{"paper_id":"1744deb0-6656-46c8-8017-f8702bebe327","body_text":"Endoscopic transabdominal cervical cerclage replacement \nafter recurrent late miscarriage.\nJournal:BMJ Case Reports\nManuscript IDDraft\nManuscript Type:Case report\nDate Submitted by the \nAuthor:n/a\nComplete List of Authors:Hirsch, Martin; Oxford University, Oxford Endometriosis CaRe Centre\nReisel, Dan; University College London; University College London \nHospitals NHS Foundation Trust, Reproductive Medicine Unit\nSaridogan, Ertan; University College London, Elizabeth Garrett Anderson \nInstitute for Women's Health; University College London NHS Foundation \nTrust, Reproductive Medicine Unit\nDavid , Anna ; University College London, EGA Institute for Women's \nHealth; NIHR University College London Hospitals Biomedical Research \nCentre,  \nKeywords:Pregnancy < Obstetrics and gynaecology, Materno-fetal medicine < \nPaediatrics\n \n\n\nTITLE OF CASE\nEndoscopic transabdominal cervical cerclage replacement after recurrent late miscarriage.  \nSUMMARY\nTransabdominal cerclage (TAC) is a recognised treatment for recurrent spontaneous late miscarriage or \npreterm birth due to cervical weakness. This can be performed via an open procedure before and during \npregnancy, or a laparoscopic technique preconception. Complications include cerclage failure and suture \nmigration. We present a case highlighting these complications where laparoscopic removal of an open \nTAC and replacement led to two successful term deliveries. A 30-year-old African woman with a fibroid \nuterus, adenomyosis and a history of three spontaneous mid-trimester losses, had an open TAC at 13 \nweeks of gestation. Preterm premature rupture of the membranes (PPROM) occurred shortly after and at \n18 weeks of gestation she underwent surgical evacuation of the uterus. Subsequent hysteroscopy \nconfirmed migration of the cerclage through the cervical canal. We demonstrate the application of \nendoscopic gynaecological surgery to remove and replace the TAC with two successful term births by \nCaesarean section in the ensuing pregnancies.\nBACKGROUND\nVaginal cerclage is commonly used to reduce preterm birth and prevent fetal loss, often in the context of \nrecurrent miscarriage.[1] Although randomised controlled trials are still largely lacking, cerclage is \nthought to reduce the risk of perinatal death when compared with no cerclage, and may benefit the \nsmall number of women with traumatic cervical damage or genuine cervical weakness.[2, 3] In women \nwith spontaneous late miscarriage or preterm birth following a full dilatation Caesarean section, vaginal \ncervical cerclage may be less effective, requiring a different approach.[4] \nIn women for whom vaginal cerclage fails, transabdominal cerclage (TAC) has been advocated. This \nrequires more extensive surgery than vaginal cerclage, and delivery is usually via caesarean section. \nAmongst those women with recurrent miscarriage and extreme prematurity, neonatal survival increases \nfrom 3-36% prior to TAC to up to 73-100% in a review of published case series.[5, 6] This is supported by \na recent randomised controlled trial that demonstrated reduced rates of preterm birth and fewer fetal \nlosses associated with transabdominal cerclage compared with vaginal cerclage performed either via the \nMacdonald (low vaginal) or Shirodkar (high vaginal) technique.[7]\nOpen TAC was first described in 1965 whereby a Pfannenstiel incision was used to enter the abdominal \ncavity prior to opening the uterovesical fold with caudal displacement of bladder and siting of the \ncerclage at the cervico-isthmic junction. This procedure can be performed up to 14/15 week’s gestation \nbut evidence from a large case series suggests that it is more efficacious if performed preconception.[8] \nThe first laparoscopic TAC was performed in 1998 but was complicated by an injury to the uterine artery \nrequiring clipping.[9] Guidance from NICE on the procedure was published in 2007 and updated in \n2019.[10, 11] The surgical technique for laparoscopic TAC is important as the Mersilene® (Ethicon, LCC, \nUSA) suture needs to be accurately placed at the cervico-isthmic junction immediately medial to the \nuterine vessels.[12] Therefore, it can be a challenging operation, especially when the uterus has \nadditional pathology such as fibroids, adenomyosis or previous surgery, including suture placement. \nLaparoscopic procedures are most commonly performed prior to pregnancy with the benefit of pre-\npregnancy insertion, particularly for laparoscopic procedures, being the ability to use a uterine \nPage 1 of 7\n\nmanipulator to facilitate acute ante and retroversion of the uterus during suture insertion. The risks of \nbleeding, infection and thromboembolism are lower prior to pregnancy but there is the potential for \nsubsequent infertility, albeit small. First trimester miscarriage is often managed via surgery, with cautious \ncervical dilatation and uterine evacuation. While a relatively safe procedure, complications of TAC have \nbeen identified following both open and laparoscopic procedures but remain poorly reported in \npublished case series. These complications include suture migration, rectouterine fistula some years \nlater, uterine rupture, and fetal growth restriction.[5, 13] Laparoscopic TAC removal after pregnancy \nfailure has been reported but without concurrent reinsertion or subsequent pregnancy.[14-16]\nWe report a case of endoscopic removal of a migrated open TAC suture with replacement and \nsubsequent two term births.\nCASE PRESENTATION\nA 30-year-old African woman with raised BMI (31), a fibroid uterus and adenomyosis presented with a \nhistory of recurrent spontaneous late miscarriages at 15 and 23+5 weeks of gestation; in her third \nongoing pregnancy her cervix funnelled through an elective low vaginal cerclage placed at 14 weeks and \nshe delivered at 22+5 weeks of gestation. Laparoscopic pre-pregnancy TAC was recommended but she \nconceived rapidly and therefore underwent an open TAC with Mersilene® tape placed at 13 weeks of \ngestation, and a posterior tied knot. Although the surgery was uneventful three days later she ruptured \nher membranes. With ongoing anhydramios and the development of infection she proceeded to \ntermination of pregnancy at 18 weeks of gestation. An uncomplicated cervical dilatation and evacuation \n(D&E) was performed under ultrasound guidance to preserve the integrity of the TAC. \nINVESTIGATIONS If relevant\nAn ultrasound 6 weeks following this pregnancy showed an intact TAC but subsequent outpatient \nhysteroscopy at 3 months confirmed part of the TAC suture had migrated through into the cervical canal. \nThe patient underwent extensive counselling about endoscopic removal and reinsertion under general \nanaesthetic and agreed to proceed.\nDIFFERENTIAL DIAGNOSIS If relevant\nN/A\nTREATMENT If relevant\nUnder general anaesthesia a combined hysteroscopic and laparoscopic procedure was performed. Using \nan operative hysteroscope (AlphaScope®, Gimmi, DE) with cold scissors the suture was visualised in the \ncervical canal and released (Video 1; time 00:32). During laparoscopy the patient had healthy adnexa \nwith no evidence of pelvic endometriosis. The uterovesical fold was thickened in keeping with previous \ncerclage insertion. Sharp dissection with the Thunderbeat® (Olympus Corp, Japan) advanced bipolar \ndevice enabled dissection of the uterovesical fold with haemostasis while the suture was identified and \nremoved (Video 1; time 2:25). The uncomplicated reinsertion of a modified Mersilene® tape TAC medial \nto uterine vessels and immediately lateral to cervico-isthmic junction was performed with an anterior \nPage 2 of 7\n\ncervical knot. Care was taken to lay the tape flat on the uterus and to cut the ends to 1–2 cm (Video 1; \ntime 3:18). This technique uses a modified curved to straight blunt needle with Mersilene® (Ethicon US, \nLCC, USA) tape.\nOUTCOME AND FOLLOW-UP\nThe patient conceived spontaneously with a low risk combined test Down’s syndrome screen. She began \nlow dose aspirin 150mg at night and vaginal Cyclogest 200mg pessary at night due to her history of \nrecurrent perinatal loss. She underwent serial cervical length ultrasound examination from 12 weeks of \ngestation which confirmed a long cervix (36mm) with the TAC remaining at the level of the cervical \nisthmus (Figure 1). She developed two asymptomatic urinary tract infections in the second trimester \nwhich were treated with oral antibiotics. She was diagnosed with gestational diabetes at 18 weeks of \ngestation and was prescribed metformin 500mg at night at 22 weeks which continued until the end of \npregnancy. Fetal growth velocity was suboptimal with the estimated fetal weight <5th centile on \ncustomised fetal charts. At 37+1 weeks she received two doses of betamethasone steroids to mature the \nfetal lungs and an elective Caesarean section was performed two days later.  The cerclage was seen at \nthe level of the internal cervical os, and the uterine incision was placed 2cm above. The delivery was \nstraight forward and the estimated blood loss was 400ml. A live male infant was born weighing 2050g \nwith good Apgar score at 1 and 5 minutes. Postoperative recovery was complicated by fever and \nendometritis on day 2 postnatal which resolved with intravenous antibiotics. She spontaneously \nconceived again two years later, and had an uneventful pregnancy, but again complicated by gestational \ndiabetes which was managed with metformin treatment. Delivery was an elective Caesarean section at \n37+4 weeks with a live male infant born weighing 2620g with good Apgar scores. Postnatal recovery was \nuncomplicated.\nDISCUSSION Include a very brief review of similar published cases\nTransabdominal cerclage is a complex procedure with associated immediate and delayed complications. \nSuture migration is rare, and a solitary case report highlights its occurrence even in the absence of \ndilatation and evacuation.[15] When dilatation and curettage or evacuation is required caution must be \ntaken although the complication rate is low. The largest case series spanning 20 years at a single centre, \nfollowed 142 women with a TAC in situ.[17] Amongst this cohort, 19 uterine evacuations of pregnancy \nloss occurred with a solitary minor complication, bleeding (300ml), requiring uterine compression. \nSuccessful pregnancy following these procedures was common. Similar outcomes were reported in a case \nnotes review of 19 women at high risk for second trimester loss and early preterm delivery, who were \ntreated with a preconception TAC.[18] There is one case report of D&E performed at 18 weeks through a \nTAC with a successful ensuing pregnancy.[19]\nHistoric pathways led many women to being treated with transvaginal cervical cerclage irrespective of \nthe cause. The NHS England Saving Babies Lives Care Bundle Version Two recommends that women with \na previous failed transvaginal cerclage should have their care managed by an experienced clinical team \nable to offer the most appropriate management options.[20] The multidisciplinary team approach of \nminimally invasive gynaecologists and pre-term birth specialists at University College London Hospitals \nhas resulted in an established pathway for the management of women requiring an elective pre-\nPage 3 of 7\n\npregnancy laparoscopic TAC.[6]  Similar teams have developed under the umbrella of the UK Preterm \nClinical Network as recommended in Saving Babies Lives Care Bundle.[21]\nThis case report adds to the limited existing evidence demonstrating the feasibility of laparoscopic \nremoval of TAC following pregnancy loss, failure, or complication. We report the first hysteroscopic \nfreeing, laparoscopic TAC removal and simultaneous re-insertion with successful subsequent two \ndeliveries of healthy infants at term gestation.\nLEARNING POINTS/TAKE HOME MESSAGES 3-5 bullet points\nTHIS IS A REQUIRED FIELD\nTIP: This is the most crucial part of the case – what do you want readers to remember when seeing their \nown patients?\n\u0003Transabdominal cerclage is a recognised treatment for recurrent spontaneous late miscarriage or \npreterm birth due to cervical weakness. \n\u0003This can be performed via an open procedure before and during pregnancy, or a laparoscopic \ntechnique preconception. \n\u0003Laparotomy can be avoided with laparoscopic removal of failed TAC with simultaneous re-\ninsertion. \nREFERENCES\n1. McManemy J, Cooke E, Amon E, Leet T. Recurrence risk for preterm delivery. Am J \nObstet Gynecol. 2007 Jun;196(6):576.e1-6; discussion 576.e6-7.\n2. Alfirevic Z, Stampalija T, Medley N. Cervical stitch (cerclage) for preventing preterm birth in \nsingleton pregnancy. Cochrane Database Syst Rev. 2017 Jun 6;6(6):CD008991.\n3. Owen J, Hankins G, Iams JD, Berghella V, Sheffield JS, Perez-Delboy A, et al. Multicenter \nrandomized trial of cerclage for preterm birth prevention in high-risk women with shortened \nmidtrimester cervical length. Am J Obstet Gynecol. 2009 Oct;201(4):375.\n4. Watson HA, Carter J, David AL, Seed PT, Shennan AH. Full dilation cesarean section: a risk factor \nfor recurrent second-trimester loss and preterm birth. Acta Obstet Gynecol Scand. 2017 Sep;96(9):1100-\n1105.\n5. Gibb D, Saridogan, E. The Role of Transabdominal Cervical Cerclage Techniques in Maternity \nCare, The Obstetrician & Gynaecologist. 18.2 (2016): 117-25. \n6. Saridogan E, O'Donovan OP, David AL. Preconception laparoscopic transabdominal cervical \ncerclage for the prevention of midtrimester pregnancy loss and preterm birth: a single centre experience. \nFacts Views Vis Obgyn. 2019 Mar;11(1):43-48. \n7. Shennan A, Chandiramani M, Bennett P, David AL, Girling J, Ridout A, Seed PT, Simpson N, \nThornton S, Tydeman G, Quenby S, Carter J. MAVRIC: a multicenter randomized controlled trial of \ntransabdominal vs transvaginal cervical cerclage. Am J Obstet Gynecol. 2020 Mar;222(3):261.e1-261.e9.\n8. Dawood F, Farquharson RG. Transabdominal cerclage: preconceptual versus first trimester \ninsertion. Eur J Obstet Gynecol Reprod Biol. 2016 Apr;199:27-31.\n9. Scibetta JJ, Sanko SR, Phipps WR. Laparoscopic transabdominal cervicoisthmic cerclage. Fertil \nSteril. 1998;69(1):161-163. \n10. NICE guidance. Interventional procedures guidance [IPG228]: Laparoscopic cerclage for \nprevention of recurrent pregnancy loss due to cervical incompetence. 2007. \nPage 4 of 7\n\n11. NICE. Laparoscopic cerclage for cervical incompetence to prevent late miscarriage or preterm \nbirth. National Intitute for Health and Care Excellence. 2019. \n12. Suff N, Kuhrt K, Chandiramani M, Saridogan E, David A, Shennan AH. Development of a video to \nteach clinicians how to perform a transabdominal cerclage, 1 Nov 2020, In: American Journal of \nObstetrics & Gynecology MFM. 2, 4, p. 100238\n13. Hawkins E, Nimaroff M. Vaginal erosion of an abdominal cerclage 7 years after laparoscopic \nplacement. Obstet Gynecol. 2014 Feb;123(2 Pt 2 Suppl 2):420-423.\n14. Scarantino SE, Reilly JG, Moretti ML, Pillari VT. Laparoscopic removal of a transabdominal cervical \ncerclage. Am J Obstet Gynecol. 2000 May;182(5):1086-8.\n15. Carter JF, Soper DE. Laparoscopic removal of abdominal cerclage. JSLS. 2007 Jul-Sep;11(3):375-7.\n16. Agdi M, Tulandi T. Placement and removal of abdominal cerclage by laparoscopy. Reprod Biomed \nOnline. 2008 Feb;16(2):308-10.\n17. Dethier D, Lassey SC, Pilliod R, Einarsson JI, McElrath T, Bartz D. Uterine evacuation in the setting \nof transabdominal cerclage. Contraception. 2020 Mar;101(3):174-177. \n18. Groom KM, Jones BA, Edmonds DK, Bennett PR. Preconception transabdominal cervicoisthmic \ncerclage. Am J Obstet Gynecol. 2004 Jul;191(1):230-4.\n19. Chandiramani M, Chappell L, Radford S, Shennan A. Successful pregnancy following mid-trimester \nevacuation through a transabdominal cervical cerclage. BMJ Case Rep. 2011 Jun 29;2011:bcr0220113841. \ndoi: 10.1136/bcr.02.2011.3841. \n20. NHS England. Saving Babies’ Lives Version Two. 2019. \n21. Story L, Simpson NAB, David AL, Alfirevic ZZ, Bennett PR, Jolly M, et al. Reducing the impact of \npreterm birth: Preterm birth commissioning in the United Kingdom. Eur J Obstet Gynecol Reprod Biol X. \n2019;3:1–5.\nFIGURE/VIDEO CAPTIONS\nFigure 1: Laparoscopic TAC in situ – 16 weeks.\nVideo 1: Hysteroscopic freeing, laparoscopic TAC removal with simultaneous re-insertion. \nPATIENT’S PERSPECTIVE\nTIP: This is an important section and gives the patient/next of kin the opportunity to comment on their \nexperience. This enhances the case report and is strongly encouraged.\nIt was such a relief for me not to have to have another big cut on my tummy for the repeat TAC \nprocedure. Recovery from the open TAC surgery took a few weeks. But the laparoscopic procedure was \nfar less painful and I got over it really quickly in comparison.\nINTELLECTUAL PROPERTY RIGHTS ASSIGNMENT OR LICENCE STATEMENT\nI, [Anna L. David], the Author has the right to grant and does grant on behalf of all authors, an exclusive \nlicence and/or a non-exclusive licence for contributions from authors who are: i) UK Crown employees; ii) \nwhere BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance with the relevant stated \nPage 5 of 7\n\nlicence terms for US Federal Government Employees acting in the course of the their employment, on a \nworldwide basis to the BMJ Publishing Group Ltd (“BMJ”) and its licensees,  to permit this Work  (as \ndefined in the below licence), if accepted, to be published in BMJ Case Reports and any other BMJ \nproducts and to exploit all rights, as set out in our licence author licence.\n \nDate: 3 November 2021\nPLEASE SAVE YOUR TEMPLATE WITH THE FOLLOWING FORMAT:\nSubmitting author’s last name and date of submission, e.g. Smith_November_2018.doc\nEXAMPLE OF A WELL PRESENTED CASE REPORT\nResection of a large carotid paraganglioma in Carney-Stratakis syndrome: a multidisciplinary feat\nPage 6 of 7\n\nPage 7 of 7","source_license":"CC0","license_restricted":false}