Version May 2024
INTRODUCTION — In selected patients with cervical insufficiency, transabdominal placement of a cerclage at the cervicoisthmic junction rather than transvaginal cerclage is performed to reduce the risk of spontaneous pregnancy loss and/or preterm birth. This topic will discuss issues related to transabdominal cervicoisthmic cerclage. Issues related to cervical insufficiency and transvaginal cervical cerclage are reviewed separately:
●(See "Cervical insufficiency".)
●(See "Transvaginal cervical cerclage".)
CANDIDATES FOR A TRANSABDOMINAL RATHER THAN A TRANSVAGINAL APPROACH
Criteria — The transabdominal approach is a more morbid procedure than the transvaginal approach, especially if laparotomy rather than laparoscopy is performed for placement, and a cesarean birth is generally required. Therefore, most experts recommend reserving the transabdominal approach for patients with cervical insufficiency who meet one (or both) of the following criteria:
●Unable to undergo a transvaginal procedure because an extremely short or absent cervix, amputated cervix, marked cervical scarring, or cervical defect makes it technically impossible to perform.
●Failure to deliver a healthy newborn after at least one previous prophylactic transvaginal cerclage (ie, history-indicated or ultrasound-indicated but not a physical examination-indicated cerclage [also called rescue or emergency cerclage]).
The technique (McDonald versus Shirodkar) used for the previous cerclage does not influence our decision. No compelling evidence indicates that, before resorting to a transabdominal approach, a Shirodkar cerclage should be attempted in the pregnancy after a failed prophylactic McDonald cerclage.
The Society for Maternal-Fetal Medicine also recommends offering transabdominal cerclage placement to patients with a previous transvaginal cerclage (history or ultrasound indicated) that resulted in a subsequent spontaneous singleton birth before 28 weeks of gestation [1].
Evidence
●Open approach – In the above patient groups, several observational studies have reported that a transabdominal approach was associated with better birth outcomes than the transvaginal approach, thus justifying its higher morbidity [2-4].
The only randomized trial comparing the two approaches in 111 patients with a failed vaginal cerclage (prior birth at 14 to 28 weeks despite cerclage [physical examination-indicated cerclages were excluded]) confirmed this benefit, transabdominal cerclage resulted in a lower rate of preterm birth <32 weeks (8 versus 33 percent, relative risk [RR] 0.23, 95% CI 0.07-0.76; number needed to treat to prevent one preterm birth: four) [5]. The trial also found no benefit of placing a high vaginal cerclage (involving mobilization of the bladder from the anterior cervix to allow the suture to be placed higher) compared with a low vaginal cerclage (preterm birth <32 weeks: RR 1.15, 95% CI 0.62-2.16), although it was not powered to detect a clinically significant difference in this outcome. The techniques used for high and low transvaginal cerclage were at the clinician's discretion, but almost all used Mersilene tape.
●Laparoscopic approach – The laparoscopic approach is equally effective and probably superior to the open approach as long as the provider has the requisite laparoscopic experience to perform the procedure.
In a systematic review of 83 observational studies that evaluated pregnancy outcome after laparoscopic versus open transabdominal cerclage performed during pregnancy and between pregnancies in nearly 3400 patients, neonatal survival was >90 percent and gestational age at birth was >36 weeks overall for both approaches, and neither approach appeared to be superior [6]. However, the subgroup undergoing an open interval procedure had slightly less favorable outcomes (neonatal survival 79 percent, gestational age at birth 32 weeks) than the other subgroups (open pregnancy procedure, laparoscopic procedure during pregnancy or as an interval procedure).
Why is the transabdominal approach more effective? — Improvement in birth outcome from transabdominal cerclage may be related to [7]:
●More proximal placement of the stitch (at the level of the internal os)
●Decreased risk of caudal suture migration as the uterus enlarges, and
●Absence of a foreign body in the vagina that could promote infection and inflammation
In the randomized trial described above [5], it is unclear why higher placement of transvaginal cerclage did not result in a benefit compared with lower placement; the small number of patients in the trial may have been a factor. As with any surgical procedure, we believe the technical skill and the experience of the operator are important factors for a successful outcome.
CONTRAINDICATIONS — Contraindications to transabdominal cerclage are similar to those for transvaginal cervical cerclage. The major contraindications are clinical scenarios where the procedure is unlikely to reduce the risk of preterm birth or improve fetal outcome:
●Fetal anomaly incompatible with life
●Intrauterine infection/chorioamnionitis
●Active uterine bleeding
●Active preterm labor
●Preterm prelabor rupture of membranes (PPROM)
●Fetal demise
Fetal membranes prolapsing through the external cervical os is a relative contraindication because the risk of iatrogenic rupture of the membranes in this setting may exceed 50 percent [8,9].
Placenta previa on ultrasound examination is not a contraindication to cerclage placement; whether it decreases the risk of bleeding from the previa is controversial [10-12].
Twin pregnancy is not a contraindication to transabdominal cerclage placement, but data are limited [13,14]. The larger uterine size of a twin pregnancy may make access to the lower uterus challenging with open or laparoscopic approach, which is the reason some surgeons perform the procedure earlier in these pregnancies.
TIMING
Overview — In patients who meet criteria for transabdominal cerclage placement, the procedure can be performed either preconception in patients planning to conceive or in early pregnancy after ultrasound assessment of the embryo/fetus. There is no consensus as to the best approach.
No randomized trials have compared outcomes with preconception versus postconception cerclage.
●A review of 14 observational studies of abdominal cerclage published between 1990 and 2013 and involving a total of 678 patients reported live birth rates were similar whether abdominal cerclage was performed before or during pregnancy [15].
●In a subsequent observational study of 161 consecutive patients who underwent preconception or first-trimester transabdominal cerclage, preconception cerclage was associated with more successful pregnancies >34 weeks (90 versus 74 percent) and fewer serious surgical complications (bladder injury, bleeding >500 mL; 0/96 versus 34/65) [16].
Issues with preconception placement — Advantages of preconception placement include [17]:
●The surgeon has optimum exposure
●The risk of injury to the pregnancy is eliminated, and
●The risk of excessive procedure-related bleeding is reduced compared with procedures performed during pregnancy
Very limited data suggest preconception placement does not impair fertility [18,19]. Still, up to 26 percent of patients in a systematic review underwent the procedure and did not go on to have a pregnancy; the reasons for not conceiving were not provided [20].
Issues with placement during pregnancy — In patients presenting in early pregnancy, a transabdominal cerclage should be placed in the late first trimester to early second trimester because:
●The risk of spontaneous pregnancy loss is lower than earlier in gestation
●Major structural anomalies can be excluded by ultrasound performed at 11 to 13 weeks
●Information from early aneuploidy screening (if desired) is available, and
●The uterus is not too large to make it technically challenging
Later placement (≥14 to 15 weeks) is undesirable since the large size of the uterus makes the procedure more difficult, especially if performed laparoscopically, and thus may be associated with a higher risk of complications. However, case reports have described performing the procedure at 18 to 24 weeks [21]. The Society for Maternal-Fetal Medicine suggests first-trimester placement but adds that transabdominal cerclage can still be considered before 22 weeks of gestation [1].
PROCEDURE
Choice of open versus laparoscopic technique — Due to lower morbidity, the laparoscopic approach is preferable when technically feasible and the requisite surgical expertise is available. (See 'Complications' below.)
Preoperative preparation — We do not administer prophylactic antibiotics or perform a vaginal prep. We do place a bladder catheter for continuous drainage because natural filling of the bladder during surgery obstructs the operative field.
Open transabdominal approach — The following is a general approach to the open procedure, recognizing that practice patterns vary.
●Either general or neuraxial anesthesia can be used, depending on surgeon and patient preference.
●The patient is usually placed in the supine position, but a modified lithotomy position is used if intraoperative transvaginal manipulation of the uterus or transvaginal ultrasound examination of the cervix is necessary [22].
●The abdominal cavity is entered through a transverse (including Maylard) or vertical incision and the peritoneal bladder reflection is taken down by sharp and blunt dissection to expose the cervicoisthmic junction, the uterine artery, and the parametrial vessels.
●The uterine vessels are palpated between the thumb and forefinger and should be drawn laterally away from the uterus, thereby exposing an avascular space immediately adjacent to the cervicoisthmic junction between the lateral wall of the uterus and the ascending and descending branches of the uterine arteries.
It may help to have an assistant elevate and cradle the uterus out of the pelvis to provide optimum exposure of the vessels and isthmus. Handling the uterus gently is particularly important during pregnancy to avoid kinking the uterine blood supply and disrupting the placenta, as well as to maintain uterine quiescence.
●A 15 cm long, 5 mm Mersilene tape (polyester tape) is passed through this avascular space from anterior to posterior. This can be achieved using a Mersilene band preloaded onto a needle or by creating a tunnel through this avascular space and the posterior leaf of the broad ligament using a long right-angled forceps or Moynihan clamp. Alternatively, the Mersilene band can be placed through the lateral myometrium to minimize the risk of trauma to the uterine vessels. A polypropylene suture can be used instead of Mersilene tape, but we prefer Mersilene because of its larger surface area.
Care should be taken as the nearby paracervical veins are prone to injury. If venous bleeding occurs, it can usually be controlled with a hemostatic clip.
●The identical procedure is repeated on the opposite side, except the needle is passed from posterior to anterior.
●The Mersilene tape is wrapped around the posterior uterine isthmus at the level of the uterosacral ligament insertions, made to lie flat against the uterus, tied to slightly compress the intervening tissue, and secured with a triple square knot (figure 1). The ends can be sutured to the tape with fine nonabsorbable sutures [23]. The surgeon's preference determines the anterior versus posterior location of the knot.
●If the procedure is performed during pregnancy, ultrasound is occasionally used to monitor the fetal heart rate to ascertain that blood flow through the uterine artery has not been compromised by the procedure and to ensure that the membranes are above the level of the cerclage.
Laparoscopic approach — Videos of the laparoscopic technique are available online. Robotic-assisted transabdominal laparoscopic cerclage has been performed successfully in nonpregnant and pregnant patients [24-27]. Cost-effectiveness versus conventional laparoscopy has not been established.
The following is a general approach to the laparoscopic procedure, recognizing that practice patterns vary.
●The procedure is performed under general anesthesia with the patient in dorsal lithotomy position.
●Port placement is at the discretion of the surgeon but typically includes three to four ports: one in the midline for the camera, two in the bilateral lower quadrants, and one in an upper quadrant.
●For cases performed during pregnancy, it is important to assess the size and position of the gravid uterus to avoid it during entry. A sponge stick or other instrument that does not enter the cervix can be used to delineate the cervicovaginal junction and help position the uterus [28,29]. In nonpregnant patients, we use a uterine manipulator for this purpose.
●The procedure is begun by opening the vesicouterine peritoneum across the lower uterine segment with an ultrasonic scalpel or monopolar shears. The bladder is reflected caudad, and the cervicoisthmic junction is skeletonized to reveal the uterine vessels anteriorly.
●A nonabsorbable suture should be used. The most commonly described suture for laparoscopic cerclage is the 5 mm Mersilene polyester tape. Double arm CTX or BP-1 needles can be used, with each needle straightened to allow passage through the ports and to facilitate cerclage placement. Ultrasound guidance can be used to assist placement and avoid entry into the amniotic cavity [30].
●The knot may be tied anteriorly or posteriorly. If tying the knot anteriorly, each needle is passed posteriorly to anteriorly using the uterosacral ligaments as landmarks. The needle should be inserted at the level of the cervicoisthmic junction, medial to the uterine vessels and lateral to the cervix. If the needle is placed too lateral, it can cause bleeding from the uterine vessels. If the needle is placed too medial, it can impair the cerclage's performance or enter the cervix. If using Mersilene tape on a blunt needle, it is good to err on being slightly too medial during placement, and if significant resistance is felt, then move the trajectory slightly more laterally. If the patient is not pregnant and a uterine manipulator is in place, the uterus can be carefully moved from an anteverted to retroverted position and twisted slightly to assist with needle passage. Once passed, the needles are cut off and removed.
●Intracorporeal knot tying is more feasible when using the Mersilene tape. The Mersilene suture is tied tightly around the cervix with six knots. Some surgeons will then tack the ends of the Mersilene tape down to the lower uterine segment with a 2-0 silk suture. The suture may prevent the ends of the tape from eroding into the bladder and may ease identification of the cerclage during an eventual cesarean birth.
●The vesicouterine peritoneum may then be reapproximated with running 2-0 Monocryl suture (Ethicon) that is tied intracorporeally.
Alternative approaches
Cervicoisthmic cerclage via a transvaginal approach — A transvaginal approach to the cervicoisthmic area has also been described. It involves placement of a "high" Shirodkar cerclage at the level of the cervicoisthmic junction after surgical reflection of the bladder anteriorly and the rectum posteriorly. In some studies it appeared to be less morbid than the transabdominal approach and to have similar efficacy if actually placed in the cervicoisthmic area, but experience is limited [31-34]. One randomized trial reported transabdominal cerclage was superior to high vaginal cerclage and the latter was not superior to a low vaginal cerclage; however, high placement was described as "mobilization of the bladder from the anterior cervix allowing the suture to be placed higher", which is not equivalent to cervicoisthmic placement [5].
POSTOPERATIVE CARE AND FOLLOW-UP — Postoperative care is routine. Postoperative follow-up is similar to that with transvaginal cerclage, but routine transvaginal cervical length screening is unnecessary in patients with a transabdominal cerclage in situ [1].
Most patients are discharged to home after the laparoscopic procedure but stay in the hospital for approximately two days after an open laparotomy. (See "Transvaginal cervical cerclage", section on 'Postoperative care and follow-up'.)
COMPLICATIONS — A systematic review of 83 observational studies evaluated pregnancy outcome after laparoscopic (LC) and open (AC) transabdominal cerclage placement performed during pregnancy and between pregnancies in nearly 3400 patients [6]. The following findings are specifically for procedures performed during pregnancy (LC n = 489, AC n = 1010):
●Blood loss >400 mL (LC: 0 percent, AC: 3.3 percent)
●Wound infection (LC: 0 percent, AC: 0.5 percent)
●Fetal loss within two weeks of the procedure (LC: 0 percent, AC: 0.9 percent)
●Preterm prelabor rupture of membranes (PPROM; LC: 5.5 percent, AC: 6.3 percent)
●Chorioamnionitis (LC: 1.9 percent, AC: 0.1 percent)
●Other pregnancy complications (LC: 24 percent, AC: 4.7 percent); other pregnancy complications included chromosomal abnormalities, maternal disease, placental abnormalities or insufficiency, vaginal blood loss, fetal distress, uterine rupture, and congenital abnormalities
The following findings are specifically for procedures interval procedures (LC n= 675, AC n = 183):
●Blood loss >400 mL (LC: 0.1 percent, AC: 0.4 percent)
●Wound infection (LC: 0.1 percent, AC: 3.1 percent)
●PPROM (LC: 5.2 percent, AC: 22.1 percent)
●Chorioamnionitis (LC: 0 percent, AC: 4.9 percent)
●Other pregnancy complications (LC: 3.5 percent, AC: 3.0 percent)
Other adverse events, which appear to be rare, have been described in case reports and small case series and include fetal death (from inadvertent ligation of the uterine arteries), suture migration, bladder or small bowel injury, rectovaginal fistula, and maternal discomfort [3,20,35].
DELIVERY
Timing and route — In patients who have undergone transabdominal cerclage placement, we suggest planned cesarean birth at 36+0 to 37+6 weeks of gestation to avoid the risk of uterine rupture during labor. In patients with preterm labor before 36 weeks, we would perform a cesarean birth immediately at the onset of regular uterine contractions if the pregnancy is ≥34 weeks or upon determination of lack of response to tocolysis in pregnancies <34 weeks. Uterine rupture with fetus and placenta floating in the abdomen has been reported in a patient at 39+2 weeks with a transabdominal cerclage who had contracted for four hours [36]. The Society for Maternal-Fetal Medicine suggests planned cesarean birth between 37+0 and 39+0 weeks of gestation [1].
At cesarean, the fetus is delivered through a hysterotomy incision made above the cerclage.
Of note, although case reports have described laparoscopic or transvaginal cerclage removal before delivery to allow a trial of labor and vaginal birth, we recommend not performing either procedure as both are technically challenging and potentially morbid.
Management of the cerclage after delivery — An advantage of transabdominal cervicoisthmic cerclage over transvaginal cervical cerclage is the ability to leave the suture in place for future pregnancies. The cerclage can be removed at cesarean birth if the patient is not planning additional pregnancies or left in place if future pregnancies are planned.
If the cerclage is not removed at cesarean birth and childbearing has been completed, one author (EN) does not perform an additional surgical procedure just to remove an asymptomatic cerclage, given the procedure is not straightforward, there is a risk of injury, and the risk of complications if the cerclage is left in situ appears to be very low. He has seen only two cases of erosion, which occurred following a radical trachelectomy and cerclage placement. The other author (SC) generally removes an abdominal cerclage when childbearing is complete, unless the patient is a poor surgical candidate or if surgical removal is anticipated to be difficult.
It remains unclear which approach, if any, is better since the risk of infection and erosion are very low either way and data are limited to case reports. In these reports, failure to remove a transabdominal cerclage has been associated with adverse events several years after placement, including infection and erosion of the cerclage into the vagina [37]. Although indirect evidence, erosion of synthetic materials used in genitourinary procedures is well-described, as are complications from prolonged retention of vaginally placed cerclages [38-40].
There are limited data on the frequency of abdominal cerclage reuse and outcomes. A prospective study of 22 consecutive patients who underwent a successful laparoscopic transabdominal cerclage and became pregnant a second or third time with the initial cerclage in place reported high neonatal survival rates (22 out of 22 newborns of the initial postcerclage pregnancy, 21 out of 22 newborns in the second pregnancy, and 3 out of 3 newborns in the third pregnancy) [41]. The authors did not report any cerclage-related complications.
MANAGEMENT OF FETAL DEMISE
First-trimester demise — In the event of a fetal demise in the first trimester, cervical dilation and evacuation (D&E) of the uterus can be safely and effectively performed without removal of the transabdominal cerclage.
Early-to-mid second-trimester demise — For an early second-trimester fetal loss, D&E can be accomplished successfully in some cases with the cerclage in situ [42,43]. It may be possible to dilate the cervix adequately to allow insertion of a 12 to 16 mm cannula and Sopher forceps; osmotic dilators can be used to facilitate dilation, if necessary; misoprostol should not be used for cervical ripening if a cerclage is in place. Cannulae up to 16 mm permit evacuation of gestations through approximately 16 to 18 weeks and at greater gestational ages if the products of conception are highly macerated. However, the cerclage may become disrupted by these procedures.
If the cerclage needs to be removed, this can be performed laparoscopically, followed by transvaginal D&E. It is technically feasible to remove the cerclage through a transvaginal colpotomy, thereby permitting vaginal delivery [44]. However, in practice, transvaginal cerclage removal is far more difficult than reported and is generally not recommended.
Late second-trimester and third-trimester demise — The cerclage generally has to be removed to allow passage of the mid-to-late second-trimester and third-trimester fetus and placenta. Cerclage removal can be performed laparoscopically, followed by induction of labor. However, several cases of successful D&E at 17 to 21 weeks with the transabdominal cerclage in place have been described and were performed by physicians with the requisite surgical expertise [43].
The authors do not perform laparotomy and hysterotomy for removal of the products of conception to leave the cerclage intact. If laparotomy is necessary to remove the cerclage, they remove the cerclage, evacuate the uterus transcervically, and then replace the cerclage abdominally (if desired) in order to avoid incising the myometrium and thereby increasing the risk of uterine rupture in a subsequent pregnancy. The cerclage can also be placed at a later time. (See 'Timing' above.)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Cervical insufficiency (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Advantages of transabdominal versus transvaginal cerclage – A transabdominal cerclage is placed at the cervicoisthmic junction. Potential advantages of this procedure over the transvaginal approach include: placement at the level of the internal os, reduced risk of suture migration, no foreign body in the vagina that could promote infection, and option of retention of the suture in situ for future pregnancies. (See 'Why is the transabdominal approach more effective?' above.)
●Candidates – Transabdominal cervicoisthmic cerclage is performed in patients with cervical insufficiency who have either failed at least one previous prophylactic transvaginal cerclage or in whom a transvaginal cerclage is technically impossible to perform due to an extremely short or absent cervix, amputated cervix, marked cervical scarring, or cervical defect. (See 'Candidates for a transabdominal rather than a transvaginal approach' above.)
●Timing – In patients who meet criteria for a transabdominal cerclage, the procedure can be performed either preconceptionally in patients planning to conceive or in the late first/early second trimester. (See 'Timing' above.)
●Procedure – Transabdominal cerclage can be performed using an open or laparoscopic approach. Due to lower morbidity, the laparoscopic approach is preferable when the requisite surgical expertise is available. (See 'Choice of open versus laparoscopic technique' above and 'Open transabdominal approach' above and 'Laparoscopic approach' above.)
●Complications – Rates of complications such as blood loss >400 mL, procedure-related fetal loss, and wound infection are generally lower for the laparoscopic compared with the open procedure and even lower for cerclages placed prior to conception. (See 'Complications' above.)
●Delivery – Delivery after transabdominal cerclage is by cesarean birth. We suggest planning the procedure for 36+0 to 37+6 weeks of gestation, and immediately performing the procedure at the onset of regular uterine contractions if labor occurs prior to the scheduled delivery. The infant is extracted through a hysterotomy incision made above the stitch; the stitch can then be removed or, if future pregnancies are planned, it is left in place. (See 'Timing and route' above and 'Management of the cerclage after delivery' above.)
●Management of fetal demise – First-trimester and often second-trimester fetal demise can be managed without removing the cerclage. (See 'Management of fetal demise' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Jon Ivar Einarsson, MD, PhD, MPH, who contributed to earlier versions of this topic review.
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