Trachelorraphy in cases of recurrent second trimester loss and prior failed vaginal cerclage
European Journal of Obstetrics & Gynecology and Reproductive Biology, pages 126 - 129
To evaluate the obstetric results of trachelorraphy in the prevention of recurrent second trimester loss in cases of prior failed vaginal cerclage.
Data were collected retrospectively and prospectively from medical records. The analysis examined data for 18 women who underwent trachelorraphy between 2004 and 2013 at a tertiary referral unit in France. All patients in this high-risk population had a history of two or more second trimester losses, or one second trimester loss and one preterm labour, and at least one prior failed transvaginal cerclage. The main outcome measures were: livebirth rate; rate of second trimester loss; and surgical complications.
Twenty pregnancies were conceived in 16 patients following trachelorraphy. Three patients experienced two pregnancies. Among the 20 pregnancies, there was one case of fetal loss in the first trimester; this pregnancy was excluded from the analysis. Of the remaining 19 pregnancies, there were nine (47%) term deliveries (after 37 weeks of gestation), seven (32%) preterm deliveries and three (16%) second trimester losses. The overall fetal survival rate was 84%. Surgical outcomes were excellent, with no complications.
Trachelorraphy is a safe, reproducible, easy-to-learn procedure for the prevention of recurrent second trimester loss in cases of prior failed vaginal cerclage. The procedure has encouraging and favourable perinatal outcomes in patients with a poor obstetric history.
Keywords: Trachelorraphy, Second trimester loss, Preterm birth, Vaginal cerclage, Laparoscopic abdominal cerclage.
Second trimester loss remains an important issue in obstetric practice. A predominant factor in second trimester loss is cervical insufficiency  , which is estimated to complicate 0.1–1.0% of all pregnancies. Cervical insufficiency can also lead to preterm birth, which is an important contributor to neonatal morbidity and death. Diagnosis is usually made retrospectively based on a history of recurrent second trimester loss (or early preterm delivery) following painless cervical dilatation in the absence of contractions, bleeding or other causes of recurrent pregnancy loss  . Other definitions of cervical insufficiency include ‘recurrent second trimester or early third trimester loss of pregnancy caused by the inability of the uterine cervix to retain a pregnancy until term’  , and ‘a physical defect in the strength of the cervical tissue that is either congenital (inherited) or acquired’  . The aetiology of cervical insufficiency can be classified as: (1) a mechanical failure of the cervix to remain closed against the increasing uterine distention pressure; or (2) a functional failure due to premature cervical ripening  .
Without specialized treatment, cervical insufficiency has a high likelihood of recurrence in subsequent pregnancies. The traditional treatment for cervical insufficiency is vaginal cerclage  and , and abdominal cerclage is an alternative for patients in whom previous vaginal cerclage has failed, or vaginal cerclage is unfeasible because of an extremely short or absent cervix  . Trachelorraphy represents another option for cervical insufficiency, as described by Lash and Lash in 1950  , but this procedure is not widely used.
This study reports a series of 18 women with cervical insufficiency with a history of second trimester loss or preterm labour, and prior failed vaginal cerclage. Patients were treated over a 9-year period in an obstetric gynaecological unit where the preferred policy is to correct the cervical defect using trachelorraphy.
Materials and methods
Eighteen trachelorraphies were performed between 2004 and 2012. Sixteen patients subsequently conceived and were included in this study. Data were collected retrospectively and prospectively from medical records.
Twenty pregnancies were conceived in 16 women following trachelorraphy. Three patients experienced two pregnancies. There was one case of fetal loss in the first trimester, so 19 pregnancies were included in the analysis.
All patients in this high-risk population had a history of two or more second trimester losses, or one second trimester loss and one preterm labour, and at least one prior failed transvaginal cerclage. Prior failed transvaginal cerclage was defined as preterm birth at <37 weeks of gestation following transvaginal cerclage.
Trachelorraphy was first described by Lash and Lash in 1950  , but the procedure used at the study centre is a modification of the original technique. The cervix and the vagina must be as free of infection as possible, and mid cycle is the optimal time to perform the procedure. Trachelorraphies were performed when patients were not pregnant. The technique involves:
- general or regional anaesthesia;
- bladder catheterization;
- confirmation of the diagnosis of cervical insufficiency by the easy passage of a No. 8 Hegar dilatator without discomfort;
- crossen section (medium sagittal anterior colpotomia);
- vesicovaginal detachment and moderately vesico-uterine to address the uterine isthmus;
- catheterization of the internal cervical os using a No. 8 Hegar dilatator;
- large (10 mm × 15 mm) diamond resection in the sagittal axis of the anterior surface of the cervix on each side of the uterine isthmus, which corresponds to the internal os;
- sometimes possible to cut the anterior lip of the cervix to the isthmus and then exceed by 1 cm, and resect a triangle on either side at the level of the isthmus ( Fig. 1 );
- closure of one level deep suture ( Fig. 2 );
- overcoat suture;
- verification of occlusion to Hegar dilatator No. 6 or 7;
- colporrhaphy suture;
- unsystematic bladder catheterization for 24 h;
- hospital stay of 2 days; and
- no attempt to conceive for 3 months after surgery.
Following trachelorraphy, vaginal cerclage is performed in the first trimester (vaginal cerclage is directed to the closed external cervical os, and trachelorraphy is used to reduce the size of the internal cervical os), and caesarean section is required for delivery.
Before trachelorraphy, data on gravidity, parity, number of deliveries or fetal losses, gestational age at delivery or fetal loss, number of prior transvaginal cerclage procedures, number of living children, maternal and neonatal outcomes were collected. Following trachelorraphy, data on number of pregnancies, complications during pregnancy, age at delivery, labour and method of delivery, number of living children, and maternal and neonatal outcomes, and infant weight at delivery were collected. In cases of fetal loss, the gestational age at time of loss and the circumstances surrounding the loss were noted. Operative data were also collected for all patients.
Data for before and after trachelorraphy were compared using Chi-squared test, and p < 0.05 was considered to indicate significance.
Twenty pregnancies were conceived in 16 patients following trachelorraphy. Three patients experienced two pregnancies. There was one case of fetal loss in the first trimester, and this pregnancy was excluded from the analysis. Mean parity before trachelorraphy was 1 and mean gravidity was 3 ( Table 1 ).
|Number of prior vaginal cerclage procedures||1.13||1–3|
All women had a history of two or more second trimester losses, or one second trimester loss and one preterm labour. All patients had experienced at least one prior failed transvaginal cerclage.
Outcomes before trachelorraphy ( Table 2 )
Before trachelorraphy, 52 pregnancies were observed in 16 women. The mean rate of second trimester loss and preterm delivery was 88%. There were 40 (77%) second trimester losses, six (12%) preterm deliveries and six (12%) term deliveries. The 52 pregnancies resulted in nine living children (17%).
|Before trachelorraphy||After trachelorraphy||p|
|52 pregnancies||19 pregnancies|
|Second trimester fetal loss (14–24 weeks)||40||77||3||16||0.009|
|Preterm delivery (24–30 weeks)||5||10||1||5||NS|
|Total: second trimester fetal loss (14–24 weeks) and preterm delivery (24–30 weeks)||45||4||0.01|
|Preterm delivery (30–37 weeks)||1||2||6||32||0.001|
|Delivery at term (>37 weeks)||6||12||9||47||0.01|
Outcomes following trachelorraphy ( Table 2 )
Twenty pregnancies were conceived following trachelorraphy. There was one case of fetal loss in the first trimester, and this pregnancy was excluded from the analysis. Of the remaining 19 pregnancies, one of which was a twin pregnancy, there were nine (47%) term deliveries, seven (32%) preterm deliveries and three (16%) second trimester losses. Preterm deliveries occurred between 34 and 37 weeks of gestation in three cases (16%), and at less than 34 weeks of gestation in four cases (34+6, 34+5, 33, 32+1 and 31+3 weeks). For successful cases (i.e. living children), the average gestational age at delivery was 36 weeks. The fetal survival rate was 84% (n = 16).
The number of second trimester losses between 14 and 24 weeks of gestation was significantly higher before trachelorraphy, and the number of infants delivered at term (>37 weeks) was significantly higher following trachelorraphy ( Table 2 ).
Failed trachelorraphy was defined as delivery prior to neonatal viability (between 13 and 24+6 weeks of gestation, before which paediatricians do not resuscitate at the study hospital). Three patients experienced failed trachelorraphy with a mean gestational age at presentation of 21 weeks (range 18–23 weeks). The circumstances surrounding these losses were as follows:
- one woman experienced chorioamnionitis twice before trachelorraphy, and aborted at 22 weeks of gestation following trachelorraphy, again in the context of chorioamnionitis;
- one woman experienced two second trimester losses and one loss at 14 weeks of gestation before trachelorraphy, and aborted at 18 weeks of gestation following trachelorraphy; and
- one woman experienced one second trimester loss following trachelorraphy at 23 weeks of gestation, and one term delivery.
Complications of surgery
There were no significant operative or postoperative complications associated with trachelorraphy. No cases of blood loss, blood transfusion, bowel or bladder injury, urinary tract infection or fever were reported. In addition, there were no cases of uterine rupture during pregnancy or labour.
Course of pregnancy
Fourteen vaginal cerclage procedures were performed during the first trimester. Complications such as preterm premature rupture of membranes, chorioamnionitis and premature contractions occurred in less than 24% of pregnancies. The mode of delivery was vaginal birth in cases of second trimester loss, and caesarean section in other cases, except for three women for whom labour was rapid. There were no cases of postpartum haemorrhage.
All newborns were healthy, and mean birth weight was 3125 g.
In 1950, Lash and Lash  reported an association between cervical insufficiency and recurrent second trimester loss, and described how this could be diagnosed and repaired satisfactorily with trachelorraphy. Cervical cerclage was first proposed by Shirodkar in 1955  . This intervention is based on the assumption that the structural integrity of the cervical tissue has insufficient strength to act as a barrier to delivery when growth of the gestational sac increases intrauterine pressure. In 1957, McDonald  simplified the technique such that the bladder does not need to be dissected free. However, despite over half a century of use, it still remains an obstetric dogma. In 1965, Benson and Durfee  introduced an alternative to the vaginal approach: the placement of a cerclage at the cervical isthmus. This procedure is performed by laparotomy, and is used when the vaginal approach is not feasible due to altered cervical anatomy (i.e. congenital anomaly, scarring due to cone biopsy or laceration at delivery). Novy  reported that the indications should include failed transvaginal cerclage in a previous pregnancy. Cervico-isthmic cerclage is reported to lead to a successful pregnancy outcome rate of 76.5–100%; however, the morbidity associated with the surgical procedure is significant  . Advances in the field of minimally invasive surgery have led to laparoscopic placement of sutures within the abdominal cavity. Laparoscopic abdominal cerclage can be performed during the first trimester of pregnancy or as an interval procedure, when the patient is not pregnant.
The authors believe that, anatomically, trachelorraphy is the best repair. Trachelorraphy is performed at the level of the internal cervical os, which is the area of cervical defect responsible for cervical insufficiency and therefore for second trimester loss and preterm delivery. Trachelorraphy was performed in front of the cervix in the midline, thus avoiding uterine artery injuries that have been observed when the cerclage was placed higher in the case of vaginal cerclage. In vaginal cerclage, the higher placement of the suture may be better at preventing funnelling at the internal os, and reduce the risk of preterm premature rupture of membranes. Some researchers have assumed that the higher the suture is placed, the better, as this provides a longer functional cervix  . With cerclage, it is difficult to identify the internal os precisely. A comparison of cerclage using the Shirodkar and MacDonald methods by ultrasound cervical measurement revealed a greater increase in cervical length associated with the Shirodkar technique  . Transabdominal cerclage by laparoscopy provides superior views of the uterine cervico-isthmic junction compared with vaginal or abdominal surgery, which allows close approximation to the level of the internal cervical os when placing the suture laparoscopically. The present study identified no complications during or after the procedure, and no complications during labour and delivery. No cases of cervical synechia or stenosis were identified after asking patients about pain and regularity of menstruation. Trachelorraphy is safer than transabdominal cerclage. The literature reports a complication rate of 3.4% for transabdominal cerclage, and this procedure has been found to increase the risk of serious operative complications (e.g. perioperative blood loss, blood transfusion) and postoperative complications  . Abdominal placement of the suture results in increased risk of intra-operative injury to the uterine arteries; this could result in haemorrhage, with the resultant risk of blood transfusion and the rare, yet real, risk of maternal death. Other intra-operative risks include increased risk of injury to surrounding viscera. Following trachelorraphy, the risk of infectious morbidity and/or venous thrombo-embolism may be increased. Endoscopic surgery offers a minimally invasive approach, with great benefits over traditional laparotomy, and a slightly improved rate of perioperative complications compared with cervico-isthmic cerclage placed by laparotomy (10% vs. 0–25%, respectively). The benefits of laparoscopic cerclage include fewer adhesions, less postoperative pain and faster recovery. The main complication of both approaches is excessive blood loss. It is better if transabdominal cerclage is placed when a woman is not pregnant, because laparoscopic insertion of a suture is more challenging during pregnancy as an intrauterine manipulator cannot be used and the size of the pregnant uterus can impede proper visualization during surgery.
Unlike laparoscopy, trachelorraphy is an easy technique for surgeons to learn, and is easily reproducible.
Following trachelorraphy, women have to give birth via elective caesarean section. However, as trachelorraphy is performed vaginally, only one laparotomy is required which provides favourable conditions for caesarean section. Transabdominal cerclage requires two laparotomies: one for insertion of the cerclage and one for caesarean section. The possibility of other complications needs to be considered, such as intrauterine death in the second trimester requiring a hysterotomy if a dilatation and evacuation cannot be performed through the cervix. In the case of transabdominal cerclage, the suture can be tied so that a first trimester loss can be evacuated. However, a second trimester loss or preterm labour would necessitate removal of the cerclage by laparotomy or, possibly, colpotomy. In this study, the second trimester losses were delivered vaginally, without any complications. One other advantage of trachelorraphy and abdominal cerclage is that a cerclage can stay in place for subsequent pregnancies; in this study, three patients experienced two pregnancies following trachelorraphy.
Trachelorraphy increases the rate of fetal survival. In this study, trachelorraphy led to increased rates of term delivery of living children, and decreased the rate of second trimester losses, with fewer maternal and fetal complications. Trachelorraphy is performed when the patient is not pregnant, which avoids obstetric complications such as preterm premature rupture of membrane. Most case series of transabdominal cerclage have reported equivalent results  and . In terms of prevention of preterm birth, the same results were observed regardless of whether abdominal cerclage was performed during the first trimester of pregnancy or when the patient was not pregnant , , , , and . A case of intrauterine growth restriction due to inadvertent ligation of the uterine arteries has been reported in the literature  . However, all newborns in the present study were healthy.
Trachelorraphy is a safe, reproducible, easy-to-learn procedure for women with a poor obstetric history for the prevention of recurrent second trimester loss in cases of prior failed vaginal cerclage.
-  J. Ludmir. Sonographic detection of cervical incompetence. Clin Obstet Gynecol. 1988;31:101-109 Crossref
-  J.H. Harger. Cervical cerclage: patient selection, morbidity, and success rates. Clin Perinatol. 1983;10:321-341
-  S.M. Althuisius, G.A. Dekker, H.P. van Geijn, D.J. Bekedam, P. Hummel. Cervical incompetence prevention randomized cerclage trial (CIPRACT): study design and preliminary results. Am J Obstet Gynecol. 2000;183:823-829 Crossref
-  R. Simcox, A. Shennan. Cervical cerclage in the prevention of preterm birth. Best Pract Res Clin Obstet Gynaecol. 2007;21:831-842 Crossref
-  A. Shennan, B. Jones. The cervix and prematurity: etiology, prediction and prevention. Semin Fetal Neonatal Med. 2004;9:471-479 Crossref
-  Z. Alfirevic, T. Stampalija, D. Roberts, A.L. Jorgensen. Cervical stitch (cerclage) for preventing preterm birth in singleton pregnancy. Cochrane Database System Rev. 2012;4:CD008991
-  R. Brown, R. Gagnon, M.F. Delisle, Maternal Fetal Medicine Committee. Cervical insufficiency and cervical cerclage. J Obstet Gynaecol Can. 2013;35:1115-1127
-  A.F. Lash, S.R. Lash. Habitual abortion: the incompetent internal os of the cervix. Am J Obstet Gynecol. 1950;59:68-76
-  V.N. Shirodkar. A new method of operative treatment for habitual abortion in the second trimester of pregnancy. Antiseptic. 1955;52:299-300
-  I.A. McDonald. Suture of the cervix for inevitable miscarriage. J Obstet Gynaecol Br Commonw. 1957;64:346-353
-  R.C. Benson, R.B. Durfee. Transabdominal cervicouterine cerclage during pregnancy for the treatment of cervical incompetency. Obstet Gynecol. 1965;25:145-155
-  M.J. Novy. Transabdominal cervicoisthmic cerclage: a reappraisal 25 years after its introduction. Am J Obstet Gynecol. 1991;164:1635-1641 [Discussion 1641–2]
-  F.K. Lotgering, I.P. Gaugler-Senden, S.F. Lotgering, H.C. Wallenburg. Outcome after transabdominal cervicoisthmic cerclage. Obstet Gynecol. 2006;107:779-784 Crossref
-  M. Katz, C. Abrahams. Transvaginal placement of cervicoisthmic cerclage: report on pregnancy outcome. Am J Obstet Gynecol. 2005;192:1989-1992 Crossref
-  P. Rozenberg, M.V. Senat, A. Gillet, Y. Ville. Comparison of two methods of cervical cerclage by ultrasound cervical measurement. J Matern Fetal Neonatal Med. 2003;13:314-317
-  V. Zaveri, F. Aghajafari, K. Amankwah, M. Hannah. Abdominal versus vaginal cerclage after a failed transvaginal cerclage: a systematic review. Am J Obstet Gynecol. 2002;187:868-872 Crossref
-  R.H. Debbs, G.A. DeLa Vega, S. Pearson, H. Sehdev, D. Marchiano, J. Ludmir. Transabdominal cerclage after comprehensive evaluation of women with previous unsuccessful transvaginal cerclage. Am J Obstet Gynecol. 2007;197:317.e1-317.e4 Crossref
-  G. Davis, V. Berghella, M. Talucci, R.J. Wapner. Patients with a prior failed transvaginal cerclage: a comparison of obstetric outcomes with either transabdominal or transvaginal cerclage. Am J Obstet Gynecol. 2000;183:836-839 Crossref
-  R. Al-Fadhli, T. Tulandi. Laparoscopic abdominal cerclage. Obstet Gynecol Clin North Am. 2004;31:497-504 Crossref
-  J.F. Carter, D.E. Soper, L.M. Goetzl, J.P. Van Dorsten. Abdominal cerclage for the treatment of recurrent cervical insufficiency: laparoscopy or laparotomy?. Am J Obstet Gynecol. 2009;201:111.e1-111.e4 Crossref
-  W.L. Whittle, S.S. Singh, L. Allen, et al. Laparoscopic cervico-isthmic cerclage: surgical technique and obstetric outcomes. Am J Obstet Gynecol. 2009;201:364.e1-364.e7 Crossref
-  N.B. Burger, J.I. Einarsson, H.A. Brölmann, F.E. Vree, T.F. McElrath, J.A. Huirne. Preconceptional laparoscopic abdominal cerclage: a multicenter cohort study. Am J Obstet Gynecol. 2012;207:273.e1-273.e12 Crossref
© 2014 Elsevier Ireland Ltd, All rights reserved.