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Validity of indications for transabdominal cervicoisthmic cerclage for cervical incompetence
Volume 172, Number 6 Am J Obstet Gynecol
team, if all these patients are provided for in the private community under the existing format, there may be compromised care. Although I can't quantitate it, working in the clinic makes me feel that this program is extremely valuable. It is important that these patients be managed by a health care team. Time constraints, and our lack of overall knowledge of the socioeconomic dynamics of poverty and how it affects care, limit what the obstetrician can provide. I do agree that the private patients would certainly have benefited by having the collaboration of both certified nurse-midwives and the obstetri-
Cammarano, Herron, and Parer
cian. Optimum care for all patients in this country would benefit from such a collaborative relationship. With regard to the incentive for vaginal birth after cesarean section, because insurance companies will probably mandate that all patients who have had a prior cesarean section will have to undergo vaginal birth incentives may be a moot point. In hopes of encouraging more vaginal births after cesarean deliveries the financial incentives could be reversed. Regarding external versions, all patients who had a breech presentation, either in the clinic or privately, were offered and encouraged to have external version.
Validity of indications for transabdominal cervicoisthmic cerclage for cervical incompetence C.L. Cammarano, MD, M.A. Herron, RN, BSN, and J.T. Parer, MD, PhD San Francisco, California OBdECTIVE: Our purpose was to review the indications for transabdominal cervicoisthmic cerclage to determine whether it is a valid alternative to transvaginal cerclage. STUDY DESIGN: A retrospective review of transabdominal cerclage patients at one institution from 1978 to 1994, analysis of the indications for the transabdominal rather than the vaginal approach, and evaluation of fetal outcomes was performed. RESULTS: Twenty-three patients underwent 24 transabdominal cerclages. The primary indication for transabdominal cervicoisthmic cerclage was failed transvaginal cerclage in 14 patients and anatomic unsuitability for transvaginal cerclage in nine. Of the latter, five were a result of diethylstilbestrol exposure and four a result of cervical surgery. All patients were successfully delivered of one or more live babies (total 28, including two sets of twins). Two losses occurred, one after rupture of membranes at 21 weeks on the second pregnancy after cerclage placement and one intraoperative loss with herniation of the membranes. The live birth rate was 93%, compared with 18% salvage of pregnancies beyond the first trimester before the transabdominal cervicoisthmic cerclage procedure. Complications included blood loss requiring transfusion (four patients), although none of these occurred in the last 12 patients. CONCLUSION: We conclude that all the patients had a history compatible with incompetent cervix requiring a cerclage, and none were suitable candidates for a vaginal cerclage. We further conclude that with strict indications transabdominal cervicoisthmic cerclage offers a high rate of fetal salvage with a minimum of complications in patients with extremely poor obstetric histories because of cervical incompetence. (AM J OBSTETGYNECOL1995; 172:1871-5.)
Key words: Transabdominal cervicoisthmic cerclage, cervical incompetence Transabdominal cervicoisthmic cerclage was first introduced in 1975 by Benson and Durfee ~ as an alterFrom the Department of Obstetrics, Gynecolog~ and Reproductive Sciences, University of California, San Francisco. Presented at the Sixty-first Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Scottsdale, Arizona, October 24-29, 1994. Reprint requests:Julian 7", Parer, MD, PhD, University of California, San Francisco, Department of Obstetrics, Gynecology, and Reproductive Sciences, 513 Parnassus, Rm. HSE-1462, Box 0550, San Francisco, CA 94143. Copyright © 1995 by Mosby-Year Book, Inc. 0002-9378/95 $3.00 + 0 6/6/63568
native to transvaginal cerclage in a small subset of women. Subsequendy, numerous reports have shown improved outcome after this procedure, with fetal salvage rates approaching 90%. ~-8These reports suggested that with certain indications transabdominal cervicoisthmic cerclage is a valid alternative to transvaginal cerclage. These indications consisted of the following conditions: (1) congenitally short or extensively amputated cervix, (2) marked scarfing of the cervix, as after unsuccessful transvaginal cerclage, (3) deeply notched multiple cervical defects, (4) penetrating forniceal lac1871
1872 Cammarano, Herron, and Parer
June 1995 Am J Obstet Gynecol
Table I. Pregnancy history before t r a n s a b d o m i n a l cerclage and indications for p r o c e d u r e Trimester of termination
Case No.
1
Date
Age ( y r )
Gravidity
Third
3/78
23
4
1
37
4
0
2
I
Second
L I First
living children
Indication for TAC
0
1
4
0
0
Scarred cervix; failed vaginal cerclage x 1 Deep cervical laceration, failed vaginal cerclage x 2 Anatomic defect on posterior cervical wall, failed vaginal cerclage x 3 Surgical amputation of cervix, failed vaginal cerclage x 1 Deep cone biopsy, posterior lip of cervix absent Anatomically short cervix (DES) Cervical laceration to lateral fornix, failed vaginal cerclage x 3 Short cervix (DES), failed vaginal cerclage x 1 Short cervix (DES), failed vaginal cerclage x 1 DES, failed vaginal cerclage x 2 DES, cervical erostion and laceration from prior successful vaginal cerclages DES, cervical absence from deep cone biopsy Deep cone biopsy, failed vaginal cerclage x 2 Deep cone biopsy, failed vaginal cerclage x 2 DES, failed vaginal cerclage x 1 DES, inadequate length for vaginal cerclage Short cervix from deep cone biopsy DES, multiple surgeries for dysplasia Anatomically short cervix, inadequate length for vaginal cerclage Failed vaginal cerclage x 1 Failed vaginal cerclage x 3, deep cone biopsy Inadequate length for vaginal cerclage Cervical scar to fornix, failed vaginal cerclage x 2
3
3
1/86
25
4
0
3
1
0
4
4/83
37
11
1
3
7
0
5
5/84
27
3
3
0
0
2
6
7/86
28
1
0
1
0
0
7
2/87
32
5
1
3
1
1
8
11/86
31
2
1
1
0
1
9
5/87
30
2
0
2
0
0
10
7/87
29
2
1
1
0
1
11
2/88
33
4
2
1
1
2
12
2/88
36
2
0
0
2
0
13
9/87
31
2
0
2
0
0
14
12/89
32
5
0
4
1
0
15
4/90
39
5
0
3
2
0
16
5/90
37
3
0
2
1
0
17
9/90
38
3
1
2
0
1
18
9/91
33
1
0
0
1
0
19
9/91
31
3
0
2
1
0
20
3/92
37
3
0
2
1
0
21
6/92
35
6
0
5
1
0
22
9/92
37
2
1
1
0
1
23
7/93
32
7
1
3
3
1
TAC, Transabdominal cervicoisthmic cerclage; DES, diethylstilbestroi.
erations, (5) subacute cervicitis, (6) wide or extensive cervical conization, (7) cervicovaginal fistulas after abortion, and (8) o n e or m o r e previous vaginal cerclage failures.
In this r e p o r t we e x a m i n e d the indications for transa b d o m i n a l cervicoisthmic cerclage in cases w h e r e it was believed that transvaginal cerclage was not w a r r e n t e d and e x a m i n e d its effectiveness.
Volume 172, Number 6 Am J Obstet Gynecol
Cammarano, Herron, and Parer
1873
Table II. Details of transabdominal cerclage and outcome
Case No. 1 2a 2b 3 4a
Week of cerclage 17 14 In place, previous pregnancy 13 14
EBL (ml) 100 400 100 1300
5
In place 14
6
18
1300
7a
13
500
7b
In place, previous pregnancy; replaced after hysterotomy at 21 wk 3 days In place In place 13 14
500
4b
7c 7d 8 9a
100
Operative complications
Delivery
Birth weight (gin)
-
36 wk 38 wk 1 day 37 wk 5 days
2650 3140 3380
38 wk 3 days
3000
None None None Membranes prolapsed and ruptured during procedure, suture placed after abortion, transfusion (1 u)
m
38 wk 38 wk
None Pancytopenia (moderate), transfusion (4 U) Uterine artery puncture, moderate blood loss
m
100 200
None Bleeding ~om leh sided suture, transfusion (2 U)
9b 10 11
In place 17 13
200 300
12 13 14 15 16
13 14 13 13 13
75 250 150 100 100
None Transfusion (1U autologous) None None None None None
17 18 19 20 21 22 23
15 15 12 12 13 15 13
100 250 50 200 200 100 50
None None None None None None None
38 wk 2 days
3000 3500 3500* 3740
36 wk 3 days
2300
SROM hyste~ ectomy
350
37 wk 5 days 38 wk 6 days 36 wk 38 wk
2980 3640 3000 3268
Term 34 wk 3 days 37 wk 6 days
Unavailable 2430 3590
39 wk Term 36 wk 4 days 34 wk 5 d a y s 33 wk 4 days
3420 3000 2680 Unavailable 1480 2120" 3320 3350 Unavailable 3750 3620 2130 3210
Term 38 wk 37 wk 2 days 37 wk 37 wk 6 days 33 wk 1 day 38 wk
EBL, Estimated blood loss; SROM, spontaneous rupture of membranes. *Twins.
Material and methods Twenty-three patients were referred for evaluation for placement of a transabdominal cerclage; these patients underwent 24 procedures. Table I summarizes the obstetric histories and indications for cerclage in these patients. In most cases the patient had undergone one or more attempts at vaginal cerclage. Histories of McDonald cerclage, Shirodkar cerclage, or both appeared with equal frequency. In one patient (case 4) a Lash procedure was attempted to repair the cervix before referral. The operation was performed at a mean gestational age of 14.5 weeks with a range of 12 to 18 weeks (Table II) in a m a n n e r previously described in detail. 7 One
surgeon (J.T.P.) performed all procedures; he was assisted by either another attending physician or a fellow in maternal-fetal medicine. After fetal viability was confirmed, the procedure was performed with the patient u n d e r general, continuous epidural or continuous spinal anesthesia. A vertical skin incision was performed in all cases. The bladder peritoneum was reflected and the cervix palpated. A tunnel through the paracervical tissue was created at the level of the internal cervical os, and a 5 m m Mersilene (Ethicon, Somerville, N.J.) polyester fiber band was used for the cerclage. The knot was tied anteriorly, and the ends were then tacked down with a nonabsorbable suture. Prophylactic antibiotics were not given, except in one patient (case 22) where
June 1995
1874 Cammarano,Herron, and Parer
Am J Obstet Gynecol
Table I l L Maternal pregnancy-related data before transabdominal cervicoisthmic cerclage (n = 23)
Age (yr) Gravidity No. of living children
Mean
Range
32.6 3.6 0.5
23-39 1- 11 0-2
membranes were bulging at the time of surgery. Tocolytics were not used prophylactically, although many patients did receive them later in pregnancy.
Results The results after cerclage are shown in Table II. Twenty-three patients underwent 24 transabdominal cerclages. A summary 9 f the maternal precerclage pregnancy data is given in Tables III and IV. Before placement of the transabdominal cervicoisthmic cerclage these 23 patients had 60 pregnancies lasting beyond the first trimester, which culminated in 11 live births for a fetal salvage rate of 18%. The primary indication for transabdominal cervicoisthmic cerclage was failed transvaginal cerclage in 14 patients and anatomic unsuitability for transvaginal cerclage in nine. Of the latter, five were from DES exposure and four from cervical surgery. One DES-exposed patient (case 11) had two prior successful vaginal cerclages that left the cervix too lacerated at the next pregnancy to attempt a third. All patients were successfully delivered of one or more live babies (total 29 including two sets of twins). All live-born infants were delivered after 33 weeks, 19 of whom were > 37 weeks. All patients had at least modified bed rest throughout pregnancy and about haft received tocolytic therapy. Delivery was by cesarean section in all cases. In cases where childbearing was completed, the suture was removed. The postcerclage results are summarized in Table V. Precerclage and postcerclage outcomes are summarized in Table VI. There were two fetal losses. The first was an intraoperative failure (case 4a) during placement of the suture, when the membranes "hourglassed" through the absent cervix and, during an attempt at reduction, ruptured and the fetus was expelled. After the placenta was removed, the stitch was placed and the patient had a successful pregnancy. The second loss occurred in case 7b. The cerclage was successful for the initial pregnancy. However, rupture of membranes occurred at 21.5 weeks in the second pregnancy. At the time of hysterotomy another suture was placed and was successful in two subsequent pregnancies. The major complication other than fetal loss was hemorrhage. Five patients had blood loss > 400 ml, and four patients required transfusion. Three patients had hemorrhage directly related to the procedure itself. In case 4a no cervix was palpable, and suture placement
Table IV. History and major indication for transabdominal cerclage Failed vaginal cerclage Fetal wastage with incompetent cervix, and very short or deranged cervix Fear of fetal wastage, with very short cervix
14 7 2
too low in the lower uterine segment resulted in heavy bleeding, membrane prolapse, and fetal loss. This patient required removal of the original suture, curettage of the uterus, and replacement of the suture. The cumulative blood loss was 1300 ml. The patient was given 1 unit of blood at an intraoperative hematocrit of 29%. The postoperative hematocrit was stable at 30%. In case 9 a left uterine vein was lacerated during tunneling and required ligation. This resulted in an estimated 500 ml blood loss and transfusion of 2 units on the first postoperative day for orthostasis and a hematocrit of 20%. There was a 500 ml estimated blood loss in case 7a but no transfusion after a uterine artery puncture and ligation. In case 6 there was a preexisting autoimmune pancytopenia of unknown cause. The preoperative hematocrit was 29%, and platelets were 113,000 × 106.L -l. Bleeding time and coagulation panel were normal. A blood loss of 1300 ml resulted during surgery and four units of packed red blood cells was given. The patient was extensively counseled before surgery as to the likelihood of transfusion. The fifth patient, case 11, received an autologous unit at a postoperative hematocrit of 33%. Excluding these patients, the average blood loss was 200 ml. There have been no transfusions in the last 12 patients.
Comment Recent data indicate that transabdominal cervicoisthmic cerclage remains a viable alternative to vaginal cerclage in those patients who have recurrent pregnancy loss. A recent review by Novys reported a cumulatie success rate of 90% in the world literature. This surpasses the overall success rate reported for transvaginal procedures. 9 The strict indications applied to selection of patients in our series support the view that incompetent cervix is responsible for poor pregnancy outcome and that a risk-benefit assessment favors placement of transabdominal cervicoisthmic cerclage rather than vaginal cervical cerclage. In all cases either lack of cervical tissue or failed attempts at prior vaginal cerclages left transabdominal cervicoisthmic cerclage as the desired option in the current pregnancy. Cervicitis was not an indication in our series. The unique subset of patients identified by applying the above strict criteria is probably partially responsible for the uniformly good outcome. Although vaginal cerclage is an easier approach
Volume 172, Number 6
Carnmarano, Herron, and Parer
Am J Obstet Gynecol
1875
Table V. Summary of outcome after transabdominal cerclage
Mean Week of transabdominal cerclage No. of mothers with successful pregnancies after TAC Gestational age at delivery (excluding two extremely premature) Birth weight (gin) (excluding two extremely premature)
14 23 37.3
[
Range 12-18 1-3 (babies) 33 wk 1 day-39 wk
3046
1480-3740
TAC, Transabdominal cervicoisthmic cerclage. and does not require future laparotomy, in many of the patients such a procedure would have been technically difficult, if not impossible. Therefore attempting vaginal cerclage in these patients would appear to be contraindicated. In our series the fetal salvage rate before and after transabdominal cervicoisthmic cerclage is markedly improved. Although bed rest, tocolytic therapy, and improved neonatal intensive care almost certainly played a role in these outcomes, the high number of term and late-third-trimester infants delivered after compared with before transabdominal cervicoisthmic cerclage where these same modalities were available strongly suggests a major contribution from transabdominal cervicoisthmic cerclage. The major objections to transabdominal cervicoisthmic cerclage are the need for multiple laparotomies and the risk of major blood loss from operating in an extremely vascular area. With improved surgical and anesthesia techniques the risks accompanying multiple laparotomies diminishes. Furthermore, the transabdominal cervicoisthmic cerclage may be left in place for future pregnancies, whereas a vaginal cerclage must be replaced. In patients who meet the criteria for transabdominal cervicoisthmic cerclage multiple vaginal surgeries offer a comparable degree of surgical morbidity with the possibility of a lower likelihood of successful pregnancy outcome. Blood loss remains a problem in the technique described in this series. However, Novy's~ recent review describes an alternative technique of manual retraction of the uterine vessels and passage of suture in the clear space between the vessels and the uterine isthmus without tunneling. With this technique at least three of our intraoperative hemorrages may have been avoided. On the other hand, our estimated blood loss in the last 15 patients (not all reported here) is < 150 ml, possibly
Table VI. Pregnancy outcome beyond first trimester before and after transabdominal cervicoisthmic cerclage
Before ] Aj~er Deliveries beyond first trimester Fetal losses beyond first trimester Fetal salvage (%)
60 49 18
29 2 93
reflecting improved familiarity with the procedure. In addition, all patients now store autologous blood, so the adverse consequences of blood replacement are less. We conclude that the transabdominal cervicoisthmic cerclage offers a high rate of fetal salvage with a minimum of complications in patients with extremely poor obstetric histories as a result of cervical incompetence, where vaginal cerclage is not warranted. REFERENCES
1. Benson RC, Durfee RB. Transabdominal cervicouterine cerclage during pregnancy for the treatment of cervical incompetency. Obstet Gynecol 1965;25:145-55. 2. Novy MJ. "Fransabdominal cervicoisthmic cerclage for the management of repetitive abortion and premature delivery. AMJ OBSTETG~rcoc 1982;143:44-54. 3. Olsen S, Tobiassen T. Transabdominal isthmic cerclage for the treatment of incompetent cervix. Acta Obstet Gynecol Scand 1982;61:473-5. 4. Watkins RA. Transabdominal cervico-uterine suture. Aust N Z J Obstet Gynaecol 1972;12:62-4. 5. Mahran M. Transabdominal cervical cerclage during pregnancy. Obstet Gynecol 1978;52:502-6. 6. Loock W, Zur transabdominalen Zervixumschlingung nach Ardillo. Geburtshilfe Frauenheilkd 1980;40:517-9. 7. Herron MA, Parer JT. Transabdominal cerclage for fetal wastage due to cervical incompetence. Obstet Gynecol 1988;71:865-8. 8. Novy MJ. Transabdominal cervicoisthmic cerclage: a reappraisal 25 years after its introduction. AMJ OBSTETGYNECOL 1992;164:1635-41. 9. Cousins L. Cervical incompetence, 1980: a time for reappraisal. Clin Obstet Gynecol 1980;23:467-79.
team, if all these patients are provided for in the private community under the existing format, there may be compromised care. Although I can't quantitate it, working in the clinic makes me feel that this program is extremely valuable. It is important that these patients be managed by a health care team. Time constraints, and our lack of overall knowledge of the socioeconomic dynamics of poverty and how it affects care, limit what the obstetrician can provide. I do agree that the private patients would certainly have benefited by having the collaboration of both certified nurse-midwives and the obstetri-
Cammarano, Herron, and Parer
cian. Optimum care for all patients in this country would benefit from such a collaborative relationship. With regard to the incentive for vaginal birth after cesarean section, because insurance companies will probably mandate that all patients who have had a prior cesarean section will have to undergo vaginal birth incentives may be a moot point. In hopes of encouraging more vaginal births after cesarean deliveries the financial incentives could be reversed. Regarding external versions, all patients who had a breech presentation, either in the clinic or privately, were offered and encouraged to have external version.
Validity of indications for transabdominal cervicoisthmic cerclage for cervical incompetence C.L. Cammarano, MD, M.A. Herron, RN, BSN, and J.T. Parer, MD, PhD San Francisco, California OBdECTIVE: Our purpose was to review the indications for transabdominal cervicoisthmic cerclage to determine whether it is a valid alternative to transvaginal cerclage. STUDY DESIGN: A retrospective review of transabdominal cerclage patients at one institution from 1978 to 1994, analysis of the indications for the transabdominal rather than the vaginal approach, and evaluation of fetal outcomes was performed. RESULTS: Twenty-three patients underwent 24 transabdominal cerclages. The primary indication for transabdominal cervicoisthmic cerclage was failed transvaginal cerclage in 14 patients and anatomic unsuitability for transvaginal cerclage in nine. Of the latter, five were a result of diethylstilbestrol exposure and four a result of cervical surgery. All patients were successfully delivered of one or more live babies (total 28, including two sets of twins). Two losses occurred, one after rupture of membranes at 21 weeks on the second pregnancy after cerclage placement and one intraoperative loss with herniation of the membranes. The live birth rate was 93%, compared with 18% salvage of pregnancies beyond the first trimester before the transabdominal cervicoisthmic cerclage procedure. Complications included blood loss requiring transfusion (four patients), although none of these occurred in the last 12 patients. CONCLUSION: We conclude that all the patients had a history compatible with incompetent cervix requiring a cerclage, and none were suitable candidates for a vaginal cerclage. We further conclude that with strict indications transabdominal cervicoisthmic cerclage offers a high rate of fetal salvage with a minimum of complications in patients with extremely poor obstetric histories because of cervical incompetence. (AM J OBSTETGYNECOL1995; 172:1871-5.)
Key words: Transabdominal cervicoisthmic cerclage, cervical incompetence Transabdominal cervicoisthmic cerclage was first introduced in 1975 by Benson and Durfee ~ as an alterFrom the Department of Obstetrics, Gynecolog~ and Reproductive Sciences, University of California, San Francisco. Presented at the Sixty-first Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Scottsdale, Arizona, October 24-29, 1994. Reprint requests:Julian 7", Parer, MD, PhD, University of California, San Francisco, Department of Obstetrics, Gynecology, and Reproductive Sciences, 513 Parnassus, Rm. HSE-1462, Box 0550, San Francisco, CA 94143. Copyright © 1995 by Mosby-Year Book, Inc. 0002-9378/95 $3.00 + 0 6/6/63568
native to transvaginal cerclage in a small subset of women. Subsequendy, numerous reports have shown improved outcome after this procedure, with fetal salvage rates approaching 90%. ~-8These reports suggested that with certain indications transabdominal cervicoisthmic cerclage is a valid alternative to transvaginal cerclage. These indications consisted of the following conditions: (1) congenitally short or extensively amputated cervix, (2) marked scarfing of the cervix, as after unsuccessful transvaginal cerclage, (3) deeply notched multiple cervical defects, (4) penetrating forniceal lac1871
1872 Cammarano, Herron, and Parer
June 1995 Am J Obstet Gynecol
Table I. Pregnancy history before t r a n s a b d o m i n a l cerclage and indications for p r o c e d u r e Trimester of termination
Case No.
1
Date
Age ( y r )
Gravidity
Third
3/78
23
4
1
37
4
0
2
I
Second
L I First
living children
Indication for TAC
0
1
4
0
0
Scarred cervix; failed vaginal cerclage x 1 Deep cervical laceration, failed vaginal cerclage x 2 Anatomic defect on posterior cervical wall, failed vaginal cerclage x 3 Surgical amputation of cervix, failed vaginal cerclage x 1 Deep cone biopsy, posterior lip of cervix absent Anatomically short cervix (DES) Cervical laceration to lateral fornix, failed vaginal cerclage x 3 Short cervix (DES), failed vaginal cerclage x 1 Short cervix (DES), failed vaginal cerclage x 1 DES, failed vaginal cerclage x 2 DES, cervical erostion and laceration from prior successful vaginal cerclages DES, cervical absence from deep cone biopsy Deep cone biopsy, failed vaginal cerclage x 2 Deep cone biopsy, failed vaginal cerclage x 2 DES, failed vaginal cerclage x 1 DES, inadequate length for vaginal cerclage Short cervix from deep cone biopsy DES, multiple surgeries for dysplasia Anatomically short cervix, inadequate length for vaginal cerclage Failed vaginal cerclage x 1 Failed vaginal cerclage x 3, deep cone biopsy Inadequate length for vaginal cerclage Cervical scar to fornix, failed vaginal cerclage x 2
3
3
1/86
25
4
0
3
1
0
4
4/83
37
11
1
3
7
0
5
5/84
27
3
3
0
0
2
6
7/86
28
1
0
1
0
0
7
2/87
32
5
1
3
1
1
8
11/86
31
2
1
1
0
1
9
5/87
30
2
0
2
0
0
10
7/87
29
2
1
1
0
1
11
2/88
33
4
2
1
1
2
12
2/88
36
2
0
0
2
0
13
9/87
31
2
0
2
0
0
14
12/89
32
5
0
4
1
0
15
4/90
39
5
0
3
2
0
16
5/90
37
3
0
2
1
0
17
9/90
38
3
1
2
0
1
18
9/91
33
1
0
0
1
0
19
9/91
31
3
0
2
1
0
20
3/92
37
3
0
2
1
0
21
6/92
35
6
0
5
1
0
22
9/92
37
2
1
1
0
1
23
7/93
32
7
1
3
3
1
TAC, Transabdominal cervicoisthmic cerclage; DES, diethylstilbestroi.
erations, (5) subacute cervicitis, (6) wide or extensive cervical conization, (7) cervicovaginal fistulas after abortion, and (8) o n e or m o r e previous vaginal cerclage failures.
In this r e p o r t we e x a m i n e d the indications for transa b d o m i n a l cervicoisthmic cerclage in cases w h e r e it was believed that transvaginal cerclage was not w a r r e n t e d and e x a m i n e d its effectiveness.
Volume 172, Number 6 Am J Obstet Gynecol
Cammarano, Herron, and Parer
1873
Table II. Details of transabdominal cerclage and outcome
Case No. 1 2a 2b 3 4a
Week of cerclage 17 14 In place, previous pregnancy 13 14
EBL (ml) 100 400 100 1300
5
In place 14
6
18
1300
7a
13
500
7b
In place, previous pregnancy; replaced after hysterotomy at 21 wk 3 days In place In place 13 14
500
4b
7c 7d 8 9a
100
Operative complications
Delivery
Birth weight (gin)
-
36 wk 38 wk 1 day 37 wk 5 days
2650 3140 3380
38 wk 3 days
3000
None None None Membranes prolapsed and ruptured during procedure, suture placed after abortion, transfusion (1 u)
m
38 wk 38 wk
None Pancytopenia (moderate), transfusion (4 U) Uterine artery puncture, moderate blood loss
m
100 200
None Bleeding ~om leh sided suture, transfusion (2 U)
9b 10 11
In place 17 13
200 300
12 13 14 15 16
13 14 13 13 13
75 250 150 100 100
None Transfusion (1U autologous) None None None None None
17 18 19 20 21 22 23
15 15 12 12 13 15 13
100 250 50 200 200 100 50
None None None None None None None
38 wk 2 days
3000 3500 3500* 3740
36 wk 3 days
2300
SROM hyste~ ectomy
350
37 wk 5 days 38 wk 6 days 36 wk 38 wk
2980 3640 3000 3268
Term 34 wk 3 days 37 wk 6 days
Unavailable 2430 3590
39 wk Term 36 wk 4 days 34 wk 5 d a y s 33 wk 4 days
3420 3000 2680 Unavailable 1480 2120" 3320 3350 Unavailable 3750 3620 2130 3210
Term 38 wk 37 wk 2 days 37 wk 37 wk 6 days 33 wk 1 day 38 wk
EBL, Estimated blood loss; SROM, spontaneous rupture of membranes. *Twins.
Material and methods Twenty-three patients were referred for evaluation for placement of a transabdominal cerclage; these patients underwent 24 procedures. Table I summarizes the obstetric histories and indications for cerclage in these patients. In most cases the patient had undergone one or more attempts at vaginal cerclage. Histories of McDonald cerclage, Shirodkar cerclage, or both appeared with equal frequency. In one patient (case 4) a Lash procedure was attempted to repair the cervix before referral. The operation was performed at a mean gestational age of 14.5 weeks with a range of 12 to 18 weeks (Table II) in a m a n n e r previously described in detail. 7 One
surgeon (J.T.P.) performed all procedures; he was assisted by either another attending physician or a fellow in maternal-fetal medicine. After fetal viability was confirmed, the procedure was performed with the patient u n d e r general, continuous epidural or continuous spinal anesthesia. A vertical skin incision was performed in all cases. The bladder peritoneum was reflected and the cervix palpated. A tunnel through the paracervical tissue was created at the level of the internal cervical os, and a 5 m m Mersilene (Ethicon, Somerville, N.J.) polyester fiber band was used for the cerclage. The knot was tied anteriorly, and the ends were then tacked down with a nonabsorbable suture. Prophylactic antibiotics were not given, except in one patient (case 22) where
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Am J Obstet Gynecol
Table I l L Maternal pregnancy-related data before transabdominal cervicoisthmic cerclage (n = 23)
Age (yr) Gravidity No. of living children
Mean
Range
32.6 3.6 0.5
23-39 1- 11 0-2
membranes were bulging at the time of surgery. Tocolytics were not used prophylactically, although many patients did receive them later in pregnancy.
Results The results after cerclage are shown in Table II. Twenty-three patients underwent 24 transabdominal cerclages. A summary 9 f the maternal precerclage pregnancy data is given in Tables III and IV. Before placement of the transabdominal cervicoisthmic cerclage these 23 patients had 60 pregnancies lasting beyond the first trimester, which culminated in 11 live births for a fetal salvage rate of 18%. The primary indication for transabdominal cervicoisthmic cerclage was failed transvaginal cerclage in 14 patients and anatomic unsuitability for transvaginal cerclage in nine. Of the latter, five were from DES exposure and four from cervical surgery. One DES-exposed patient (case 11) had two prior successful vaginal cerclages that left the cervix too lacerated at the next pregnancy to attempt a third. All patients were successfully delivered of one or more live babies (total 29 including two sets of twins). All live-born infants were delivered after 33 weeks, 19 of whom were > 37 weeks. All patients had at least modified bed rest throughout pregnancy and about haft received tocolytic therapy. Delivery was by cesarean section in all cases. In cases where childbearing was completed, the suture was removed. The postcerclage results are summarized in Table V. Precerclage and postcerclage outcomes are summarized in Table VI. There were two fetal losses. The first was an intraoperative failure (case 4a) during placement of the suture, when the membranes "hourglassed" through the absent cervix and, during an attempt at reduction, ruptured and the fetus was expelled. After the placenta was removed, the stitch was placed and the patient had a successful pregnancy. The second loss occurred in case 7b. The cerclage was successful for the initial pregnancy. However, rupture of membranes occurred at 21.5 weeks in the second pregnancy. At the time of hysterotomy another suture was placed and was successful in two subsequent pregnancies. The major complication other than fetal loss was hemorrhage. Five patients had blood loss > 400 ml, and four patients required transfusion. Three patients had hemorrhage directly related to the procedure itself. In case 4a no cervix was palpable, and suture placement
Table IV. History and major indication for transabdominal cerclage Failed vaginal cerclage Fetal wastage with incompetent cervix, and very short or deranged cervix Fear of fetal wastage, with very short cervix
14 7 2
too low in the lower uterine segment resulted in heavy bleeding, membrane prolapse, and fetal loss. This patient required removal of the original suture, curettage of the uterus, and replacement of the suture. The cumulative blood loss was 1300 ml. The patient was given 1 unit of blood at an intraoperative hematocrit of 29%. The postoperative hematocrit was stable at 30%. In case 9 a left uterine vein was lacerated during tunneling and required ligation. This resulted in an estimated 500 ml blood loss and transfusion of 2 units on the first postoperative day for orthostasis and a hematocrit of 20%. There was a 500 ml estimated blood loss in case 7a but no transfusion after a uterine artery puncture and ligation. In case 6 there was a preexisting autoimmune pancytopenia of unknown cause. The preoperative hematocrit was 29%, and platelets were 113,000 × 106.L -l. Bleeding time and coagulation panel were normal. A blood loss of 1300 ml resulted during surgery and four units of packed red blood cells was given. The patient was extensively counseled before surgery as to the likelihood of transfusion. The fifth patient, case 11, received an autologous unit at a postoperative hematocrit of 33%. Excluding these patients, the average blood loss was 200 ml. There have been no transfusions in the last 12 patients.
Comment Recent data indicate that transabdominal cervicoisthmic cerclage remains a viable alternative to vaginal cerclage in those patients who have recurrent pregnancy loss. A recent review by Novys reported a cumulatie success rate of 90% in the world literature. This surpasses the overall success rate reported for transvaginal procedures. 9 The strict indications applied to selection of patients in our series support the view that incompetent cervix is responsible for poor pregnancy outcome and that a risk-benefit assessment favors placement of transabdominal cervicoisthmic cerclage rather than vaginal cervical cerclage. In all cases either lack of cervical tissue or failed attempts at prior vaginal cerclages left transabdominal cervicoisthmic cerclage as the desired option in the current pregnancy. Cervicitis was not an indication in our series. The unique subset of patients identified by applying the above strict criteria is probably partially responsible for the uniformly good outcome. Although vaginal cerclage is an easier approach
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Table V. Summary of outcome after transabdominal cerclage
Mean Week of transabdominal cerclage No. of mothers with successful pregnancies after TAC Gestational age at delivery (excluding two extremely premature) Birth weight (gin) (excluding two extremely premature)
14 23 37.3
[
Range 12-18 1-3 (babies) 33 wk 1 day-39 wk
3046
1480-3740
TAC, Transabdominal cervicoisthmic cerclage. and does not require future laparotomy, in many of the patients such a procedure would have been technically difficult, if not impossible. Therefore attempting vaginal cerclage in these patients would appear to be contraindicated. In our series the fetal salvage rate before and after transabdominal cervicoisthmic cerclage is markedly improved. Although bed rest, tocolytic therapy, and improved neonatal intensive care almost certainly played a role in these outcomes, the high number of term and late-third-trimester infants delivered after compared with before transabdominal cervicoisthmic cerclage where these same modalities were available strongly suggests a major contribution from transabdominal cervicoisthmic cerclage. The major objections to transabdominal cervicoisthmic cerclage are the need for multiple laparotomies and the risk of major blood loss from operating in an extremely vascular area. With improved surgical and anesthesia techniques the risks accompanying multiple laparotomies diminishes. Furthermore, the transabdominal cervicoisthmic cerclage may be left in place for future pregnancies, whereas a vaginal cerclage must be replaced. In patients who meet the criteria for transabdominal cervicoisthmic cerclage multiple vaginal surgeries offer a comparable degree of surgical morbidity with the possibility of a lower likelihood of successful pregnancy outcome. Blood loss remains a problem in the technique described in this series. However, Novy's~ recent review describes an alternative technique of manual retraction of the uterine vessels and passage of suture in the clear space between the vessels and the uterine isthmus without tunneling. With this technique at least three of our intraoperative hemorrages may have been avoided. On the other hand, our estimated blood loss in the last 15 patients (not all reported here) is < 150 ml, possibly
Table VI. Pregnancy outcome beyond first trimester before and after transabdominal cervicoisthmic cerclage
Before ] Aj~er Deliveries beyond first trimester Fetal losses beyond first trimester Fetal salvage (%)
60 49 18
29 2 93
reflecting improved familiarity with the procedure. In addition, all patients now store autologous blood, so the adverse consequences of blood replacement are less. We conclude that the transabdominal cervicoisthmic cerclage offers a high rate of fetal salvage with a minimum of complications in patients with extremely poor obstetric histories as a result of cervical incompetence, where vaginal cerclage is not warranted. REFERENCES
1. Benson RC, Durfee RB. Transabdominal cervicouterine cerclage during pregnancy for the treatment of cervical incompetency. Obstet Gynecol 1965;25:145-55. 2. Novy MJ. "Fransabdominal cervicoisthmic cerclage for the management of repetitive abortion and premature delivery. AMJ OBSTETG~rcoc 1982;143:44-54. 3. Olsen S, Tobiassen T. Transabdominal isthmic cerclage for the treatment of incompetent cervix. Acta Obstet Gynecol Scand 1982;61:473-5. 4. Watkins RA. Transabdominal cervico-uterine suture. Aust N Z J Obstet Gynaecol 1972;12:62-4. 5. Mahran M. Transabdominal cervical cerclage during pregnancy. Obstet Gynecol 1978;52:502-6. 6. Loock W, Zur transabdominalen Zervixumschlingung nach Ardillo. Geburtshilfe Frauenheilkd 1980;40:517-9. 7. Herron MA, Parer JT. Transabdominal cerclage for fetal wastage due to cervical incompetence. Obstet Gynecol 1988;71:865-8. 8. Novy MJ. Transabdominal cervicoisthmic cerclage: a reappraisal 25 years after its introduction. AMJ OBSTETGYNECOL 1992;164:1635-41. 9. Cousins L. Cervical incompetence, 1980: a time for reappraisal. Clin Obstet Gynecol 1980;23:467-79.