Cervical Insufficiency Management with Elective Transvaginal Cervicoisthmic Cerclage

Background Transabdominal cervicoisthmic cerclages (TACIC) are currently recommended for cervical insufficiency, which is-(1) refractory to the conventional vaginally applied cervical cerclages or (2) in an anatomically short cervix. We aim to determine the feasibility and effectiveness of the cervicoisthmic cerclage applied transvaginally (TVCIC), instead of the invasive TACIC, in preventing preterm births (< 32 weeks of gestation) in women with previously failed cervical cerclages. Materials and Methods This retrospective case series included consecutive patients who had a history of elective cervical cerclage failure in the previous pregnancy and, therefore, underwent elective TVCIC (preconceptionally or antenatally) in the current pregnancy between 2015 and 2023 in our tertiary care setting. Fetal survival-to-discharge rate was analyzed as a secondary outcome. The TVCIC technique is performed as follows: The bladder is reflected away from the cervix by sharp dissection, leaving the utero-vesical fold of the peritoneum intact. With a posterior colpotomy, the Pouch of Douglas is entered. Bilaterally, a 5-mm Mersilene tape is passed anteroposteriorly, cranial to the uterosacral ligaments, encircling through the lateral cervical tissue, and tied posteriorly. The anterior and posterior colpotomies are then closed with interrupted sutures-burying the knot in the Pouch of Douglas. Ideally, at term, the women undergo an elective cesarean delivery, and the cerclage may be left in situ-if the woman desires future pregnancies. Results In twenty-seven women with previous cervical cerclage failure, TVCIC was electively performed (twenty-three during 7-16 weeks of gestation and four preconceptionally). All but one (n = 26/27, 96.3%) of the gestations carried beyond 32 weeks of gestation, whereas 77.8% (n = 21/27) gestations completed 37 weeks. The fetal survival-to-discharge rate was 96.3% (n = 26/27). There were no procedure-related maternal or neonatal complications. Conclusion TVCIC can be further explored as an alternative to transabdominal cervicoisthmic cerclages in a larger, multicentric study in a similar population.