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Table of Contents
CASE REPORTS
Year : 2021  |  Volume : 26  |  Issue : 3  |  Page : 212-214

Two successful live births following trans-abdominal cervicoisthmic cerclage in a woman with recurrent miscarriages


1 Department of Obstetrics and Gynaecology College of Medicine, University of Lagos, and Lagos University Teaching Hospital, Lagos, Nigeria
2 Senior Registrar, Department of Obstetrics and Gynaecology Lagos University Teaching Hospital, Lagos, Nigeria

Date of Submission12-Sep-2020
Date of Decision18-Dec-2020
Date of Acceptance02-Feb-2021
Date of Web Publication20-Apr-2021

Correspondence Address:
Aloy Okechukwu Ugwu
Senior Registrar, Department of Obstetrics and Gynaecology Lagos University Teaching Hospital, Lagos.
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmh.IJMH_61_20

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  Abstract 

Cervical insufficiency, previously known as cervical incompetence, has been described as painless cervical dilation that leads to mid-trimester miscarriage in the absence of other causes. Recently, it has expanded to include women with a prior spontaneous preterm birth and evidence of cervical shortening (<25mm) on transvaginal ultrasound at a gestational age less than 18 weeks. Cerclage is an obstetric procedure performed for prevention of miscarriage and preterm birth in women with cervical incompetence; it can be done via vaginal or abdominal route. We present a case of a 32-year-old woman, now P2+5 (2 alive), with a history of five recurrent midtrimester pregnancy losses who was evaluated and worked up for abdominal cerclage after several failed cervical cerclages, who later had two successful pregnancies and deliveries via elective caesarean section. This case is presented as a reminder that such cases still exist, and the skill must be passed on to a younger generation of doctors as it may become useful when such cases are presented.

Keywords: Abdominal cerclage, failed vaginal cerclage, successful live births


How to cite this article:
Omisakin SI, Ugwu AO, Fagbolagun OA, Olanrewaju O. Two successful live births following trans-abdominal cervicoisthmic cerclage in a woman with recurrent miscarriages. Int J Med Health Dev 2021;26:212-4

How to cite this URL:
Omisakin SI, Ugwu AO, Fagbolagun OA, Olanrewaju O. Two successful live births following trans-abdominal cervicoisthmic cerclage in a woman with recurrent miscarriages. Int J Med Health Dev [serial online] 2021 [cited 2021 Dec 9];26:212-4. Available from: https://www.ijmhdev.com/text.asp?2021/26/3/212/313955




  Introduction Top


Cervical insufficiency is defined as inability of the uterine cervix to retain a pregnancy in the second trimester, without uterine contractions.[1] The diagnosis is history based, which requires that a patient must have experienced three pregnancy losses, and or transvaginal sonographic assessment of the cervix in pregnancy.[2] It is the most important cause, responsible for 15% of recurrent spontaneous midtrimester miscarriage.[3],[4] It has also been estimated that cervical incompetence will complicate 0.1% to 2% of all pregnancies.[4],[5]

The use of transabdominal cervicoisthmic cerclage should be considered in carefully selected women with a previous failed transvaginal cerclage, and a significantly attenuated exocervix.[2],[4] Other nonclassic indications for prophylactic transabdominal cerclage (TAC) that may be considered include severe cervical hypoplasia without history of cervical insufficiency, radical trachelectomy, and higher order multifetal gestations.[4],[5]

The adoption of TAC rather than repeat transvaginal cerclage has been deemed to be more successful in high-risk cases. Its most important feature is the ability to insert the stitch at the level of the internal cervical os, which is rather almost impossible to achieve via the transvaginal route.[5],[6]


  Case Report Top


Mrs. MAO is a 32-year-old now P2+5 2A woman who had a spontaneously conceived pregnancy and presented at 10 weeks and 2 days of gestation. She had five recurrent spontaneous pregnancy losses between 2011 and 2016 at 18–28 weeks of gestation. She had failed vaginal cervical cerclage in the last two pregnancies. She was counseled on the diagnosis and the need for abdominal cervical cerclage placement at laparotomy. She consented and was scheduled for cervical cerclage at 14 weeks of gestation. A repeat ultrasound scan was done the day before cerclage insertion to re-establish fetal viability and rule out obvious structural anomalies. Findings at surgery revealed a deficient cervix with a short anterior lip and an absent large portion of the posterior cervical lip.

Under regional anesthesia by subarachnoid block, she was cleaned and draped. The abdomen was accessed through a Pfannenstiel incision, deepened into the peritoneal cavity. Gentle abdominal exploration was performed to assess the space around the uterine isthmus. The uterovesical peritoneal reflection was divided transversely, and the bladder was carefully displaced downward to expose the uterine isthmus and the tortuous uterine vasculatures. A vessel-free paracervical area was identified medial to the junction of the ascending and descending branches of the uterine artery. A finger was passed posteriorly from the right side of the uterus and placed at this spot above the uterosacral ligament; this further displaced the uterine vasculature laterally. A tapered long right angled clamp was then used to perforate the posterior leaf of the broad ligament from the anterior side with the guiding finger in situ. The jaws of the clamps were then opened, and the needle-free end of a 20-cm-long and 0.5-cm-wide Mersilene (Ethicon GmbH, Norderstedt, F. R. G.) ribbon was grasped and carefully pulled through the paracervical tissue from the posterior to the anterior. The other end of the ribbon was passed through the back of the uterus to the left side of the uterus, and the procedure was repeated on the contralateral side at the cervicoisthmic junction. The tape was pulled firmly around the cervix, and the pulsating uterine arteries were palpated to ascertain the correct position of the ribbon medial to the uterine vasculature. It was then tied firmly on the anterior side of the cervix with a square knot, and the ends were cut with a length of about 0.5cm and fixed to the band with fine non-absorbable sutures. The uterovesical peritoneum and bladder were used to cover the knot. The anterior abdominal wall was closed in layers, and the skin was subcuticularly apposed. During the whole procedure, the uterus was kept warm and wet and it remained within the abdominal cavity. Nifedipine was used as a tocolytic. On discharge after the operation, she was referred back to the antenatal clinic for normal care thereafter. Pregnancy was uneventful until 37 weeks and 5 days when she was scheduled for elective cesarean section and was delivered of a live female neonate with good Apgar score and birth weight of 3.4 kg. She had normal puerperium and was discharged to a family planning and cytology clinic.

She presented again in January 2019 for booking at a gestational age of 13 weeks 3 days. Pregnancy again progressed successfully to 37 weeks 4 days; she was scheduled for elective cesarean section and was delivered of a live female neonate with good Apgar score and birth weight of 3.2 kg.


  Discussion Top


Cervical insufficiency not only poses a management dilemma to the modern-day obstetrician, but it is also a source of anxiety for the couples with recurrent pregnancy wastage. Risk factors for cervical insufficiency include surgical trauma to the cervix from cone biopsy, loop electrosurgical excision, cervical amputation, mechanical dilation of the cervix, or obstetric injuries such as compression necrosis, spontaneous and iatrogenic cervical laceration, and extension of the uterine incision into the cervix during cesarean section. Others are congenital müllerian anomalies, deficiencies in cervical collagen and elastin, connective tissue disorder, and in utero exposure to diethylstilboestrol.[3],[7]

Cervical insufficiency is a clinical diagnosis based on the history of a recurrent midtrimester miscarriage, or sonographic evidence of a short cervical length of less than 25mm.[7],[8] In nonpregnant women, several other methods have been suggested to aid in the diagnosis of cervical insufficiency; these include radiographic imaging of balloon traction on the cervix, Foley’s catheter traction test using a size 16 F balloon filled with 1ml of water (6mm), hysterosalpingography-dilated internal os > 8mm, easy passage of a size 8 Hegar’s/Pratt’s dilator number 15–17, use of a balloon elastance test, and use of graduated cervical dilators to calculate a cervical resistance index (5–7).[8]

The surgical approaches in treating cervical insufficiency include the use of transvaginal cerclage of McDonald, Shirodikar, lash and lash, Baden, Salles, Wurm Szendi, or Hefner type. The surgical approaches in the management of cervical insufficiency include the use transvaginal cerclage (methods of which include McDonald, Shirodikar, lash and lash, Baden, Salles, Wurm Szendi or Hefner type), transabdominal cerclage (which could be via laparotomy or laparoscopy) or very rarely by the use of pessaries (ARABIN or Hodge) or Baylor Balloon.[11],[12],[13] Transabdominal cerclage is not popular in our environment because of the lack of expertise. Preterm labor, midtrimester rupture of membranes, and intrauterine fetal death are some of the complications after transabdominal cerclage.[8] The need for operative abdominal delivery subsequently is also a major drawback.[8],[9],[10]

Mrs MAO had abdominal cerclage by using the modified technique of Benson and Durfee.[8],[9],[10] The cerclage was left in situ, and she was able to achieve two successful pregnancies.

Ethical approval

Ethical approval for this article was obtained from the human research and ethics committee of the public tertiary hospital where the patient was being managed (ADM/DCST/HREC/APP/3237).

Consent

The authors certify that they have obtained all appropriate patient consent. In the consent form, the patient has given her consent for her clinical information to be reported in the journal. The patient understood that all her identifiable information will not be published.

Guarantor

The corresponding author will be the guarantor for this article.

Acknowledgment

The authors thank the entire staff of the department who contributed in the patient’s management.

Financial support and sponsorship

Nil.

Conflict of interest

The authors declare that there is no conflict of interest.



 
  References Top

1.
ACOG Practice Bulletin No. 142: Cerclage for the management of cervical insufficiency. Obstet Gynecol;123(2, part 1):372-9.  Back to cited text no. 1
    
2.
Knudtson EJ, Peck J, Skaggs V, Elimian A, Goodman J, Stanley J Evaluation of outcomes after transabdominal cervicoisthmic cerclage. Arch Gynecol Obstet 2010;281:891-4.  Back to cited text no. 2
    
3.
Berghella V, Rafael TJ, Szychowski JM, Rust OA, Owen J Cerclage for short cervix on ultrasonography in women with singleton gestations and previous preterm birth: A meta-analysis. Obstet Gynecol 2011;117:663-71.  Back to cited text no. 3
    
4.
Berghella V, Ludmir J, Simonazzi G, Owen J Transvaginal cervical cerclage: Evidence for perioperative management strategies. Am J Obstet Gynecol 2013;209:181-92.  Back to cited text no. 4
    
5.
Sumners JE, Kuper SG, Foster TL Transabdominal cerclage. Clin Obstet Gynecol 2016;59:295-301.  Back to cited text no. 5
    
6.
Dawood F, Farquharson RG Transabdominal cerclage: Preconceptual versus first trimester insertion. Eur J Obstet Gynecol Reprod Biol 2016;199:27-31.  Back to cited text no. 6
    
7.
Roman A, Suhag A, Berghella V Overview of cervical insufficiency: Diagnosis, etiologies, and risk factors. Clin Obstet Gynaecol2016;59:237-40.  Back to cited text no. 7
    
8.
Ades A, Dobromilsky KC, Cheung KT, Umstad MP Transabdominal cervical cerclage: Laparoscopy versus laparotomy. J Minim Invasive Gynecol 2015;22:968-73.  Back to cited text no. 8
    
9.
Shaltout MF, Maged AM, Elsherbini MM, Elkomy RO Laparoscopic transabdominal cerclage: New approach. J Matern Fetal Neonatal Med 2017;30:600-4.  Back to cited text no. 9
    
10.
Feys S, Faes E, Leroij Y, Jacquemyn Y Clinical case reports laparoscopic placement and removal of abdominal cerclage: A case report. J Clin Case Rep 2015;5:10-2.  Back to cited text no. 10
    
11.
Umstad MP, Quinn MA, Ares A Transabdominal cervical cerclage. Aust N Z J Obstet Gynaecol 2012;50:460-4.  Back to cited text no. 11
    
12.
Egbaname Aigere SO, Egagifo O, Igberase GO Live birth following abdominal cervical cerclage in a woman with recurrent pregnancy losses. Afr J Med Health Sci 2017;16:131-2.  Back to cited text no. 12
    
13.
Donald G, Ertan S The role of transabdominal cervical cerclage techniques in maternity care. Obstet Gynaecol 2016;18:117-25.  Back to cited text no. 13
    




 

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