginal delivery; all patients received intravenous antibiotics due to the clinical diagnosis of chorioamnionitis, and 1 patient was septic with a positive blood culture for Escherichia coli. The mean gestational age at delivery if the pregnancy continued past viability was 35.8 2.9 weeks (range, 24.5–39.0 wk) (Table 4). The net number of weeks of pregnancy gained for those patients who had experienced a previous pregnancy loss was 13.5 weeks of gestation with a 6.5-fold increase in the number of liveborn chil- dren compared with the pregnancy imme- diately preceding the cerclage. Twelve ba-

www.AJOG.org

Obstetrics Research

TABLE 4

Effect of timing and indication for cerclage on pregnancy outcome

Indication for cervico-isthmic cerclage

Previous T2 loss / cone biopsy

31.2 / 7.8 w (17–38 w)

Previous failed vaginal cerclage / cone biopsy

34.1 / 5.3 w (20–38 w)

Nulliparous with prior cone biopsy

1 delivery at 34 w

3 delivery at 37 w

Timing of cerclage: mean GA at delivery for pregnancies 12 w

Cerclage placed in pregnancy

32.9 / 8.8 w

Cerclage placed nonpregnant

34.5 / 4.9 w

Pregnancy failures (perioperative loss, IUFD, delivery 24 w, NND)

Cerclage placed in pregnancy

n 7

Cerclage placed nonpregnant

n 2

IUFD , intrauterine fetal demise; NND, neonatal death. Whittle. Laparoscopic cervico-isthmic cerclage. Am J Obstet Gynecol 2009.

bies were admitted to the neonatal intensive care unit, 1 baby died due to ex- treme prematurity, and no other long- term sequelae of prematurity were re- ported. Nine patients have had a second term ( 37 weeks) pregnancy with the same cerclage in situ, and 1 patient has had 3 term pregnancies. Two patients had a twin gestation at the time of cerclage place- ment in the first trimester; both patients delivered healthy children after 34weeks of gestationwith nolong-term complications of preterm birth. Overall, the timing of cerclage place- ment did not influence the gestational age at delivery but cerclage failure did occur more often when the cerclage was placed during that pregnancy (Table 4). The indi- cation for cerclage did not affect the gesta- tional age at delivery, butin the small num- ber of patients for whom the cerclage was placed due to insufficient cervical tissue there was no cerclage failure (Table 4). Table 5 presents the outcome of previ- ously published retrospective cohorts of cervico-isthmic cerclage placed by both laparotomy and laparoscopy with an op- erative complication rates of 0-25% and fetal survival rates between 60-100%.

C OMMENT

Cervical incompetence, defined as preg- nancy loss following painless cervical di- latation, has been traditionally treated

with a cerclage placed in the vaginal por- tion of the cervix in the subsequent preg- nancy. 1 This therapeutic intervention is based on the assumption that the struc- tural integrity of the cervical tissue has insufficient strength to act as a barrier to delivery against the increasing intrauter- ine pressure of the growing gestational sac. 1 When this vaginal cerclage fails to hold the cervix closed or cannot be placed due to insufficient cervical tissue, an alternative approach is the placement of a cerclage at the cervico-isthmus of the uterus. Conventionally, this type of cer- clage is placed in the first trimester of pregnancy through a laparotomy; how- ever, with the advent of minimally inva- sive surgery, placement by laparoscopy has been described in case reports and series ( Table 5 ). 7-30 The purpose of this study was to describe the surgical tech- nique for the laparoscopic cervico-isth- mic cerclage, its associated obstetric out- comes, and compare these outcomes with the traditional laparotomy ap- proach using previously reported co- horts that describe both rates of opera- tive complications and fetal survival.

Surgical considerations

The advantages of a minimally invasive approach are well established; we pro- vide evidence that this approach confers similar if not a slightly improved rate of

perioperative complications as the cer- vico-isthmic cerclage placed by laparot- omy (10% vs 0-25%, respectively; Table

5 ). The main complication of either ap-

proach was excessive blood loss—in our series no patient required a blood trans- fusion. The second most common com- plication was the conversion to laparot- omy due to surgical visibility—such a complication should be considered in the context that 58 women were spared a laparotomy by having the cerclage placed laparoscopically. Since the cer- clage is placed similar to a “noose” in the area of the cervical isthmus, a potential complication is compression of the uter- ine vessels leading to compromised uter- ine blood flow and subsequent fetal de- mise; our perioperative losses could be attributed to uterine vessel compression but may also be in part due to specific vessel ligation to arrest excessive bleed- ing. The reported perioperative loss rate by us and others did not occur with any greater incidence using the laparoscopic approach and likely is a risk of this type of cerclage regardless of the surgical ap- proach. As the uterine size increases it does become a technically more chal- lenging procedure; although we reported only 2 cases of cerclage placement in the second trimester, 1 was complicated by conversion andfetal loss. In addition, the conversion to laparotomy did occur more frequently when the patient was pregnant. Placement of this cerclage us- ing a vaginal approach with tissue dissec- tion similar to that of a vaginal hysterec- tomy has recently been described; this technique may be advantageous for women who present in the late first or early second trimester. 31 A #1 Prolene suture was chosen in this study with the rationale based on ease of handling for placement and removal compared with the traditional 5 mm Mersilene tape; this rationale is similarly supported by Rust et al 32 in the choice of suture material for a vaginal cerclage. The successful results we present support the use of this type of suture material in regard to its integrity and strength. Concerning the technique for knot tying, since the Roeder knot strength has been determined to be equivalent to the intracorporeal knot,

OCTOBER 2009 American Journal of Obstetrics & Gynecology 364.e4

Research Obstetrics

www.AJOG.org

TABLE 5

Cumulative results of cervico-isthmic cerclage placed during pregnancy by laparotomy and cervico-isthmic cerclage placed by laparoscopy in both pregnant and nonpregnant patients

Cerclage placed by laparotomy:

Patient

Pregnancy

Intraoperative complication a rate, %

Fetal survival

study and year

no.

no.

rate, %

Benson and Durfee 1965

10

13

Not reported

82

Watkins 1972

2

2

Not reported

100

Mahran 1978

10

10

0

70

Olsen and Tobiassen 1982

17

17

Not reported

88

Novy 1982

16

22

Not reported

95

Wallenberg and Lotgering 1987

13

16

0

94

Herron and Parer 1988

8

13

Not reported

85

Van Dongen et al 1991

14

16

14.2

96

Novy 1991

20

21

0

90

Cammarano et al 1995

23

29

21.7

93

Anthony et al 1997

13

15

7.6

87

Craig and Fliegner 1997

4

5

25

60

Turnquest et al 1999

11

12

0

83

Davis et al 2000

40

40

0

97

Lotgering et al 2006

101

101

5

93.5

Debbs et al 2007

75

75

4

96

Scibetta et al 1998

1

1

0

100

Lesser et al 1998

1

1

0

100

Mingione et al 2003

11

12

9

83

Cho et al 2003

20

19

0

95

Gallot et al 2003

3

2

0

100

Ghomi et al 2006

1

1

0

100

Aboujaoude et al 2007

1

1

0

Not reported

Agdi et al 2008

1

1

0

100

Reid et al 2008

2

0

0

100

Current study

65

67

10.7

80

a Intraoperative complications include: cystotomy, bleeding 500c, bleeding requiring transfusion, perioperative pregnancy loss, ruptured fetal membranes. Whittle. Laparoscopic cervico-isthmic cerclage. Am J Obstet Gynecol 2009.

the posterior location of our knot place- ment favors the Roeder knot especially with the bulky pregnant uterus. 33 We conclude that the laparoscopic approach for the placement of the cervico-isthmic cerclage confers a similar rate of periop- erative complications as the traditional laparotomy and is best completed non- pregnant or early in the first trimester.

Obstetric considerations

In our series, the fetal survival rate was 80.6%; however, takinginto account that 3 losses were in the first trimester and that 1 patient suffered anintrauterine demise not

attributable to the cerclage, the true cer- clage success rate should be defined by the pregnancies lost at the time of surgery (2 cases) and the number of live, take home babies (58 cases) after the first trimester is completed. By this definition, the rate of cerclage success was 89%, making the ob- stetric outcome after laparoscopic cervico- isthmic cerclage comparable to that of the abdominal approach and to that reported by others using a laparoscopic approach (Table 5). Based on the failures that occurred in our series, what has become apparent is

364.e5 American Journal of Obstetrics & Gynecology OCTOBER 2009

that cervical incompetence is a complex disease that cannot be treated solely with the placement of a cerclage—either vagi- nally or at the cervico-isthmus; multiple etiologies lead to a common final pathway of undesired cervical dilatation and efface- ment. Cervical incompetence should be described in 2main categories:mechanical and functional. Mechanical incompetence implies that the cervical components do not have the strength to maintain the structure of the cervix through gestation. 1 Postulated risk factors include: cervical structural anomalies due to in utero dieth-

www.AJOG.org

Obstetrics Research

FIGURE

www.AJOG.org Obstetrics Research FIGURE D A, Laparoscopic intraabdominal view of the placement of the suture to
www.AJOG.org Obstetrics Research FIGURE D A, Laparoscopic intraabdominal view of the placement of the suture to
www.AJOG.org Obstetrics Research FIGURE D A, Laparoscopic intraabdominal view of the placement of the suture to
D
D

A, Laparoscopic intraabdominal view of the placement of the suture to pass from the posterior aspect of the broad ligament window through anteriorly to prepare the trailing suture length for the final step; in this step the needle and suture sit lateral to the uterine vessels. B, Laparoscopic intraabdominal view of the placement of the suture through both peritoneal broad ligament windows in preparation for the knot tying. C, Laparoscopic intraabdominal view of the suture placement in the sit at the level of the internal cervical os, above the uterosacral ligaments, the knot at the posterior aspect of the uterus. D, Schematic representation of cervico-isthmic cerclage placement ( blue ) medial to the uterine vessels and above the uterosacral ligaments.

Whittle. Laparoscopic cervicoisthmic cerclage. Am J Obstet Gynecol 2009.

ylstilbestrol exposure, overdilatation of the cervix during pregnancy termination, cer- vical trauma from conization or loop elec- trosurgical excision procedures, congeni- tal mullerian anomalies, obstetric trauma including cervical lacerations, prolonged second stage of labor, precipitous deliv- ery. 1 Each risk factor describes a type of damage to the anatomic elements of the cervix and should be the defining indica- tion(s) for the cervico-isthmic cerclage re- gardless of the surgical approach. Given that each of the cerclage failures we reported in our series occurred in women who presented with symptoms

and signs consistent with chorioamnioni- tis, we propose that these patients may have an underlying pathology resulting in prematurity that is not solely attributable to mechanical cervical failure. A similar proposal has been suggested by Drakely et al, 34 who reported a 5% dual pathology rate in women with second trimester preg- nancy loss. Functionalincompetenceis the premature triggering of the cervical ripen- ing process that occurs at term; postulated risk factors include subacute or acute in- fection of the genitourinary tract and/or uterine cavity, abnormal placental devel- opment, suspension of the antiinflamma-

tory effects of progesterone, and preterm labor. 1 Each risk factor describes a proin- flammatory environment that promotes cervical ripening for which a cervical cer- clage will not suspend. The patients for whom the cerclage failed in this present pregnancy each presented with a clear in- fectious/inflammatory process and each had experienced a previous pregnancy loss with a similar presentation. Himes and Simhan 35 have reported that placental in- flammatory lesions including acute cho- rioamnionitis are associated with a signifi- cant risk of recurrent spontaneous preterm birth. Furthermore, Edmondson

OCTOBER 2009 American Journal of Obstetrics & Gynecology 364.e6

Research Obstetrics

www.AJOG.org

et al 36 reported that chronic endometritis leading to chronic deciduitis plays a role in the etiology of preterm labor and prema- ture rupturedmembranes. Detailed exam- ination of the past obstetric history and placental pathology(ies) is imperative to identify risk factors for pregnancy loss, in particular a history of recurrent infectious/ inflammatory preterm birth, that are not related to the structuralintegrity of the cer- vix. In such cases, counseling in regard to realistic expectations of the cerclage must be undertaken and potential role for chronic antibiotic and/or progesterone therapy must be explored. However, each of the patients who failed the cervico-isth- mic cerclage had a previous failed vaginal cerclage, which can cause damage to the structural integrity of the cervix, com- pounding the riskfor pregnancyloss by su- perimposing riskfor mechanicalfailure on a background of inflammatory/infectious risk factors for premature cervical ripen- ing. As such, we recommend a compre- hensive evaluation of all women prior to cervico-isthmic cerclage placement in- cluding: radiographic evaluation of the uterine cavity, thrombophilia screen, de- tailed evaluation of obstetric history espe- cially placenta pathology, cervico-vaginal swabs, and endometrial biopsy if any evi- dence of inflammatory lesions within the previous placental pathology. Patient se- lection remains the greatest challenge to and predictor of cerclage success regardless of the location of its placement. In summary, our data indicated that the cervico-isthmic cerclage placed laparo- scopically comparesfavorablywith the tra- ditional laparotomy approach in regard to operative technique, risk of complications, and obstetric outcome; in the carefully se- lected patient this cerclage may provide a reasonable alternative to achieve preg-

nancy success.

f

REFERENCES

1. Shennan A, Jones B. The cervix and prema-

turity: aetiology, prediction and prevention. Se- min Fetal Neonatal Med 2004;9:471-9.

2. Benson RC, Durfee RB. Transabdominal cer-

vico uterine during pregnancy for the treatment of cervical incompetency. Obstet Gynecol

1965;25:145-55.

3. McDonald IA. Suture of the cervix for inevita-

ble miscarriage. J Obstet Gynaecol Br Emp

1957;64:346-50.

4. Novy MJ. Transabdominal cervicoisthmic

cerclage for the management of repetitive abor- tion and premature delivery. Am J Obstet Gy- necol 1982;1:44-54.

5. Lotgering FK, Gaugler-Senden IP, Lotgering

SF, Wallenburg HC. Outcome after transab-

dominal cervicoisthmic cerclage. Obstet Gy- necol 2006;107:779-84.

6. Scibetta JJ, Sanko SR, Phipps WR. Laparo-

scopic transabdominal cervicoisthmic cer- clage. Fertil Steril 1998;69:161-3.

7. Reid GD, Wills HJ, Shukla A, Hammill P.

Laparoscopic transabdominal cervico-isthmic

cerclage: a minimally invasive approach. Aust N

21. Herron MA, Parer JT. Transabdominal cer-

clage for fetal wastage due to cervical incom- petence. Obstet Gynecol 1988;71:865-8.

22. Van Dongen PWJ, Nijhuis JG. Transab-

dominal cerclage. Eur J Obstet Gynecol

1991;41:97-104.

23. Novy MJ. Transabdominal cervicoisthmic

cerclage: a reappraisal 25 years after its intro- duction. Am J Obstet Gynecol 1991;164:

1635-41.

24. Cammarano CL, Herron MA, Parer JT. Va-

lidity of indications for transabdominal cerclage for cervical incompetence. Am J Obstet Gy- necol 1995:172:1871-5.

Z

J Obstet Gynaecol 2008;48:185-8.

25.

Anthony GS, Walker RG, Cameron AD,

8.

Agdi M, Tulandi T. Placement and removal of

Proce JL, Walker JJ, Calder AA. Transabdom-

abdominal cerclage by laparoscopy. Reprod Biomed Online 2008;16:308-10.

9. Aboujaoude R, Maloof P, Alvarez M, Al Khan

A. A novel method for laparoscopic abdominal

cerclage utilizing minimally invasive hydrodis- section: a case report. J Reprod Med

2007;52:428-30.

10. Ghomi A, Rodgers B. Laparoscopic ab-

dominal cerclage during pregnancy: a case re- port and a review of the described operative techniques. J Minim Invasive Gynecol 2006;

13:337-41.

11. Gallot D, Savary D, Laurichesse H, Bour-

nazeau JA, Amblard J, Lémery D. Experience

with three cases of laparoscopic transabdomi- nal cervico-isthmic cerclage and two subse- quent pregnancies. BJOG 2003;110:696-700.

12. Cho CH, Kim TH, Kwon SH, Kim JI, Yoon

SD, Cha SD. Laparoscopic transabdominal

cervicoisthmic cerclage during pregnancy.

J Am Assoc Gynecol Laparosc 2003;10:363-6.

13. Mingione MJ, Scibetta JJ, Sanko SR,

Phipps WR. Clinical outcomes following interval laparoscopic transabdominal cervico-isthmic cerclage placement: case series. Hum Reprod

2003;18:1716-9.

14. Lesser KB, Childers JM, Surwit EA. Trans-

abdominal cerclage: a laparoscopic approach. Obstet Gynecol 1998;9:855-6.

15. Leyland NA. Laparoscopic cervical cerclage—

video presentation. American Association of Gy-

necologic Laparascopists 30th Annual Clinical Meeting; Miami, FL: 2002.

16. BonjerHJ,HazebroekEJ,KazemierG,Giuffrida

MC, Meijer WS, Lange JF. Open versus closed es- tablishment of pneumoperitoneum in laparoscopic surgery. Br J Surg 1997;84:599-602.

17. Watkins RA. Transabdominal cervico-uter-

ine suture. AustNZJ Obstet Gynaecol

1972;12:62-4.

18. Mahran M. Transabdominal cervical cer-

clage during pregnancy: a modified technique. Obstet Gynecol 1978;52:502-6.

19. Olsen S, Tobiassen T. Transabdominal isth-

mic cerclage for the treatment of incompetent cervix. Acta Obstet Gynecol Scand 1982;

61:473-5.

20. Wallenburg HC, Lotgering FK. Transab-

dominal cerclage for closure of the incompetent cervix. Eur J Obstet Gynecol Reprod Biol

1987;25:121-9.

inal cervico-isthmic cerclage in the manage- ment of cervical incompetence. Eur J Obstet Gynecol 1997;72:127-30.

26. Craig S, Fliegner JRH. Treatment of cervical

incompetence by transabdominal cervico-isth- mic cerclage. Aust NZ J Obstet Gynecol

1997;37:407-11.

27. Turnquest MA, Britton KA, Brown HL. Out-

come of patients undergoing transabdominal

cerclage: a descriptive study. J Matern Fetal Med 1999;8:225-7.

28. Davis G, Berghella V, Talucci M, Wapner

RJ. Patients with a prior failed transvaginal cer- clage: a comparison of obstetric outcomes with either transabdominal or transvaginal cerclage. Am J Obstet Gynecol 2000;183:836-9.

29. Hole J, Tressler T, Martinez F. Elective and

emergency transabdominal cervicoisthmic cer-

clage for cervical incompetence. J Reprod Med

2003;48:596-600.

30. Debbs RH, De La Vega GA, Pearson S, Seh-

dev H, Marchiano D, Ludmir J. Transabdominal cerclage after comprehensive evaluation of

women with previous unsuccessful transvaginal cerclage. Am J Obstet Gynecol 2007;197:

317.e1-4.

31. Katz M, Abrahams C. Transvaginal place-

ment of cervicoisthmic cerclage: report on pregnancy outcome. Am J Obstet Gynecol 2005;92:1989-92; discussion 1992-4.

32. Rust OA, Atlas RO, Jones KJ, Benham BN,

Balducci J. A randomized trial of cerclage ver- sus no cerclage among patients with ultrasono- graphically detected second-trimester preterm dilatation of the internal os. Am J Obstet Gy- necol 2000;183:830-5.

33. Sharp HT, Dorsey JH, Chovan JD, Holtz

PM. A simple modification to add strength to the Roeder knot. J Am Assoc Gynecol Laporsc

1996;3:305-7.

34. Drakeley AJ, Quenby S, Farquharson RG.

Mid-trimester loss—appraisal of a screening protocol. Hum Reprod 1998;13:1975-80.

35. Himes KP, Simhan HN. Risk of recurrent

preterm birth and placental pathology. Obstet Gynecol 2008;112:121-6.

36. Edmondson N, Bocking A, Machin G, Rizek

R, Watson C, Keating S. The prevalence of chronic deciduitis in cases of preterm labor without clinical chorioamnionitis. Pediatr Dev Pathol 2008;2:1.

364.e7 American Journal of Obstetrics & Gynecology OCTOBER 2009