Operative complications and fetal morbidity encountered in 300 prophylactic transabdominal cervical cerclage procedures by one obstetric surgeon

Abstract

This retrospective cohort study identifies complications associated with transabdominal cerclage (TAC). In 300 procedures performed over a 24 year time span, 11 (3.7%) surgical complications were encountered. Fetal loss (prior to 20 weeks) occurred in 4.1% of pregnancies. The median estimated blood loss among patients was 100 ml, with blood loss sufficient to require transfusion only once. Considering patients with classical indications, the gestational age at delivery was greater (37 weeks) after TAC than in the latest pre-TAC pregnancy (24 weeks) (p < 0.001). Lower uterine dehiscence in four patients and uterine rupture in one, underscore the advisability of early term delivery after fetal lung maturity is assured. A survival rate of 98.0% was calculated among infants that were delivered at >24 weeks' gestation. Our results demonstrate that complications encountered in placing a TAC were unusual and generally manageable. This communication may assist the surgeon to balance risks in individual clinical circumstances more adequately.

Transabdominal Cerclage

“…Achievement of overall pregnancy success is limited to about 95%, probably due to the collateral risks inherent in the pregnancies addressed with this technique. 24 The latter success criterion (delivery after 28 wk is achieved) is most applicable to multifetal pregnancies. 13 Technical failure of the TAC itself, allowing the cervix to open in the second trimester, will undoubtedly occur, but should be quite unusual.…”

“…15 Interestingly, intraoperative and postoperative fetal losses, both occurring before 20 weeks gestation and after that, have been predominantly in multifetal pregnancies. 24 Singleton fetal loss within 2 weeks of surgery occurred in only 3 of 226 cases (1.3%) and 1 twin pregnancy and 2 fetuses in a triplet pregnancy were lost in the same timeframe.…”

“…26 However, uterine rupture after TAC placement in a previously scarred uterus is rare, occurring only once in our experience. 24,27 This patient had a unicornuate uterus with a prior hysterotomy. Uterine rupture is particularly pertinent, though, as the effects can be catastrophic on the mother's and fetus's wellbeing.…”

“…Incidence of wound infections, bladder or bowel damage, and necessity for hysterectomy at the time of the TAC appears to be rare. 15,24,25 We have encountered 1 bowel injury in a patient who had had a large bowel perforation with generalized peritonitis years before the TAC. Bowel preparation and general surgery availability was part of the preparation in this case because of the history.…”

“…24 The complications assessed included wound infection, organ damage, hemorrhage requiring blood transfusion, and fetal loss. This report found the rate of transfusion was <1% despite the concern for hemorrhage described above.…”