For more than a decade, the capacity to perform cervicoisthmic cerclage by laparoscopy has provided a minimally invasive alternative for some women to the often-complicated traditional abdominal approach that was first reported in 1965.
With a laparoscopic cerclage performed by 12 weeks' gestation, patients for whom conventional vaginal cerclage has failed or is not possible have had successful deliveries without the extended midline incision, considerable hospital stays, or significant risks to the mother and fetus that are associated with the conventional abdominal approach.
Laparoscopic cerclage is a highly innovative procedure that has offered hope and delivered good outcomes. Still, one has to ask, are we really achieving all we can for our patients?
Does it not make sense to intervene earlier—before pregnancy—in certain high-risk women with anatomically altered or deficient cervices and/or with previous failures of conventional vaginal cerclages for cervical incompetence?
The notion of “interval cerclage” as opposed to interventional or “rescue” cerclage is an idea whose time has come. There are significant numbers of women who would substantially benefit from the insertion of a cervicoisthmic cerclage in the nonpregnant state—when the surgeon is not constrained by the contents, size, or fragility of the gravid uterus or challenged by the marked pelvic vascularity and other physiological changes of pregnancy.
The pregnant women who have undergone laparoscopic cervicoisthmic cerclage under our care have experienced failures of conventional vaginal cerclages, and many have suffered repeated second-trimester losses.
These high-stakes cases involving patients who are desperate for a successful pregnancy have led us to believe that one failure is enough—or, in the cases of patients who have other clear risk factors such as anatomically altered cervices, that one failure is too many.
As we move further into the era of reproductive technology and extended reproductive years, pregnancies are increasingly high-stakes experiences with a limited number of assisted cycles. Women do not have time to spare and do not want to take risks. Older women seeking to have a child not only are more likely to have had in vitro fertilization and other fertility treatments, they also are more likely to have had a loop electrosurgical excision procedure (LEEP), cone biopsy, or other procedure that has been associated with cervical incompetence. Many of these women are possible candidates for interval cerclage.
This type of cerclage requires a new thought process—a new mind-set—as well as new and creative collaboration between skilled laparoscopic surgeons and the perinatologists who are following and counseling these patients.
By working in teams, with the perinatologist cultivating a relationship with an experienced laparoscopic surgeon, specialists can work together to bring the option of interval cerclage into discussions with patients who have poor obstetric histories due to cervical incompetence or serious risk factors associated with poor pregnancy outcomes, and then see the procedure through when it is deemed worthwhile and desirable.
In our experience, once we met each other and became aware of each other's interests and expertise, it seemed only natural to collaborate and offer these patients interval laparoscopic cerclage.
The Benefits
Ironically, we have shifted in the last 5–10 years from early-pregnancy cerclage based largely on history toward cerclage that is performed based on ultrasound measurement of cervical length during pregnancy. Cervical change rarely occurs before 12–14 weeks' gestation, which means that by the time of “discovery” of a short cervical length, cerclage is all the more difficult and risky to perform.
The advantages to an interval approach to cerclage are numerous: The surgeon does not have to contend with the burden of an intrauterine pregnancy associated with the increased pelvic vascularity of pregnancy (up to 25% of the maternal circulation moves through the pelvis at this time) or the increased uterine size, which can be constraining, particularly for a laparoscopic approach.
Beyond 12–14 weeks, in fact, it becomes almost impossible with a laparoscopic approach to gently manipulate the uterus to see both the front and back of the lower uterine segment. Avoiding interventions close to the gravid uterus, of course, is always desirable. And with an interval cerclage, healing is typically completed by the time pregnancy occurs.
For a surgeon with advanced laparoscopic experience, the laparoscopic approach to a cervicoisthmic cerclage is generally much easier and safer than a “true” transvaginal cervicoisthmic cerclage.
Some experienced surgeons—though very few—have performed classical cervicoisthmic cerclage transvaginally during early pregnancy in the belief that a higher cerclage placement is more effective than a lower one. When the stitch is placed high at the level of the cervicoisthmic junction—or even higher—and above the level of the cardinal ligaments, the stitch is less likely to slip down along the cervix. It is supported from underneath by the cardinal ligaments.