Transvaginal Cervicoisthmic Cerclage Research Articles

Pre-Pregnancy Transvaginal Double Cervico-Isthmic Cerclage To Treat Women With Previous Conventional Failed Cerclage For Cervical Insufficiency: A Novel Modification of Treatment

Objective: To report pregnancy outcome following a pre-pregnancy transvaginal cervico-isthmic cerclage using a double non-absorbable synthetic polyester thread in a population of high-risk pregnant women. Methods: A retrospective descriptive study with a continuous series of 76 women presenting with at least one prior prophylactic failure of McDonald cerclage and submitted a pre-gestational transvaginal cervico-isthmic cerclage by the same surgical team between 2010 and 2019. The pregnancy outcome was analyzed for the first subsequent pregnancy of 64 women. The main outcome measure was the overall survival rate. Results: The median age of the patients was 30 years (SD 4.9; range 19-45 years). No intra-operative complication occurred. The median operating time was 39.8 minutes (range 35.5-55.8 min). Cesarean delivery was systematically performed in all patients. The mean gestational age at delivery was 35.5 weeks (SD 5.67; range 16-39 weeks), term birth rate (≥37 weeks) was 64.1%; 84.4% of babies were delivered at ≥34.0 weeks gestation. The overall neonatal survival rate was 94%. Conclusion: The pre-conceptional transvaginal cervico-isthimic cerclage here described as Shirodkar-Barini surgery is safe and results in high percentage of live born babies and low prematurity rate on the following pregnancy, in the patients with heavy obstetrics past suggestive of cervical incompetence and previous prophylactic McDonald’s failure

Isthmic retroperitoneal cerclage via vNOTES as a potential alternative to an abdominal cerclage: First technique description.

ObjectiveTo describe a new technique for performing an isthmic retroperitoneal cerclage via vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES). DesignStepwise explanation of the surgical technique using original video footage. This study was exempted from requiring hospital IRB. SettingDepartment of Obstetrics and Gynaecology, Imelda Hospital, Belgium. InterventionA circumferential vaginal incision is made around the cervix after infiltration of the tissue with local anaesthetic and adrenaline. The bladder is deflected from the cervix up to the level of the isthmus but the peritoneum is not opened. The rectum is deflected from the cervix up to the level of the isthmus but the peritoneum is not opened. A Gelpoint vPath (9.5 cm) (Applied Medical, Rancho Santa Margarita) is used as a vNOTES port. The inner ring of the Alexis is inserted into the retroperitoneal dissection space around the cervix, covering the bladder anteriorly and the rectum posteriorly. An insufflation stabilization bag (ISB) is connected to the Gelseal cap to minimize pressure fluctuations within the confines of the retroperitoneal operative space. The paracervical space is opened just inferior to the uterine artery. A paracervical tunnel is made from the anterior to the posterior retroperitoneal space just lateral to the cervix and just inferior to the uterine artery. This procedure is performed bilaterally. A vessel loop is inserted from anterior to posterior through the paracervical tunnel on each side of the cervix. The Gelseal cap is removed and an Ethibond-2 suture is tied to the vessel loop. The Gelseal cap is placed again. By pulling on the vessel loop, it is replaced by the Ethibond suture. The Ethibond suture is now tied endoscopically to complete the cerclage; alternatively the suture could be tied vaginally without endoscopic instruments to the surgeon's preference. The vNOTES port is removed and the vaginal mucosa is sutured to the cervix again using a resorbable suture. DiscussionAbdominal cerclage is the preferred approach to treat patients with refractory cervical insufficiency [1]. Over the last 20 years this technique increasingly gets performed laparoscopically with similar success rates [2]. The new transvaginal approach demonstrated in this video article may help reduce the invasivess even more by avoiding abdominal incisions and opening the peritoneum, while still benefiting from the vNOTES endoscopic visualization and minimally invasive instruments [3]. The cerclage is placed permanently at the level of the isthmus, similar to an abdominal cerclage. It is placed more cranially than a McDonald or Shirodkar cerclage and leaves no non-resorbable sutures in the vagina [4]. It can be an alternative to a conventional transvaginal cervicoisthmic cerclage [5,6] in patients with a narrow vagina and without uterine descensus. Following the guidelines of the IDEAL collaboration we present this technique to be peer reviewed in its early developmental phase before starting further studies [7]. ConclusionThis is a first feasibility and technique description report on performing a retroperitoneal isthmic cervical via vNOTES. This technique should be considered new, not to be performed on pregnant patients or outside of clinical trials, and only in carefully counselled patients.

A comparison of pregnancy outcome of emergency modified transvaginal cervicoisthmic cerclage performed in twin and singleton pregnancies.

To compare the pregnancy outcome of emergency cerclage performed in twin and singleton pregnancies. A retrospective trial was carried out in the Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital in Zhejiang, China, from January 2013 to December 2018. A total of 89 women with acute cervical incompetence underwent the emergency cerclage. Main outcome measures were gestational age at delivery and the fetal outcome. There were 31 twin and 58 singleton pregnancies that underwent emergency cerclage. In singleton pregnancies, gestational age at delivery (31.57 ± 6.11 vs 28.81 ± 4.34, p = 0.016), and prolongation of pregnancy (8.69 ± 6.13 vs 5.41 ± 3.72, p < 0.001) were greater, and the preterm delivery rate before 34weeks was lower (53.4% vs 80.6%, p = 0.011) compared with twin pregnancies. Fetal weight was greater in singletons than in twins (2377.3 ± 862.1 vs 1630.3 ± 557.6, p < 0.001), but the fetal survival rate was similar. The proportion of twin gestations was significantly higher in the group with preterm delivery before 34weeks (44.6% vs 18.2%, p = 0.011) and the proportion of previous term delivery was higher in the group with delivery at or after 34weeks (30.3% vs 12.5%, p = 0.039). The group with preterm delivery before 34weeks had a significantly larger size of visible membranes at cerclage than the group with delivery at or after 34weeks (2.23 ± 0.86 vs 1.64 ± 0.80, p = 0.001). In binary logistic regression analysis, twin gestations and a larger size of visible membranes were associated with an increased risk of preterm delivery. The pregnancy outcome of emergency cerclage appears to have a better prognosis in singleton pregnancies than in twin pregnancies, and twin pregnancy is a risk factor for preterm delivery.

Clinical efficacy of surgical opportunity of the modified transvaginal cervicoisthmic cerclage in treatment of the cervical incompetence

Objective: To explore the surgical opportunity of the transvaginal cervicoisthmic cerclage in the treatment of the cervical incompetence and the effect on the pregnancy outcomes. Methods: A Retrospective controlled trial was carried out between January 2014 and December 2018 in the Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital in Zhejiang, China and a total of 1 027 patients with cervical incompetence underwent the transvaginal cerclage. According to the different surgical opportunity, the patients were divided into two groups: the conception cerclage (n=736) and the preconception cerclage (n=291), and the former were divided into two subgroups depending on the condition of the cervix, the history indicated conception cerclage (n=511) and the ultrasound indicated conception cerclage (n=225). Main outcome measures were the gestational age, term delivery rate, the fetal weight and the fetal survival rate. Results: After the cerclage, the gestational age was (36±4) weeks, the term delivery rate was 69.6% (710/1 020), the fetal weight was (3 038±624)g and the fetal survival rate was 94.7% (966/1 020). Compared with the ultrasound indicated conception cerclage subgroup, the gestational age, the term delivery rate, and the fetal weight were all significantly higher in the history indicated conception cerclage subgroup [(37±4) vs (36±5) weeks, t=2.691; 72.8% vs 62.7%,χ(2)=7.593; (3 091±594) vs (2 963±756) g, t=2.396; all P<0.05], but the fetal survival rate was comparable in these two groups(95.3% vs 92.9%, χ(2)=1.772, P>0.05). There were no significant differences in the gestational age, the term delivery rate, the fetal weight and fetal survival rate between the history indicated conception cerclage and the preconception cerclage (all P>0.05). Conclusion: The transvaginal cervicoisthmic cerclage is a promising and safe technique for improving obstetric outcomes in women with cervical incompetence, and the history indicated conception cerclage is better than the ultrasound indicated cerclage.

Emergency vaginal cervico-isthmic cerclage

ObjectiveCervical cerclage is the principal treatment for women with a cervical insufficiency, which is a predominant factor in second trimester loss and preterm birth. A cervico-isthmic cerclage is recommended in case of a previous failure of McDonald cerclage or in case of an absent portio vaginalis of the cervix. In women who have prolapsed membranes at or beyond a dilated external cervical os before 24 weeks of gestation, an emergency cerclage can sometimes be performed. The aim of this study is to report our experience with emergency transvaginal cervico-isthmic cerclage. Study designThis is a retrospective, single-centre study conducted between 2009 and 2017 of women who received a transvaginal cervico-isthmic emergency cerclage. Emergency cerclage was defined as cerclage performed on women who had prolapsed membranes at or beyong a dilated external cervical os before 24 weeks of gestation. The exclusion criteria were twin pregnancy, preterm rupture of membranes, and clinical or biological signs of infection. ResultsThree women were included. One woman had a history of failure of emergency McDonald cerclage during her previous pregnancy. The two other women had a failure of McDonald cerclage during index pregnancy. All women presented prolapsed membranes at or beyond a dilated external cervical os as defined for an emergency cerclage. The emergency cerclage was performed at a mean gestational age of 21.5 weeks of gestation. The average gestational age of delivery was 38.5 weeks of gestation by caesarean section. ConclusionDespite the small number of women, this study shows that this type of cerclage was effective in pregnancy prolongation for women at high risk of preterm birth in case of McDonald cerclage failure. Nevertheless, this technique requires a trained surgical team. A randomised trial should be performed to evaluate the need for emergency vaginal cervico-isthmic cerclage.

Transvaginal cervicoisthmic cerclage for patients with extremely high-risk history of preterm delivery.

Transvaginal cervicoisthmic cerclage was carried out in 12 such patients who were at high-risk of premature delivery. Patients who underwent transvaginal cervicoisthmic cerclage had undergone conization, cervical radical hysterectomy or another form of extensive cervical resection, or had a history of third-trimester miscarriage or premature delivery despite having previously undergone cervical cerclage several times for cervical incompetence. There were seven cases of pregnancy after extensive conization, and four had a history of failed cervical cerclage. Two of these cases were the same individual, who became pregnant twice after extensive conization and gave birth to a live infant each time. The mean age at surgery was 35.7 years, and cerclage was performed at 11-19 weeks' gestation. All of the infants survived to hospital discharge. Transvaginal cervicoisthmic cerclage may be considered effective for patients with the history of recurring pregnancy loss due to previous failure of prophylactic cerclage.

A comparison of pregnancy outcome of modified transvaginal cervicoisthmic cerclage performed prior to and during pregnancy.

To compare the pregnancy outcome of the modified transvaginal cerclage performed preconception and during pregnancy. A retrospective trial was carried out in the Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital in Zhejiang, China. A total of 604 women with cervical incompetence underwent the cerclage, and the time of the operation was decided by the patients or depended on when the patient presented. Main outcome measures were the gestational age and the fetal outcome. After the cerclage, the mean gestational age at delivery and the term delivery rate were significantly higher in history-indicated conception cerclage compared to preconception cerclage (36.8±3.7 vs 35.8±4.7, p<0.01; 76.1 vs 66.9%, p<0.05). The mean gestational age at delivery and the term delivery rate were significantly higher in ultrasound-indicated compared to physical examination-indicated conception cerclage (35.0±5.7 vs 31.0±5.5, p<0.01; 63.2 vs 23.3%, p<0.001). The fetal survival rate had no difference in these two comparisons, respectively. The modified transvaginal cervicoisthmic cerclage is a promising and safe technique to improve obstetric outcomes in women with cervical incompetence in different cerclage indications, and history-indicated conception cerclage appears to have better pregnancy outcome.

Fertility and pregnancy outcomes after transvaginal cervico-isthmic cerclage

IntroductionPrematurity is the leading cause of neonatal morbidity and mortality. Cervical insufficiency seems to be the main risk factor. Treatment is cervical cerclage. In case of failure, a cervico-isthmic cerclage by Fernandez’ technique, with the placement of a polypropylene sling by vaginal approach during the first trimester of pregnancy, has proven its effectiveness.The aim of our study is to report effectiveness of Fernandez’ cervico-isthmic cerclage in subsequent pregnancies. Materials and methodsThis retrospective study, was conducted from March 2002 to April 2014 in the gynecologic department of two teaching hospitals. The inclusion criterion was history of cervico-isthmic cerclage using Fernandez's technique during the previous pregnancy. This study received IRB approval number CEROG 2016-GYN-0302. Results125 women underwent a definitive cervico-isthmic cerclage. The total percentage of neonatal survival after 14 weeks was 91% and the total percentage of neonatal survival after 24 weeks of gestation was 98.2%.Out of 114 women, 33 desired a second pregnancy. Out of which 29 had a spontaneous pregnancy. The percentage of total neonatal survival rate after 14 weeks was 92.86% and the percentage of total neonatal survival after 24 weeks was 96.3%.Out of the 29 women with a second pregnancy, 5 women achieved a third pregnancy. The five births occurred after 37 weeks of gestation with a percentage of total neonatal survival of 100%. ConclusionThe cervico isthmic cerclage using the technique of Fernandez makes it possible to obtain subsequent pregnancies without further surgery with very satisfactory results regarding neonatal survival.

Transvaginal cervicoisthmic cerclage using a polypropylene sling: Pregnancy outcome

To report pregnancy outcome following prophylactic transvaginal cervicoisthmic cerclage using a polypropylene sling in a population of high-risk pregnant women. A retrospective study with a continuous series of 57 women presenting with prior failure of McDonald cerclage (n = 47) and/or absent portio-vaginalis of the cervix (n = 10). Cervicoisthmic cerclage was performed between 12 and 16 weeks of gestation (median 14 weeks' gestation). No intraoperative complication occurred. Preterm labor treated with parenteral tocolysis occurred in 14 women (24%). Cesarean delivery was systematically performed. Median gestational age at delivery was 37.2 weeks' gestation (interquartile range: 36.5-38.0). Overall neonatal survival rate was 94%. Transvaginal cervicoisthmic cerclage using a polypropylene sling may be considered as an effective alternative to the transabdominal cervicoisthmic cerclage in women presenting with previous cerclage failure.

Fertility Outcome Following Transvaginal Cervicoisthmic Cerclage Using a Polypropylene Sling

Transabdominal cervicoisthmic cerclage is beneficial in most women with cervical incompetence, for whom a conventional transvaginal procedure is inadequate or would be impossible. A large number of studies have reported that the fetal survival rate after the procedure increases from 70% to 95%. The high morbidity, however, associated with transabdominal cervicoisthmic cerclage limits its use. Recent studies have shown that a new procedure for transvaginal cervicoisthmic cerclage, using a macroporous monofilament polypropylene sling, may be an effective minimally-invasive alternative to transabdominal cervicoisthmic cerclage in women who present with a previous cerclage failure. This study evaluated the effect of the new procedure on the fertility and subsequent pregnancy outcomes among 57 women who underwent prophylactic transvaginal cervicoisthmic cerclage in a previous (reference) pregnancy, because of a high risk for preterm delivery. At 12 months or more after the reference pregnancy, telephone interviews were conducted to assess each patient's subsequent fertility. Of the 57 women interviewed, 8 had an inadequate follow-up of less than 12 months, 13 were lost to follow-up, 2 women required removal of the sling after cesarean delivery, and 1 needed a hemostatic peripartum hysterectomy. Among the other 33 women interviewed, 14 desired a subsequent pregnancy and 19 did not. One of the 14 women wanting a subsequent pregnancy had previously known tubal infertility and did not undergo in vitro fertilization. A total of 7 (54%) of the 13 subsequently became pregnant with the following outcomes: 1 had a spontaneous abortion at 11 weeks of pregnancy; 1 delivered at 22 weeks after spontaneous premature membrane rupture; 1 had a cesarean delivery at 25 weeks; and 4 had a term cesarean delivery at a median duration of 37 weeks (interquartile range = 37-38 weeks). The median birth weight of the 4 neonates was 3040 gm (interquartile range = 2500-3250 g). The investigators concluded from these findings that, subsequent successful pregnancy is possible when a transvaginal cervicoisthmic cerclage (specifically a polypropylene sling) is in place.

Fertility outcome following transvaginal cervicoisthmic cerclage using a polypropylene sling

Objective To report fertility and pregnancy outcomes following transvaginal cervicoisthmic cerclage with a polypropylene sling during a previous pregnancy. Methods A continuous series of 57 women who underwent prophylactic cervicoisthmic cerclage during a previous (reference) pregnancy were enrolled. Telephone interviews were carried out to evaluate each patient's subsequent fertility. Results Among the 57 women interviewed, 8 had an inadequate follow-up, 13 women were lost to follow-up, 1 woman required a hemostatic hysterectomy, and 2 women required removal of the sling. Nineteen women did not desire a subsequent pregnancy. Of the 14 women who did desire a subsequent pregnancy, 1 woman had previously known tubal infertility. Of the 13 remaining women, 7 subsequently became pregnant. One woman had a spontaneous abortion (11 weeks of pregnancy); 1 woman delivered at 22 weeks of pregnancy, after a spontaneous premature membrane rupture; 1 woman had a cesarean delivery at 25 weeks of pregnancy; and 4 patients had a cesarean delivery after 37 weeks of pregnancy. Median duration of the 4 subsequent pregnancies at delivery was 37 weeks (interquartile range [IQR], 37–38 weeks). Median birth weight was 3040 g (IQR, 2500–3250 g). Conclusion Subsequent pregnancy is possible after transvaginal cervicoisthmic cerclage using a synthetic sling.

Technique de cerclage cervico-isthmique par voie vaginale avec bandelette de polypropylène: technique de Fernandez

To assess the efficacy of performing transvaginal cervico-isthmic cerclage using synthetic tape in prevention of preterm labor in high-risk women.A retrospective analysis of 24 transvaginal cerclages using polypropylene tape performed in women presenting with high risk of preterm delivery: prior histories of pregnancy losses in the second trimester, prior failure of Mac Donald's cerclage and/or absent portio vaginalis of the cervix. Cerclage was performed between 12 and 16 weeks of gestation. A polypropylene tape was placed at the cervicoisthmic junction by vaginal route.The median age of the patients in this series was 32.1 years (range 22-39 years). No intra-operative complication occurred. The median operating time was 34.9 minutes (+/-5.1) (range 30-45 min). Cesarean delivery was systematically performed in all patients since the cerclage was considered to be definitive. Mean gestational age and birth weight at delivery were respectively 37.1 weeks (+/-1.8) and 2850 g (+/-745). Preterm birth rate was 19% (4/21). Birth at less than 32 weeks occurred in only one patient (4%). In one case, the tape has been removed later because symptomatic vaginal erosion was noted. One neonatal death occurred following amniotic fluid infection at 34 weeks. At the present time, 3 women are at 22, 26 and 26 weeks of gestation with no preterm labor.Transvaginal cerclage using polypropylene tape may be considered as an effective and minimally invasive alternative to transabdominal cervico-isthmic cerclage in women presenting with high risk of preterm delivery.

Novel application of polypropylene sling: Transvaginal cervicoisthmic cerclage in women with high risk of preterm delivery

Study objective To describe a novel technique of transvaginal cervicoisthmic cerclage with a polypropylene sling in prevention of preterm labor in pregnant women at high risk. Design Retrospective study (Canadian Task Force classification: III). Setting University hospital (department of obstetrics and gynecology). Patients Twenty-one women showing symptoms of high risk of preterm delivery: histories of pregnancy losses in the second trimester and prior failure of MacDonald’s cerclage or absent portio vaginalis of the cervix. The median age of the patients was 32.8 years (range 22–39 years). Interventions Cerclage was performed between 12 and 16 weeks’ gestation. A polypropylene tape was placed at the cervicoisthmic junction by vaginal route. Caesarean delivery was systematically performed in all patients because the cerclage was considered to be definitive. Measurements and main results No intraoperative complications occurred. The mean operating time was 36 ± 6 minutes (range 30–45 minutes). The mean length of stay was 1.4 ± 0.5 days. Mean gestational age and birth weight at delivery were respectively 37.1 ± 1.8 weeks (CI 95%: 36.4–37.9) and 2850 ± 745 g (CI 95%: 2531–3168). The preterm birth rate was 19% (4/21). One neonatal death occurred after amniotic fluid infection at 34 weeks. Birth at less than 32 weeks occurred in one patient (4%). Conclusion Transvaginal cervicoisthmic cerclage with polypropylene sling may be considered as an effective and minimally invasive alternative to the transabdominal cervicoisthmic cerclage in women presenting with high risk of preterm delivery.

Transvaginal placement of cervicoisthmic cerclage: Report on pregnancy outcome

This study was undertaken to review pregnancy course and outcome in 56 pregnancies after the placement of a cervicoisthmic cerclage transvaginally. Fifty-three pregnant patients with unique indications such as previous failure of conventional cerclages or compromised cervical anatomy, underwent transvaginal placement of a cervicoisthmic cerclage during pregnancy. There was 100% fetal survival. Preterm birth rate was 32% and births at less than 30 weeks occurred in 21% of our patients. In 6 patients, the suture was not removed and 3 patients had an additional gestation with the same suture. Serious complications included 1 instance of intraoperative bladder laceration and 1 of intrapartum cervical tear. Minor complications included a postoperative hematoma and transient urinary retention with pelvic pain in 2 patients. The placement of transvaginal cervicoisthmic cerclage was associated with favorable pregnancy outcome and may be considered as a suitable safe alternative to the transabdominal cerclage.

Transvaginal cervicoisthmic cerclage as an alternative to the transabdominal technique

Objectives: To analyse the foetal outcome after transvaginal cervicoisthmic cerclage, to determine whether it is a valid alternative to the reference transabdominal technique. Study Design: Description of the vaginal operative technique, retrospective review of 20 cervicoisthmic cerclage patients from 1990 to 2000. Results: In the curative group of women with a history of late pregnancy losses or premature deliveries and usually previous failed classical cervical cerclage, the foetal survival rate improved from 18% before cerclage to 79% after cerclage. No operative complications were reported. In the prophylactic group, typically characterised by the absence of the cervix as a consequence of surgery for invasive cervical cancers, the foetal survival rate was 83% after cerclage. Conclusions: The transvaginal cervicoisthmic cerclage allows a high foetal survival rate without complications in highly selected patients with poor obstetrical history. Because of its simplicity, this technique should replace the transabdominal route for surgeons experienced in vaginal surgery.