The role of transabdominal cervical cerclage techniques in maternity care

Key content: The transabdominal cerclage procedure aims to strengthen the cervix by placing a suture at the level of the internal os. The main indications for transabdominal suture are a grossly disrupted cervix, an absent vaginal cervix, and previous failed elective vaginal cerclage. The transabdominal cerclage was first described in 1965 and the laparoscopic modification was first reported in 1998. Published reports suggest very high neonatal survival rates with both approaches. Laparoscopic cerclage has the general advantages of minimal access surgery, such as avoiding a large abdominal incision, short hospital stay and quick recovery. Potential complications include bleeding from uterine vessels and loss of pregnancy for non‐interval procedures. The other reported complications, such as suture migration, rectouterine fistula, uterine rupture and intrauterine growth restriction, are rare. The place of transabdominal cerclage in preventing pregnancy loss and preterm birth remains a subject of debate and there is a need to audit the outcomes. / Learning objectives: To better understand the role of the cervix in miscarriage. To understand the indications for referral for transabdominal cervical cerclage. To understand the obstetric and neonatal outcomes of women after this procedure. / Ethical issues: To consider the place of this invasive procedure, with its consequent possible complications, in the management of cervical weakness in women who often have poor reproductive histories. To consider the lack of national and international availability of this potentially valuable procedure. To consider an effective system of assessment of this procedure in a referral context, and the future of this procedure

Office Hysteroscopic Treatment of Uterine Fibroids

Advances in endoscopic and therapeutic hysteroscopic technology have made the removal of submucosal fibroids possible in the outpatient setting. Removal of submucosal fibroids can be particularly challenging in the outpatients due to intramural components of some submucosal fibroids and the hard consistency of fibroids which makes specimen retrieval rather difficult through the endocervical canal. Fibroids which are <2 cm and completely intracavitary are easier to remove in the outpatients. Specimen retrieval can be addressed either by slicing the fibroid using bipolar electrodes, by using a hysteroscopic morcellator or leaving the fibroid in the uterine cavity after enucleation to be expelled with uterine contractions. Patient acceptability appears to be high in a small number of retrospective case series published in the literature. Further reports and data from prospective trials would be beneficial in improving our understanding of this procedure which appears to be performed by a relatively small number of centres

Preconception laparoscopic transabdominal cervical cerclage for the prevention of midtrimester pregnancy loss and preterm birth: a single centre experience

Background: A recent Cochrane review concluded that cervical cerclage reduces preterm birth before 37, 34 and 28 weeks of gestation and also probably reduces the risk of perinatal death. Transabdominal cerclage was developed for a subgroup in whom transvaginal cerclage had failed or was not possible. This approach appeared more effective in improving foetal survival rates or obstetric outcomes. Most commonly transabdominal cervical cerclage is placed at laparotomy (open transabdominal cerclage), but with the advance of minimal access techniques, laparoscopic transabdominal cervical cerclage is replacing the traditional open operation. The objective of this prospective case series is to explore the outcomes of pre-conception laparoscopic transabdominal cerclage procedures. Method: Data was prospectively collected from 54 women at high risk of second trimester miscarriage and preterm delivery due to cervical insufficiency undergoing pre-conception laparoscopic transabdominal cerclage by a single operator. This included demographics, obstetric and gynaecological history (including previous cervical cerclage procedures), surgical complication rates, conception and subsequent pregnancy outcomes. Results: There were 36 pregnancies progressing beyond the first trimester with a "take home baby" rate of 89% (32/36), a live birth rate of 92% (33/36) and neonatal survival rate of 97% (32/33). The mid-trimester loss (MTL) rate was 8% (3/36) with delivery rates after 37 weeks of 75% (27/36) and between 34 -37 weeks of 8% (3/36) and 23-34 weeks of 8% (3/36). Conclusions: Our prospective case series provides further evidence that laparoscopic transabdominal cerclage (TAC) is feasible, safe and effective when transvaginal cerclage fails or is not possible

Does ovarian cystectomy pose a risk to ovarian reserve and fertility?

Key content The impact of benign ovarian cysts on a woman’s fertility is dependent on the nature, size, number, bilaterality and risk of recurrence of the cyst(s). Children and adolescents presenting with pathological ovarian cysts require a multidisciplinary team approach and, where possible, fertility sparing treatment should be offered. Laparoscopic detorsion has the potential to preserve ovarian reserve and should remain the optimal treatment for ovarian torsion in girls and premenopausal women. Surgery for bilateral endometriomas has been shown to increase the risk of developing premature ovarian insufficiency. It is important to consider performing ovarian reserve assessments before any ovarian surgery in women who have not completed their family. Learning objectives To understand what factors need to be considered before making a decision to perform an ovarian cystectomy. To be aware of different surgical techniques and their impact on fertility outcomes. To take anatomical considerations into account to minimise damage to healthy ovarian tissue. Ethical issues The UK’s National Health Service does not routinely fund oocyte freezing for benign conditions