Endoscopic transabdominal cervical cerclage replacement after recurrent late miscarriage

Background

Vaginal cerclage is commonly used to reduce preterm birth and prevent fetal loss, often in the context of recurrent miscarriage.1 Although randomised controlled trials are still largely lacking, cerclage is thought to reduce the risk of perinatal death when compared with no cerclage, and may benefit the small number of women with traumatic cervical damage or genuine cervical weakness.2 3 In women with spontaneous late miscarriage or preterm birth following a full dilatation caesarean section, vaginal cervical cerclage may be less effective, requiring a different approach.4

In women for whom vaginal cerclage fails, transabdominal cerclage (TAC) has been advocated. This requires more extensive surgery than vaginal cerclage, and delivery is usually via caesarean section. Among those women with recurrent miscarriage and extreme prematurity, neonatal survival increases from 3%–36% prior to TAC to up to 73%–100% in a review of published case series.5 6 This is supported by a recent randomised controlled trial that demonstrated reduced rates of preterm birth and fewer fetal losses associated with TAC compared with vaginal cerclage performed either via the Macdonald (low vaginal) or Shirodkar (high vaginal) technique.7

Open TAC was first described in 1965 whereby a Pfannenstiel incision was used to enter the abdominal cavity prior to opening the uterovesical fold with caudal displacement of bladder and siting of the cerclage at the cervico-isthmic junction. This procedure can be performed up to 14/15 week’s gestation but evidence from a large case series suggests that it is more efficacious if performed preconception.8 The first laparoscopic TAC was performed in 1998 but was complicated by an injury to the uterine artery requiring clipping.9 Guidance from The National Institute for Healthcare Excellence (NICE) on the procedure was published in 2007 and updated in 2019.10 11 The surgical technique for laparoscopic TAC is important as the Mersilene (Ethicon, USA) suture needs to be accurately placed at the cervico-isthmic junction immediately medial to the uterine vessels.12 Therefore, it can be a challenging operation, especially when the uterus has additional pathology such as fibroids, adenomyosis or previous surgery, including suture placement.

Laparoscopic procedures are most commonly performed prior to pregnancy with the benefit of prepregnancy insertion, particularly for laparoscopic procedures, being the ability to use a uterine manipulator to facilitate acute ante and retroversion of the uterus during suture insertion. The risks of bleeding, infection and thromboembolism are lower prior to pregnancy but there is the potential for subsequent infertility, although small. First trimester miscarriage is often managed via surgery, with cautious cervical dilatation and uterine evacuation. While a relatively safe procedure, complications of TAC have been identified following both open and laparoscopic procedures but remain poorly reported in published case series. These complications include suture migration, rectouterine fistula some years later, uterine rupture and fetal growth restriction.5 13 Laparoscopic TAC removal after pregnancy failure has been reported but without concurrent reinsertion or subsequent pregnancy.14–16

We report a case of endoscopic removal of a migrated open TAC suture with concurrent replacement and subsequent two term births.

Case presentation

A woman in her thirties with raised body mass index (31 kg/m²), a fibroid uterus and adenomyosis presented with a history of recurrent spontaneous late miscarriages at 15 and 23+5 weeks of gestation; in her third ongoing pregnancy her cervix funnelled through an elective low vaginal cerclage placed at 14 weeks and she delivered at 22+5 weeks of gestation. Laparoscopic prepregnancy TAC was recommended but she conceived rapidly, and therefore, underwent an open TAC with Mersilene tape placed at 13 weeks of gestation, and a posterior tied knot. Although the surgery was uneventful 3 days later she ruptured her membranes. With ongoing anhydramios and the development of infection she proceeded to termination of pregnancy at 18 weeks of gestation. An uncomplicated cervical dilatation and evacuation (D&E) was performed under ultrasound guidance to preserve the integrity of the TAC.

Investigations

An ultrasound 6 weeks following this pregnancy showed an intact TAC but subsequent outpatient hysteroscopy at 3 months confirmed part of the TAC suture had migrated through into the cervical canal. The patient underwent extensive counselling about endoscopic removal and reinsertion under general anaesthetic and agreed to proceed.

Outcome and follow-up

The patient conceived spontaneously with a low risk combined test Down’s syndrome screen. She began low dose aspirin 150 mg at night and vaginal cyclogest 200 mg pessary at night due to her history of recurrent perinatal loss. She underwent serial cervical length ultrasound examination from 12 weeks of gestation which confirmed a long cervix (36 mm) with the TAC remaining at the level of the cervical isthmus (figure 1). She developed two asymptomatic urinary tract infections in the second trimester which were treated with oral antibiotics. She was diagnosed with gestational diabetes at 18 weeks of gestation and was prescribed metformin 500 mg at night at 22 weeks which continued until the end of pregnancy. Fetal growth velocity was suboptimal with the estimated fetal weight <5th centile on customised fetal charts. At 37+1 weeks, she received two doses of betamethasone steroids to mature the fetal lungs and an elective caesarean section was performed 2 days later. The cerclage was seen at the level of the internal cervical os, and the uterine incision was placed 2 cm above. The delivery was straight forward and the estimated blood loss was 400 mL. A live male infant was born weighing 2050 g with good Apgar score at 1 and 5 min. Postoperative recovery was complicated by fever and endometritis on day 2 postnatal which resolved with intravenous antibiotics. She spontaneously conceived again 2 years later, and had an uneventful pregnancy, but again complicated by gestational diabetes which was managed with metformin treatment. Delivery was an elective Caesarean section at 37+4 weeks with a live male infant born weighing 2620 g with good Apgar scores. Postnatal recovery was uncomplicated.