Three-dimensional ultrasound imaging of intra-abdominal cervical-isthmus cerclage.

Abstract

Cervical cerclage is used to correct cervical insufficiency in pregnancy, in order to prevent preterm delivery and associated complications. The conventional method of transvaginal placement of cervical cerclage may be difficult to perform in some patients, such as those who have undergone cervical conization, particularly those in whom the remaining cervix is short. Recently, such patients have been treated by cerclage of the cervical isthmus of the uterus, which is performed by either open or laparoscopic surgery1-5. In transvaginal uterine cervical cerclage, the patient is monitored postoperatively by direct transvaginal observation of the suture; however, this is not feasible after open surgery or laparoscopic cerclage of the cervical isthmus. Although two-dimensional (2D) transvaginal ultrasonography (TVS) has conventionally been used for monitoring of cerclages in situ, it is difficult to assess the condition of the suture using this technique. We have found that three-dimensional (3D) images obtained on TVS using the OmniView™ (GE Medical Systems, Zipf, Austria) technique can facilitate observation of suture placed intra-abdominally. A 31-year-old woman, gravida 2, para 1, with a history of preterm delivery at 34 weeks' gestation due to cervical insufficiency, presented to our hospital at 10 weeks' gestation after conceiving spontaneously. She had been diagnosed with cervical intraepithelial neoplasia and had undergone conization at another hospital at the age of 30 years. Colposcopy at the initial examination revealed that barely any of the cervix remained and its stump was not graspable, therefore, placement of transvaginal cerclage was not possible technically. Accordingly, laparoscopic cerclage of the cervical isthmus of the uterus was performed at 12 weeks' gestation. A 2D ultrasound image of the cervix at 3 weeks after the procedure is shown in Figure 1. Although the suture is visualized as bright structures anterior to and behind the internal os, it cannot be seen in its entirety. A 3D ultrasound image obtained at the same time is shown in Figure 2. The circumferential suture around the cervical canal was clearly visible, allowing assessment of its condition. Looseness or slippage of the suture was not observed within the first 3 postoperative weeks. The postoperative clinical course of the patient was uneventful. From our observations, we conclude that, as it is not possible to observe directly sutures if cervical cerclage is performed intra-abdominally, 3D ultrasonography is useful for the postoperative monitoring of their condition, such as evaluating the relationship between the stitch and cervical canal and whether the suture is loose.