Dear Editor,
Laparoscopic cerclage is an effective treatment option for cervical insufficiency
leading to repeated preterm birth. However, surgical intervention with various cerclage
techniques, such as vaginal, transabdominal laparoscopic approaches, still remains
the ultimate solution, unfortunately, without the guarantee of success.[1]
[2]
[3] There is still no consensus regarding the priority of each technique over the other.
However, when laparoscopic cerclage fails to completely treat cervical insufficiency,
an additional vaginal cerclage should be considered as a rescue intervention. We suggest
considering Shirodkar vaginal cerclage a rescue technique following laparoscopic transabdominal
cerclage which is compromised by further funneling. Here, we report, after obtaining
written consent, the cases of three patients who needed additional vaginal cerclage
to prevent further funneling and membranous bulging despite intact laparoscopic cerclage
material.
These three patients had recurrent pregnancy loss despite having undergone vaginal
cerclages. Demographic data, as well and the obstetric and surgical histories of the
patients, are shown in [Table 1]. Considering their history, the first preferred intervention was laparoscopic cerclage.
However, we detected funneling and bulging of amniotic membranes below the level of
the laparoscopic cerclage during their follow-up visits. Then, we performed an additional
Shirodkar vaginal cerclage to prevent further funneling. The images of the patients'
cervix immediately after the Shirodkar cerclage are shown in [Fig. 1]. The patients were followed-up with frequent ultrasound (US) examinations; images
of funneling following vaginal cerclage persisted in two patients, whereas funneling
disappeared completely in one patient after vaginal cerclage. All patients had uneventful
deliveries at 38 weeks.
Table 1
Demographic data, and obstetric and surgical histories of the patients
|
Patient
|
1
|
2
|
3
|
|
Age
|
36
|
33
|
34
|
|
Gravida
|
10
|
5
|
3
|
|
Para
|
1
|
1
|
0
|
|
Abortus
|
8
|
3
|
2
|
|
Previous gynecological operation
|
Septum resection
|
None
|
None
|
|
Live birth
|
1 at 28 weeks
|
1 at 30 weeks
|
None
|
|
Number of previous elective McDonald vaginal cerclages
|
3
|
2
|
1
|
|
L/S cerclage
|
+
|
+
|
+
|
|
Issue
|
Funneling
|
Funneling
|
Funneling
|
|
Week at performance of vaginal Shirodhar cerclage
|
13 weeks, 5 days
|
23 weeks, 2 days
|
26 weeks, 1 day
|
|
Delivery at
|
38 weeks, 3 days
|
38 weeks, 1 day
|
38 weeks, 2 days
|
Fig. 1 Ultrasonography images of the patients' cervixes after Shirodkar vaginal cerclage.
Laparoscopic abdominal cerclage is an effective management option for refractory cervical
insufficiency. It is reported to improve the rates of second-trimester loss and neonatal
survival,[4] and to be superior to low vaginal cerclage, especially for patients with failed
previous vaginal cerclage.[5] However, it can be insufficient in conditions such as laparoscopic interventions
with loose first knots or medial deviation into the cervical stroma during suturation,
or vaginal infections. Further funneling and bulging of amniotic membranes can be
warning signs of pregnancy loss even after an uneventful and intact laparoscopic cerclage.
This condition can be due to congenital or acquired cervical tissue defects, previous
repeated surgeries of the cervix, or a lax laparoscopic cerclage. In these cases,
we preferred to supplement the previous laparoscopic cerclage with a subsequent vaginal
one through the Shirodkar technique, which is performed at a higher level of the cervix
compared with the McDonald technique. This intervention refortified the cervix mechanically
for further dilatation. We suggest that the alternative use of this well-known technique
may be considered in such difficult cases to provide live births for patients with
long history of pregnancy loss.
Reply to Letter to the Editor
Comments by the President of the National Commission Specialized in High-Risk Pregnancy
(Febrasgo)
Rosiane Mattar1 0000-0003-1405-5371
1Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
Address for correspondence Rosiane Mattar, MD, Rua Botucatu, 740, Vila Clementino, São Paulo, SP, 04023-062,
Brazil (e-mail: rosiane.toco@epm.br).
Abdominal cerclage should be restricted to cases in which it is impossible to perform
the procedure vaginally, as it leads to greater maternal morbidity: it determines
a greater risk of bleeding, infection, rupture of the membranes, and cesarean section.
I think that, if Shirodkar cerclage was possible after laparoscopic surgery, it should
have been the first treatment option, which would reduce the risks and guarantee success.
In addition, the fact that the funnel appeared after surgery shows that the tape was
not properly tightened in the suture via the abdominal route, keeping the canal widened,
as if the cerclage had not been performed. Thus, cerclage via the abdominal route
should be very well indicated and very well performed when necessary.
Conflicts of Interests
The author has no conflict of interests to declare.
