James K Robinson, MD, MS

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Traditionally, transvaginal cerclage placed during the first or early second trimester has been a common treatment for cervical incompetence. Unfortunately, in about 13% of women with cervical incompetence, the transvaginal approach to cerclage will not work.

Benson and Durfee first described the transabdominal approach to cerclage placement in 1965.

  Placement of cerclage at the cervicoisthmic junction may be effective in decreasing the incidence of pregnancy loss in certain patients with cervical insufficiency. Generally accepted criteria for choosing the transabdominal approach to cerclage placement include: 

1. Congenitally short or amputated cervix; 

 Advantages of the transabdominal over the transvaginal approach include more proximal placement at the internal os. Furthermore, with a transabdominal cerclage, there is no vaginal foreign body, which theoretically may act as a nidus for infection. In their cohort, Davis, et al found less preterm premature rupture of membranes in women who underwent abdominal cerclage versus transvaginal cerclage for treatment of cervical incompetence (8% vs 29%, 

  Additionally, transabdominal cerclage can be used in subsequent pregnancies, which is useful in patients desiring multiple future pregnancies. 

Transabdominal cerclage also has disadvantages. Initially, the abdominal cerclage is placed during pregnancy, making it a more morbid procedure, with the potential for higher blood loss and fetal complications.The transabdominal approach generally also requires 2 laparotomies: 1 for cerclage placement and 1 for cesarean delivery. Further, contraindications for transvaginal cerclage placement-intrauterine infection, fetal anomalies or genetic syndromes incompatible with life, active bleeding, and impending miscarriage-also are true for the transabdominal approach.

We believe that in select patients, the prophylactic laparoscopic approach offers advantages over the open approach. Given the limitations of uterine manipulation during pregnancy, a pre-pregnancy or interval approach is an attractive option. Benefits of pregestational placement include decreased uterine size, decreased uterine blood flow, absence of fetal risks, and the advantages of an elective procedure over an emotionally charged urgent procedure. Patients under consideration for this procedure will have already demonstrated clear evidence of cervical incompetence and they therefore can be easily identified prior to conception. 

Articles

Traditionally, transvaginal cerclage placed during the first or early second trimester has been a common treatment for cervical incompetence. Unfortunately, in about 13% of women with cervical incompetence, the transvagincal approach to cerclage will not work.

Author | James K Robinson, MD, MS

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