Transabdominal cerclage linked to lower preterm birth vs transvaginal cerclage

In a recent study published in the American Journal of Obstetrics & Gynecology, transabdominal cervical cerclage was associated with lower rates of perinatal mortality and preterm birth than transvaginal cerclage, with comparable outcomes between open and laparoscopic abdominal techniques.¹

Preterm birth remains a major contributor to neonatal morbidity and mortality worldwide, accounting for approximately one-third of neonatal deaths.² Cervical insufficiency is a recognized pathophysiological factor in spontaneous preterm birth, and cervical cerclage has been widely used as a preventive intervention in patients at increased risk.¹

Transabdominal cerclage techniques

While transvaginal cerclage (TVC) has historically been the preferred approach because of its relative simplicity and limited invasiveness, transabdominal cerclage (TAC) has emerged as an alternative for patients with prior TVC failure, a history of cervical surgery, or an anatomically short or absent cervix. TAC can be placed through an open abdominal approach (open transabdominal cerclage [OTAC]) or by laparoscopy (laparoscopic transabdominal cerclage [LTAC]).

"Although individual studies have explored different suture techniques, none of them have conducted a comprehensive assessment to determine which type of surgery––open, laparoscopic, or transvaginal––offers the most efficacious outcomes," wrote investigators.

Comparing surgical outcomes

To address this gap, investigators conducted a systematic review and meta-analysis comparing obstetrical and neonatal outcomes associated with TVC, OTAC, and LTAC. Two independent reviewers searched PubMed, Scopus, and Web of Science from database inception through January 2024.

Eligible studies included observational cohorts and randomized controlled trials that directly compared at least 2 cerclage approaches (TVC, OTAC, or LTAC). Review articles, conference abstracts, non–peer-reviewed reports, and animal studies were excluded.

Twelve studies met inclusion criteria, encompassing 975 to 976 participants depending on outcome. Eleven studies were observational, and 1 was a randomized controlled trial. Five studies compared TVC with LTAC, 4 compared TVC with OTAC, and 3 compared OTAC with LTAC. Most cerclages were placed prophylactically, and the timing of placement ranged from before conception to the early second trimester. LTAC was more frequently performed before pregnancy than TVC.

Perinatal mortality and preterm birth rates

The primary outcomes were perinatal mortality and preterm birth. In the main analysis, TAC (combining OTAC and LTAC) was associated with a lower rate of perinatal mortality compared with TVC (risk ratio [RR], 0.36; 95% CI, 0.14–0.95). Preterm birth was also less frequent among patients who underwent TAC compared with TVC (RR, 0.49; 95% CI, 0.25–0.94). Heterogeneity ranged from moderate to high, and the overall certainty of evidence for both primary outcomes was rated as low.

Sensitivity analyses restricting the dataset to studies with a lower risk of bias or excluding twin pregnancies yielded similar findings, with reduced heterogeneity. Subgroup analyses by surgical approach showed lower rates of perinatal mortality and preterm birth for both OTAC and LTAC compared with TVC.

Secondary outcomes included fetal survival, cesarean delivery, and neonatal intensive care unit admission. Fetal survival was higher in the TAC group than in the TVC group (RR, 1.10; 95% CI, 1.02–1.20). Cesarean delivery was substantially more common among patients who underwent TAC, reflecting the requirement for operative delivery in these cases. Rates of neonatal intensive care unit admission did not differ significantly between groups, although heterogeneity was high.

Implications

In a secondary analysis comparing OTAC with LTAC, no statistically significant differences were observed in perinatal mortality or preterm birth. These findings suggest that laparoscopic and open abdominal approaches provide comparable obstetrical outcomes, although the number of directly comparative studies was limited.

"Given the frequency of prematurity and the increased associated morbidity and mortality, TACs deserve further study as a potential therapeutic option for these patients," wrote investigators.

References

1. Bobotis S, Arsenaki E, Hamilton K, et al. Transabdominal vs transvaginal cervical cerclage in the prevention of preterm birth: a systematic review and meta-analysis. Am J Obstet Gynecol. 2025;233(6):572-580. doi:10.1016/j.ajog.2025.07.026
2. Liu L, Johnson HL, Cousens S, et al; Child Health Epidemiology Reference Group of WHO and UNICEF. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet. 2012;379(9832):2151-2161. doi:10.1016/S0140-6736(12)60560-1