© Springer-Verlag Berlin Heidelberg 2015
Olav Istre (ed.)Minimally Invasive Gynecological Surgery10.1007/978-3-662-44059-9_1515. Laparoscopic Cerclage
(1)
Brigham and women’s Hospital, Boston, MA, USA
15.1 Introduction
Preterm delivery is the most common cause of neonatal morbidity and mortality, with reported preterm birth rates in Europe and other developed countries around 5–11 % of all deliveries (Lawn et al. 2010). Cervical insufficiency contributes to both preterm delivery and second-trimester fetal loss. It has been conservatively reported that cervical insufficiency complicates approximately 0.1–1 % of all pregnancies, and estimates suggest that 8 % of women with repeated second or early third-trimester losses may be affected (Ludmir 1988; Scarantino et al. 2000). In a normal pregnancy, the cervix stays both closed, with substantial length (>3 cm) and only toward the end of term the cervix starts to progressively shorten, become effaced in preparation for normal labor and delivery. In some cases, however, the cervix starts to shorten and dilates pathologically early in gestation (Alfirevic et al. 2012). This condition has been described as early as the seventeenth century by Riverius and was formerly termed ‘cervical incompetence’. While this term has largely given way to the less pejorative, ‘cervical insufficiency’ they both refer to a condition where the cervix fails to maintain an intrauterine pregnancy until term (Ludmir 1988). Cervical insufficiency is characterized by painless dilation of the cervix followed by either the premature rupture or prolapse of the fetal membranes but without uterine contractions.
The pathogenesis of the cervical insufficiency has never been well understood. It has been thought to be possibly associated with everything from congenital weakness or previous cervical trauma, such as prior cone biopsy, improperly performed pregnancy terminations, or precipitous vaginal delivery. However, several recent studies have suggested that maternal and fetal inflammations are more likely key factors contributing to premature cervical effacement and dilatation (Harger 2002; Warren et al. 2009; Rust et al. 2001; McElrath et al. 2008). Work has suggested that specific cytokines present in the maternal and fetal milieu are directly correlated to premature labor causes and more specifically to cervical insufficiency (McElrath et al. 2011; Faupel-Badger et al. 2011). Moreover, the contribution of this background of biochemical, inflammatory, and immunological stimuli could explain why the ability of the cervix to remain closed varies from pregnancy to pregnancy. It is likely that cervical insufficiency is not an independent condition but one portion of a spectrum of conditions leading to spontaneous preterm birth (Lawn et al. 2010).
Nonetheless, cervical insufficiency is associated with dramatic consequences which may contribute to further morbidity including intraamniotic infection, preterm premature rupture of the fetal membranes (PPROM) and preterm labor and delivery (PTD), and fetal loss (www.uptodate.org).
To prevent the adverse effects caused by cervical insufficiency, a variety of therapies have been proposed and will be discussed briefly in this chapter. More specifically will be discussed the laparoscopic transabdominal cerclage.
15.2 Methods to Prevent Preterm Loss Associated with Cervical Insufficiency
When cervical insufficiency is suspected, a variety of diagnostic and treatment options can be considered:
Fetal fibronectin: The fetal fibronectin test is a test performed between 24 and 35 weeks gestation and measures the fibronectin protein that leaks into the vagina. If higher concentrations are noted, the risk of preterm delivery is increased. A negative test is reassuring as the possibility of preterm labor within the next 7–10 days is diminished. However, the test has a high false-positive rate. Despite this disadvantage, there is now substantial evidence that the fibronectin test is a reasonable test to reassure pregnant women (Duhig et al. 2009; Honest et al. 2009).
Progesterone: Administration of progesterone either intramuscularly or vaginally in the second and third trimester of pregnancy, depending on the indication, has been demonstrated to reduce the risk of primary or recurrent preterm birth (Berghella et al. 2010). Intramuscular progesterone has been specifically demonstrated to reduce the risk of recurrent preterm birth in women with prior history of premature birth (Berghella et al. 2010). Therefore in this group of women, it is appropriate to conduct progesterone prophylaxis between 16 weeks and 36 weeks gestation. More research is needed in terms of efficacy and the long-term consequences of progesterone use (Arisoy and Yayla 2012).
Pessary: A pessary is a silicone device that is inserted through the vagina and provides support to the cervix. It is a noninvasive, easy to apply, and cost-effective method and has been used over the past 50 years to prevent preterm birth, without gaining much popularity though. In a recent randomized control trial, however, a significant difference was found in the prolongation of pregnancy between women with cervical shortening treated with pessary and those managed expectantly. The authors concluded that the pessary is an affordable and safe alternative in a population of appropriately selected at-risk pregnant women with a cervical length of 25 mm or less (Goya et al. 2012). Pessary presents an interesting new option in the management of cervical insufficiency.
15.3 Cerclage
Considered generally, the placement of a cervical cerclage involves the circumferential suturing of the uterine cervix or lower uterine segment. The aim is to give mechanical support and thereby maintain the cervical length and integrity. Cerclage can be placed either transvaginally or transabdominally. In 1957, Lash and Lash (1950), Shirodkar (1955), and McDonald (1957) first reported outcomes on cerclage placed transvaginally. In 1965, Benson and Durfee described the first transabdominal approach for women in whom a vaginal approach was not possible or had previously failed (Benson and Durfee 1965). More than 30 years later, in 1998, the first laparoscopically performed transabdominal cerclage was reported (Burger et al. 2011). It is currently estimated that, in the United States, cerclage is performed at a rate of 1 per every 300 pregnancies (Menacker and Martin 2008). Elsewhere in the world, cerclage placement has been reported to be higher, up to 1 per every 100 pregnancies (Al-Azemi et al. 2003). In multiple pregnancies, placement of cerclage occurs more often, up to 10 % for triplets.
15.3.1 Indication for Cerclage Placement
Historically, the indications for cerclage placement (either transabdominally or transvaginally) have been diverse and include factors such as poor obstetric history, uterine anomalies, cervical trauma, and cervical shortening seen on ultrasound examination. More recently, the Cochrane review (Alfirevic et al. 2012) divided the indications of cerclage into the following categories:
History indicated cerclage: this type of cerclage is placed because of a perceived increased risk related to a woman’s obstetric or gynecological history. The history indicated cerclage is preferably placed at 12–14 weeks of gestation, after assessment of viability and chromosomal risk. Multiple authors suggest that a history-indicated cerclage might be considered for women meeting the following three criteria (MRC/RCOG 1993; Buckingham et al. 1965; Leppert et al. 1987; Rechberger et al. 1988): (1) Two or more consecutive prior second trimester pregnancy losses or three or more early (<34 weeks) preterm births. (2) Risk factors for cervical insufficiency are present (history of cervical trauma and/or short labors or progressively earlier deliveries in successive pregnancies). (3) Other causes of preterm birth (e.g., infection, placental bleeding, multiple gestation) have been excluded.
Ultrasound-indicated cerclage: if the cervical length decreases to less than 25 mm on screening prior to 24 weeks, placement of a transvaginal cerclage could be considered (Committee opinion no. 522: 2012; Society for Maternal-Fetal Medicine Publications Committee 2012). The efficacy of this cerclage is limited to women with a prior preterm birth who are not found to have a cervical length <2.5 cm. In a randomized control trial comparing Shirodkar cerclage to expectant management in women with short cervix, no significant differences were found with regard to perinatal or maternal morbidity (To et al. 2004).
Exam indicated cerclage is a rare procedure in which a cervical suture is placed in women who are incidentally found to have a dilated cervix with or without prolapsed membranes. In order to perform this type of cerclage, the patient must not be in labor and not have heavy vaginal bleeding or infection (Liddiard et al. 2011). The complication rate, mainly due to the membrane ruptures, as well as the loss rate was higher than in other types of cerclage placement (Liddiard et al. 2011).
As elsewhere transvaginal cervical is the initial procedure of choice in our institution. However, for those with who have failed prior prophylactic methods designed to prevent recurrent spontaneous preterm birth, we reserve consideration of a transabdominal cerclage.
15.3.2 Transvaginal Cerclage
The transvaginal approach, which is most commonly used, has two primary placement techniques:
1.
The McDonald cerclage, consists of placing a purse-string suture at the cervico-vaginal junction. This cerclage is typically placed between 12 and 14 weeks of pregnancy and the stitch is generally removed around the 37th week of gestation.
2.
A Shirodkar cerclage is a similar technique, except that the sutures are placed close to the level of the internal os and are tunneled through the walls of the cervix, leaving them largely unexposed. The Shirodkar is technically more difficult than the McDonald cerclage and it involves some degree of bladder mobilization.
15.3.3 Transabdominal Cerclage
The transabdominal cerclage involves a Mersilene band (or other nonabsorbable suture material) passed around the cervicouterine isthmus at the level of the uterosacral ligament insertions with either an anterior or posterior tying of the ligature (Mingione et al. 2003). This procedure is typically reserved for patients who have failed one or more prior prophylactic techniques to prevent preterm birth (Reid et al. 2008).
Advantages of transabdominal over transvaginal cerclage are the more proximal placement of stitches (at the level of the internal os) and the ability to leave the suture in place for future pregnancies (Carter and Soper 2005). A disadvantage of this approach is the need for two surgeries during pregnancy (one to place the cerclage and a cesarean section for the delivery of the infant). Additionally, there is the possibility that additional surgery may be required in case of miscarriage or fetal demise (Lesser et al. 1998; Davis et al. 2000). In a systematic review, transabdominal cerclage was associated with a lower likelihood of perinatal death or delivery before 24 weeks of gestation (6 versus 12.5 % with repeat transvaginal cerclage), but a higher rate of serious operative complications, such as need for transfusion or organ injury (3 versus 0 %) compared with transvaginal cerclage (Zaveri et al. 2002). Subsequent studies have reported similar findings (Debbs et al. 2007). It has been suggested that the reason for the improved outcomes associated with abdominal cerclage is that the position of the cerclage at the level of the internal os (House and Socrate 2006).
The question whether cerclage should be placed via laparotomy or laparoscopy is still up for debate. In a recent systematic review comparing the effectiveness of abdominal cerclage placed via laparotomy or laparoscopy, the authors concluded that the outcomes of both methods of cerclage were excellent, with mean fetal survival rate (defined as total number of live born infants who survived the neonatal period, which is 6 weeks after delivery, divided by total number of pregnancies) between 80.9 and 90.8 %. The perioperative complication rates for both procedures were low and not significantly different, however in favor of the laparoscopic group (Burger et al. 2011).
Despite the limited available data, the present results seem to indicate that both approaches are safe and associated with good perinatal outcomes in patients with a poor obstetrical history. Therefore, it has been suggested that when possible, the abdominal cerclage should be done via laparoscopy, as this is associated with lower cost and the traditional benefits of minimally invasive surgery, such as fewer adhesions, less postoperative pain, no required hospitalization, and more timely recovery (Burger et al. 2011). However, more research with sufficient power needs to be done to define if one method is superior to the other.
15.3.4 Timing of Placement
Transabdominal cerclage placement can be performed prior to conception or, as stated by the American College of Obstetricians and Gynecologists’ guideline on cervical insufficiency (2003), during early pregnancy (11–14 weeks), after ultrasound evaluation (American College of Obstetricians and Gynecologists 2003). The preconceptional approach is associated with less blood loss and avoids the risk of pregnancy-associated complications (e.g., rupture of the fetal membranes). It is also much easier to place the cerclage in a nonpregnant patient, which shortens operating time.
Placement of an abdominal cerclage late or after the first trimester is not possible since the large size of the uterus makes the procedure difficult if not impossible and is therefore associated with higher risk. At our institution, we prefer placing the cerclage prior to conception due to the greater ease of placement and the reduced risk of complications. A laparoscopic approach is also associated with minimal morbidity and therefore seems justifiable, even in the rare cases where patients are not able to conceive after the cerclage placement.
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