Zaveri and associates (2002) reviewed 14 observational studies in which a prior transvaginal cerclage had failed to prevent preterm delivery. The risk of perinatal death or delivery before 24 weeks' gestation was only slightly lower following transabdominal cerclage compared with the risk following repeat transvaginal cerclage-6 versus 13 percent, respectively. Importantly, 3 percent of women who underwent transabdominal cerclage had serious operative complications, whereas there were none in the transvaginal group. Whittle and coworkers (2009) described 31 women in whom transabdominal cervico isthmic cerclage was done laparoscopieally between 10 and 16 weeks. he procedure was converted to laparotomy in 25 percent, and there were four failures due to chorioamnionitis. Overall, fetal survival rate approximated 80 percent.
Principal among these are membrane rupture, preterm labor, hemorrhage, infection, or combinations thereof. All are
FIGURE 18-4 Transabdominal cervicoisthmic cerclage. Following incision and sharp dissection in the vesicouterine space, the blad der is mobilized caudally. At the level of the internal os, a window is made in free space medial to the uterine vessels. This avoids vessel compression by the tightened cerclage. Care is also taken to avoid the ureter, which is lateral and posterior. The suture is passed anterior to posterior or vice versa. In this case, the knot is tied anteriorly, and the vesicouterine peritoneum is closed with absorbable suture in a running fashion. (Reproduced with permission from Hawkins JS: Lower genital tract procedures. In Yeomans ER, Hofman BL, Gilstrap LC III, et al: Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili Education, 2017.) uncommon with prophylactic cerclage. In the multicenter study by Owen and colleagues (2009), of 138 procedures, there was one instance each of ruptured membranes and bleeding. In the trial by MacNaughton and associates (1993), membrane rupture complicated only 1 of more than 600 procedures done before 19 weeks. In our view, clinical infection mandates immediate removal of the suture with labor induced or augmented. Similarly, ¥lith imminent abortion or delivery, the suture should be removed at once because uterine contractions can tear through the uterus or cervix.
Following cerclage, if subsequent cervical thinning is detected by sonographic assessment, then some consider a reinforcement cerclage. In one retrospective study, however, reinforcing cerclage sutures placed later did not significantly prolong pregnancy (Contag, 2016).
Membrane rupture during suture placement or within the irst 48 hours following surgery is considered by some to be an indication for cerclage removal because of the likelihood of serious fetal or maternal infection (Kuhn, 1977). That said, the range of management options includes observation, removal of the cerclage and observation, or removal of the cerclage and labor induction (O'Connor, 1999).
he term induced abortion is defined as the medical or surgical termination of pregnancy before the time of fetal viability.