Validity of indications for transabdominal cervicoisthmic cerclage for cervical incompetence

Objective: Our purpose was to review the indications for transabdominal cervicoisthmic cerlage to determine whether it is a valid alternative to transvaginal cerclage. Study design: A retrospective review of transabdominal cerclage patients at one institution form 1978 to 1994, analysis of the indications for the transabdominal rather than the vaginal approach, and evaluation of fetal outcomes was performed. Results: Twenty-three patients underwent 24 transabdominal cerclages. The primary indication for transabdominal cervicoisthmic cerclage was failed transvaginal cerclage in 14 patients and anatomic unsuitability for transvaginal cerclage in nine. Of the latter, five were a result of diethylstilbestrol exposure and four a result of cervical surgery. All patients were successfully delivered of one or more live babies (total 28, including two sets of twins). Two losses occurred, one after rupture of membranes at 21 weeks on the second pregnancy after cerclage placement and one intraoperative loss with herniation of the membranes. The live birth rate was 93%, compared with 18% salvage of pregnancies beyond the first trimester before the transabdominal cervicoisthmic cerclage procedure. Complications included blood loss requiring transfusion (four patients), although none of these occurred in the last 12 patients. Conclusion: We conclude that all the patients had a history compatible with incompetent cervix requiring a cerclage, and none were suitable candidates for a vaginal cerclage. We further conclude that with strict indications transabdominal cervicoisthmic cerclage offers a high rate of fetal salvage with a minimum of complications in patients with extremely poor obstetric histories because of cervical incompetence.