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To demonstrate the surgical techniques for improving safety in robotic-assisted abdominal cerclage in patients with bicornuate uteri complicated by recurrent pregnancy loss and cervical insufficiency. Stepwise demonstration with narrated video footage. An academic tertiary care hospital. Our patient is a 22-year-old G2P0020 with a history of recurrent pregnancy loss. During her first pregnancy, she was asymptomatic until 19 weeks and delivered because of a preterm premature rupture of membranes. A transvaginal cerclage was performed for her second pregnancy at 14 weeks, which ended at 16 weeks because of preterm premature rupture of membranes. The final magnetic resonance imaging report noted a "bicorporeal uterus with duplication of the uterine body, resulting in two markedly divergent uterine horns that are fused at the isthmus... unlike a typical didelphic uterus, a single, non septated cervix is noted, which shows normal appearances, measuring 3.8 cm in length." Given her history of a uterine anomaly and recurrent pregnancy loss in the absence of other biochemical factors, her maternal-fetal medicine specialist referred her to us as the patient strongly desired future viable pregnancies. The patient was counseled on multiple alternatives, including different methods of performing the cerclage, and ultimately decided on the robotic-assisted (Da Vinci Xi) prophylactic abdominal cerclage. The bicornuate uterus is a rare class IV mullerian duct anomaly caused by the impaired fusion of the mullerian ducts in the uterus, classically appearing in imaging studies as a heart-shaped uterus. This patient demographic reports a high incidence of obstetric complications. Pregnancy in such a uterus causes complications like first- and second-trimester pregnancy loss, preterm labor, low-birthweight infants, and malpresentation at delivery. 1 Researchers have postulated that there is an abnormal ratio of muscle fibers to connective tissue in a congenitally abnormal cervix. During pregnancy, an inadequate uterine volume may lead to increased intrauterine pressure and stress on the lower uterine segment, which can lead to cervical incompetence. 2 To address cervical incompetence, cervical cerclages are a commonly utilized procedure, as recent studies demonstrate that the incidence of term pregnancies in the group with documented cervical incompetence treated with cerclage placement increased from 26% to 63%. 3 One observational study noted improved obstetrical outcomes occurred with interval placement, a cerclage placed in between pregnancies in the nongravid uterus, compared with cerclage placement between 9 and 10 weeks gestation, with the mean gestational age for delivery at 32.9 weeks and 34.5 weeks when a cerclage was placed in gravid and nongravid women, respectively. 4 In addition, another retrospective study was done, which demonstrated a lower incidence of neonatal death with prophylactic cerclages. 5 Operating on a nonpregnant uterus offers several benefits, including its reduced size, fewer and smaller blood vessels, and simplified handling. Moreover, there are clearly no concerns regarding the fetus. In the decision to use a robotic-assisted platform vs. laparoscopic, a systematic review showed the rates of third-trimester delivery and live birth (LB) using laparoscopy during pregnancy were found to be 70% and 70%–100%, respectively. The same review demonstrated slightly improved outcomes via the robotic route regarding gestational age at delivery (median, 37 weeks), rates of LB (90%), and third-trimester delivery (90%). 6 Additional factors contributing to the preference for robotics in surgical procedures include incorporating advanced tools, which can enhance the robotic system's advantages compared with traditional laparoscopy. An invaluable tool in this context is the simultaneous utilization of Firefly mode, which employs a near-infrared camera system, achieved through injecting indocyanine green dye or integrating other light sources concurrently. The intravenous administration of indocyanine green is acknowledged widely for its safety and efficacy as a contrast agent in the evaluation of microvascular circulation and organ vascularization. This property equips surgeons with heightened precision when guiding the needle, proving especially advantageous when faced with challenges in visualizing vascular anatomy. In our specific case, we harnessed the capabilities of Firefly mode in conjunction with hysteroscopic light, enabling us to vividly illustrate the contours of a bicornuate uterus from both external and internal perspectives. We demonstrate a simplified technique of the abdominal cerclage, one cerclage around the internal cervical os of the uterus, using a robotic-assisted platform in a nongravid patient. The surgery began with the eversion of the umbilicus, and a 15-mm skin incision was made in the umbilicus. A Gelpoint mini advanced access site laparoscopy device was inserted into the incision, and CO 2 was allowed to insufflate the abdominal cavity with careful attention given to intraabdominal pressure. Once the DaVinci was docked, the surgeon began the creation of a bladder flap. The bladder was carefully dissected from the lower uterine segment and both uteri using monopolar scissors. The anatomical differences of a bicornuate uterus prompted the surgeon to dissect a wider circumference for safety reasons, where a wider dissection offers a better view of the uterine vessels and ease of introducing the Mersilene tape later on. Bilateral uterine vessels were further skeletonized and exposed anteriorly using blunt dissection and monopolar scissors. After further dissection and lateralization, the final result creates a landmark medial to the right uterine vessels at the level of the internal cervical os with which the needle of the Mersilene tape will be able to pass through. The Mersilene tape was guided from anterior to posterior via a previously straightened needle. Similarly, a landmark was created on the left, and the Mersilene tape was directed from anterior to posterior. The Mersilene tape was placed circumferentially around the internal cervical os of the bicornuate uterus, medial to the uterine vessels. Both ends of the Mersilene tape were then gently pulled, ensuring that the tape was lying flat on the anterior of the internal cervical os with no bowels or uterine vessels within it. The tape was then tied posteriorly at the 6 o'clock position with appropriate tension. A 2–0 silk was then sutured to the tails of the tape using the purse-string technique to ensure that it would remain securely tied and in the correct position. Hemostasis was assured. Both a hysteroscopy and a cystoscopy were done after the completion of the cerclage to ensure that no tape or sutures were seen within the cervical canal or the uterine cavity. None were observed. The success criteria for the surgery were identified as the patient's ability to attain a viable pregnancy after the cerclage placement, along with achieving LB. Subsequently, a spontaneous pregnancy was achieved. An infant weighing 3 pounds and 16 ounces was delivered by cesarean section at 36 weeks because of an oligohydramnios. The infant is currently healthy at 13 pounds. Robotic-assisted abdominal cerclage around the internal cervical os in a bicornuate uterus offers a possibly feasible and straightforward technique for surgeons seeking to reduce risks, although further research is needed. [ABSTRACT FROM AUTHOR]

STUDY QUESTION Do characteristics of the lower uterine segment and cervix modify the risk of preterm delivery in uterus transplant (UTx) recipients? SUMMARY ANSWER The cervical length showed little association with preterm delivery, however, cervical inflammation deserves further exploration as a cause of preterm delivery. WHAT IS KNOWN ALREADY UTx recipients do not have the risk factors normally used to stratify pregnancies that would benefit from cervical length assessment. In addition, unique factors related to absent tissues, a different blood supply, inflammatory processes of rejection, cervical biopsies, and a different microbiome challenge the normal progressive remodeling of the cervix and thus cervical competence. STUDY DESIGN, SIZE, DURATION This is a subanalysis of a clinical trial of 20 women undergoing uterus transplantation at Baylor University Medical Center from 2016 to 2020, in addition to two women who received transplantation outside of a research protocol at our institution through September 2022. In this report, the first 16 UTx recipients that achieved live birth are included. PARTICIPANTS/MATERIALS, SETTING, METHODS The focus of this study was 20 pregnancies that reached the second trimester in 16 women following UTx. We analyzed recipient, transplant, and donor factors to determine if characteristics were associated with delivery outcome. We compared obstetrical outcomes, including planned versus unplanned delivery, by factors such as number of superior venous anastomoses, warm ischemia and cold ischemia times, donor factors including cesarean sections, cervical biopsy results, and cervical ultrasound results. MAIN RESULTS AND THE ROLE OF CHANCE Planned term deliveries occurred in 44% (8/18) of live births. Of the preterm births, 30% (3/10) were planned and 70% (7/10) were unplanned. Unplanned deliveries occurred in women with spontaneous preterm labor, severe rejection, subchorionic hematoma, and placenta previa. Cervical length in UTx recipients averaged 33.5 mm at 24 weeks and 31.5 mm at 28 weeks, comparable to values from the general population. No relationship was seen between delivery outcome and number of veins used, ischemic time, or number of previous cesarean sections. LIMITATIONS, REASONS FOR CAUTION The study's small size allows limited conclusions. The obstetric history of all donors was limited to mode of delivery. WIDER IMPLICATIONS OF THE FINDINGS Cervical length measurements in the UTx population are not expected to deviate from those with a native uterus. While cervical length surveillance remains important, attention must be paid to the results of cervical biopsies which are obtained to monitor rejection. Inflammatory processes seem most predictive of preterm delivery. STUDY FUNDING/COMPETING INTEREST(S) No funding was provided for this study. The authors report no conflicts of interest. TRIAL REGISTRATION NUMBER NCT02656550 [ABSTRACT FROM AUTHOR]

Study objective: To demonstrate the surgical techniques for removal and replacement of a prior cerclage, repair of a cervical injury caused by the prior abdominal cerclage placement resulting in PPROM during surgery, and methods to mitigate the risk. Design: Stepwise demonstration with narrated video footage. Setting: An academic tertiary care hospital. Our patient is a 32-year-old G4P1 with a complex obstetric history. Her first pregnancy ended with a miscarriage at 7 weeks. A transvaginal cerclage was performed during her second pregnancy at 12 weeks, and she subsequently suffered from PPROM at 24 weeks. The baby was delivered via cesarean section and was 18 months old at the time of the last follow-up. Another transvaginal cerclage was performed at 14 weeks for her third pregnancy, which ended with an IUFD at 16 weeks. She subsequently underwent the removal of the vaginal cerclage and a D&C. In her fourth pregnancy, an open abdominal cerclage was attempted at 14 weeks of pregnancy. The latter caused PPROM during the surgery due to blind needle placement, which resulted in the loss of the fetus. Perioperative notes regarding that particular surgery were not accessible to us at the time of submission. She presented to us as a non-gravid patient seeking the replacement of her abdominal cerclage. Given a complex obstetric history of multiple second-trimester losses with two vaginal cerclages and one open abdominal cerclage, an abdominal cerclage was indicated at the level of the internal cervical os, regardless of cervical length, in a non-pregnant patient. Interventions: Cervical insufficiency is a condition that results in painless, recurrent pregnancy loss before the second trimester in the absence of biochemical triggers. Epidemiologically, cervical incompetence occurs in 0.1–1% of the obstetric population.1 Though rare, this condition has devastating consequences for both the expectant parents and the healthcare system, with preterm births responsible for 70% of all neonatal morbidity and mortality.2 The two most common surgical interventions aimed at resolving this condition are the transvaginal and abdominal cerclages. An abdominal cerclage has a reported success rate of 79–100% when done via laparoscopic means.3 This is the primary intervention indicated in patients with a history of failed transvaginal cerclages, a shortened or absent cervix due to cervical surgery, or uterine anomalies. Though the intervention has minimal risks and complications for the experienced surgeon in a non-gravid uterus, the difficulty exponentially increases post-conception and even more with increasing gestational age. Owing to the engorged uterine vessels during pregnancy and the amniotic sac that flanks the sides of the internal cervical os, the clearance for safe needle passage during cerclage placement is limited. This technical difficulty lends itself to causing the most common complication of abdominal cerclage: rupture of the membranes. PPROM accounts for 38% of all complications that arise during an abdominal cerclage placement4 and one of the gravest consequences is the subsequent loss of the fetus. Minimal advancement has been made in the standard techniques used to place the cerclage that would minimize the risk. Besides blind needle placement and its clear risks and ultrasound-guided technique,5,6 which would necessitate multiple specialists on hand, the surgeon suggests a trans-broad ligament approach. There is a case report by the same surgeon who performed it with great success.7 Essentially, the technique exposes the bilateral uterine vessels, which reduces the possibility of accidental damage to the arteries and eliminates the risk of blind needle placement piercing through the amniotic sac, leading to rupture of membranes and subsequent pregnancy loss.7 Multiple abdominal cerclages have been performed this way by the surgeon with a success rate of 100%; however, further research needs to be undertaken with greater power.We demonstrate three things in the video: a needleless technique to remove and replace a prior abdominal cerclage; a method to repair the internal cervical os after a cervical injury caused by the prior placement; and an abdominal cerclage placed months after the removal of the first, using standard technique. We performed all three procedures using a robotic-assisted single-site platform on a non-gravid patient.At the beginning of the surgery, the Mersilene tape from the prior abdominal cerclage was identified. The placement was regarded as being in the correct location, however it was loose circumferentially. Therefore, the decision was made to replace the tape in the same location with tighter banding. The needleless technique involved suturing the previous tape into the new one and using the prior tape to pull the new one through. This eliminated the need for another blind needle placement. However, a hysteroscopy done after the placement showed the tape within the uterine cavity. The surgeon initiated the removal of the recently placed cerclage. During the creation of the bladder flap, a 2 cm defect at the level of the internal os at the location of the prior cerclage was noted. This gaping defect left the Rumi manipulator visible and extended laterally into the broad ligament. A mutual decision was made by the surgeon and the patient's husband to repair the uterine defect during the present surgery and defer the cerclage placement to a later date. The first surgery was completed after a hysteroscopy was done, and no sutures were visualized within the uterine cavity. Five months later, the patient followed up for her abdominal cerclage placement. A preliminary hysteroscopy noted a well-healed uterine cavity. Therefore, an abdominal cerclage was placed via a robotic-assisted platform using the blind needle technique. A concluding hysteroscopy and view in fire-fly mode demonstrated no Mersilene tape or sutures within the internal cervical os. There were no complications during either surgery, and the patient was discharged on the same day for both. Conclusion: Removal and replacement of prior cerclage can be done needleless under the correct conditions. For patients referred following a failed transabdominal cerclage especially due to intraoperative cervical injury, the surgeon recommends a preliminary hysteroscopy to determine the extent of damage and prevent redundant effort. Blind needle placement remains the most standard technique in performing abdominal cerclage, yet it is one of the highest cause of complications in the surgical intervention. The repair and replacement of the cerclage were necessitated in this case after the prior surgeon had impaled the amniotic sac during blind needle placement, resulting in the loss of the fetus. Currently, the trans-broad ligament approach offers a feasible and simple technique for surgeons seeking to reduce risks, although further research is needed.

Background: Cervical insufficiency (CI) may result in preterm delivery. We sought out to perform this review and analysis to compare the efficacy of laparoscopic and open transabdominal cerclage (TAC) in patients suffering with CI.Methods: Our search included PubMed, Scopus, MEDLINE, ClinicalTrials.Gov, Cochrane and Web of Science. We analyzed the data with Open Meta-Analyst Software as well as Review Manager Software. We included observational and randomized controlled trials that included patients with CI that underwent laparoscopic cerclage or TAC.Results: We included a total of 43 studies. Laparoscopic and TAC had a positive effect by increasing gestational age (GA); for the laparoscopic group (mean deviation (MD)) = 14.86 weeks (W), 95% CI [10.67, 19.05], P < 0.001) and TAC (MD = 12.79 W, 95% CI [10.97, 14.61], P < 0.001). Furthermore, improvements in all outcomes assessed (total fetal survival rate, neonatal weight, and prevention of delivery at a gestational age of<24 weeks) were all significant with the exception of the prevention of all preterm deliveries<37 weeks; for both laparoscopic at (RR = 0.116, 95% CI [-0.006, 0.238], P = 0.063) and TAC at (MD = 1, 95% CI [0.45, 2.24], P = 1), and for prevention of deliveries<34 weeks for the laparoscopic group (RR = 0.446, 95% CI [-0.323, 1.215], P = 0.256) only.Conclusions: Although limited data prevented pregnancy and prepregnancy subgroups as well as a head-to-head comparison, we still found that in patients suffering from CI, both TAC and laparoscopic approaches to cerclage revealed a positive effect in preserving the pregnancy. [ABSTRACT FROM AUTHOR]

Aim: The study aimed to examine the usefulness of modified transabdominal cervicoisthmic cerclage (TAC) using monofilament thread for the prevention of preterm delivery in women with an extremely short cervix after deep conization. Methods: We devised a monofilament thread for picking up the seromuscular layer of the site that is slightly cephalad to the internal ostium to prevent injury of the vessels around the uterine cervix. From 2017 to 2020, we performed this modified operation in eight women (nine pregnancies) at 12–16 weeks of gestation with a history of deep cervical conization. Results: A modified TAC was successfully performed in all patients. There was no measurable bleeding, and all patients were discharged without postoperative complications. Their pregnancy courses after the operation were uneventful. Of nine, one patient had premature uterine contractions and underwent cesarean section at 36 weeks (preterm delivery). In the other eight pregnancies, planned cesarean section was performed after 37 weeks of gestation. The median birth weight of the babies was 2996 g (range 2604–3374 g). All patients were discharged on the sixth postoperative day without complications. Conclusion: A modified TAC can be safely performed and may prolong pregnancy without adverse events in patients with an extremely short cervix. [ABSTRACT FROM AUTHOR]

Aims: This study compared the effectiveness and safety of cervical cerclage combined with cervical pessary in the treatment of cervical incompetence and that of cervical cerclage alone and cervical pessary alone.Methods: We performed a prospective cohort study of women with cervical incontinence. Subjects were randomized into three groups: cerclage, pessary, and cerclage and pessary combined.Results: A total of 75 patients with cervical incompetence were enrolled: 37.3% patients had a cervical length <15 mm, and 62.5% had a cervical length of 15-25 mm. Patients with increased body mass index were significantly likely to have a short cervix (p = .06); patients with a short cervix had earlier rupture of the membrane. The cerclage and pessary groups had more spontaneous abortions than the combined treatment group, which had no abortions or premature births. The mean gestational ages at delivery for the cerclage group (37.82 weeks) and the pessary group (35.73 weeks) were smaller than for the combined treatment group (38.33 weeks). The premature rupture of membranes that was correlated with cervical length had a higher incidence in the pessary group (26.9%).Conclusion: Placement of a cervical cerclage combined with a cervical pessary is a safe technique and has a high success rate in the treatment of cervical incompetence. [ABSTRACT FROM AUTHOR]

To demonstrate the surgical techniques for improving safety in robotic-assisted abdominal cerclage via broad ligament window dissection. Stepwise demonstration with narrated video footage. An academic tertiary care hospital. Our patient is a 32-year-old G8P2143, with a history of pregnancy loss at 19 and 23 weeks and 1 failed vaginal cerclage, presented to us at 13 weeks and 5 days for abdominal cerclage. We have completed a total of 5 successful procedures with this technique on pregnant patients ranging from 9 to 14 weeks. Abdominal cerclage during pregnancy can be very risky and challenging to perform; however, it offers an increased success rate for continuing pregnancy [1]. Excessive bleeding and the rupture of membrane during the procedure could lead to pregnancy loss and a failed abdominal cerclage [ 2 , 3 ]. Therefore, seeking a feasible and safer technique would be preferable for the surgeons to decrease surgical risk and complications. We have developed a trans-broad ligament technique that would allow for the bilateral uterine vessels to be clearly exposed, thereby reducing the possibility of accidental damage to a major vessel and eliminating the risk of blind needle placement piercing through the amniotic sac resulting in rupture of membrane and subsequent pregnancy loss [ 4 , 5 ]. A dense adhesion band from the anterior uterus to the anterior abdominal wall was carefully taken down using the monopolar scissors. The assistant gently performed a digital vaginal examination to assist with the creation of a bladder flap. The bladder was carefully dissected off the lower uterine segment and uterus using the monopolar scissors. Bilateral uterine vessels were further skeletonized and exposed anteriorly using blunt dissection and the monopolar scissors. On the right, a window was created in the broad ligament using the monopolar scissors. The right uterine vessels were then further dissected and lateralized, creating a small window medial to the uterine vessels at the level of the internal cervical os. The mersilene tape was guided through the window from anterior to posterior. In a similar fashion, a window was created on the left; the mersilene tape was then guided from posterior to anterior. The mersilene tape was completely placed around the cervix circumferentially at the level of the internal cervical os, medial to the uterine vessels. Both ends of the mersilene tape were then pulled gently, while ensuring that the tape was lying flat on the anterior of the uterus. The tape was then tied anteriorly at the 12 o'clock position in an appropriate tension. A 2-0 silk was then sutured to the tails of the tape to ensure that it would remain in the correct location and prevent the loosening of the knot of mersilene tape. The pelvis was copiously irrigated, and hemostasis was assured. The fetal heart rate was 126 bpm, and patient was discharge next day. A healthy baby, 6 pounds 14 ounces, was delivered by cesarean section at 36 weeks 5 days because of early contractions and pain (Supplemental Appendix 1-4). Robotic-assisted abdominal cerclage via broad ligament window dissection offers a possibly feasible and safe technique for surgeons seeking to reduce risks, although further research is needed. [ABSTRACT FROM AUTHOR]

Study objective: To demonstrate the surgical techniques for removal and replacement of a prior cerclage, repair of a cervical injury caused by the prior abdominal cerclage placement resulting in PPROM during surgery, and methods to mitigate the risk. Design: Stepwise demonstration with narrated video footage. Setting: An academic tertiary care hospital. Our patient is a 32-year-old G4P1 with a complex obstetric history. Her first pregnancy ended with a miscarriage at 7 weeks. A transvaginal cerclage was performed during her second pregnancy at 12 weeks, and she subsequently suffered from PPROM at 24 weeks. The baby was delivered via cesarean section and was 18 months old at the time of the last follow-up. Another transvaginal cerclage was performed at 14 weeks for her third pregnancy, which ended with an IUFD at 16 weeks. She subsequently underwent the removal of the vaginal cerclage and a D&C. In her fourth pregnancy, an open abdominal cerclage was attempted at 14 weeks of pregnancy. The latter caused PPROM during the surgery due to blind needle placement, which resulted in the loss of the fetus. Perioperative notes regarding that particular surgery were not accessible to us at the time of submission. She presented to us as a non-gravid patient seeking the replacement of her abdominal cerclage. Given a complex obstetric history of multiple second-trimester losses with two vaginal cerclages and one open abdominal cerclage, an abdominal cerclage was indicated at the level of the internal cervical os, regardless of cervical length, in a non-pregnant patient. Interventions: Cervical insufficiency is a condition that results in painless, recurrent pregnancy loss before the second trimester in the absence of biochemical triggers. Epidemiologically, cervical incompetence occurs in 0.1-1% of the obstetric population.1 Though rare, this condition has devastating consequences for both the expectant parents and the healthcare system, with preterm births responsible for 70% of all neonatal morbidity and mortality.2 The two most common surgical interventions aimed at resolving this condition are the transvaginal and abdominal cerclages. An abdominal cerclage has a reported success rate of 79-100% when done via laparoscopic means.3 This is the primary intervention indicated in patients with a history of failed transvaginal cerclages, a shortened or absent cervix due to cervical surgery, or uterine anomalies. Though the intervention has minimal risks and complications for the experienced surgeon in a non-gravid uterus, the difficulty exponentially increases post-conception and even more with increasing gestational age. Owing to the engorged uterine vessels during pregnancy and the amniotic sac that flanks the sides of the internal cervical os, the clearance for safe needle passage during cerclage placement is limited. This technical difficulty lends itself to causing the most common complication of abdominal cerclage: rupture of the membranes. PPROM accounts for 38% of all complications that arise during an abdominal cerclage placement4 and one of the gravest consequences is the subsequent loss of the fetus. Minimal advancement has been made in the standard techniques used to place the cerclage that would minimize the risk. Besides blind needle placement and its clear risks and ultrasound-guided technique which would necessitate multiple specialists on hand, the surgeon suggests a trans-broad ligament approach. There is a case report by the same surgeon who performed it with great success.7 Essentially, the technique exposes the bilateral uterine vessels, which reduces the possibility of accidental damage to the arteries and eliminates the risk of blind needle placement piercing through the amniotic sac, leading to rupture of membranes and subsequent pregnancy loss.7 Multiple abdominal cerclages have been performed this way by the surgeon with a success rate of 100%; however, further research needs to be undertaken with greater power. We demonstrate three things in the video: a needleless technique to remove and replace a prior abdominal cerclage; a method to repair the internal cervical os after a cervical injury caused by the prior placement; and an abdominal cerclage placed months after the removal of the first, using standard technique. We performed all three procedures using a robotic-assisted single-site platform on a non-gravid patient. At the beginning of the surgery, the Mersilene tape from the prior abdominal cerclage was identified. The placement was regarded as being in the correct location, however it was loose circumferentially. Therefore, the decision was made to replace the tape in the same location with tighter banding. The needleless technique involved suturing the previous tape into the new one and using the prior tape to pull the new one through. This eliminated the need for another blind needle placement. However, a hysteroscopy done after the placement showed the tape within the uterine cavity. The surgeon initiated the removal of the recently placed cerclage. During the creation of the bladder flap, a 2 cm defect at the level of the internal os at the location of the prior cerclage was noted. This gaping defect left the Rumi manipulator visible and extended laterally into the broad ligament. A mutual decision was made by the surgeon and the patient's husband to repair the uterine defect during the present surgery and defer the cerclage placement to a later date. The first surgery was completed after a hysteroscopy was done, and no sutures were visualized within the uterine cavity. Five months later, the patient followed up for her abdominal cerclage placement. A preliminary hysteroscopy noted a well-healed uterine cavity. Therefore, an abdominal cerclage was placed via a robotic-assisted platform using the blind needle technique. A concluding hysteroscopy and view in fire-fly mode demonstrated no Mersilene tape or sutures within the internal cervical os. There were no complications during either surgery, and the patient was discharged on the same day for both. Conclusion: Removal and replacement of prior cerclage can be done needleless under the correct conditions. For patients referred following a failed transabdominal cerclage especially due to intraoperative cervical injury, the surgeon recommends a preliminary hysteroscopy to determine the extent of damage and prevent redundant effort. Blind needle placement remains the most standard technique in performing abdominal cerclage, yet it is one of the highest cause of complications in the surgical intervention. The repair and replacement of the cerclage were necessitated in this case after the prior surgeon had impaled the amniotic sac during blind needle placement, resulting in the loss of the fetus. Currently, the trans-broad ligament approach offers a feasible and simple technique for surgeons seeking to reduce risks, although further research is needed. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Patients with an ultra‐short uterine cervix as a result of large conization, repeated conization or radical trachelectomy (RT), are at high risk of preterm premature rupture of the membrane, which leads to preterm birth. We have commenced performing transabdominal cerclage (TAC) of the uterine cervix for these patients. In this study, we examined the safety of TAC and its impact on pregnancy. Methods: We have performed TAC in 11 patients before pregnancy: in six after large cervical operations, such as repeated conization; and in five for difficulties with cervical cerclage after RT. After laparotomy, a Teflon thread was placed in the avascular space between the uterine vessels and the uterine muscle, and tied. The clinical course of the patients after TAC and their pregnancy course were retrospectively reviewed. Results: TAC was performed safely without any complications. The mean operative duration was 53 ± 10 min, and the mean blood loss during the operation was 49 ± 64 mL. Seven women conceived within 2 years after TAC. Their pregnancy courses were favorable. Five of the women underwent scheduled cesarean sections, while two pregnancies are ongoing. Conclusions: Although there are risks of various complications as a result of the use of non‐absorbable thread and the need for two extra laparotomies, TAC can be a safe and useful option for patients who show cervical incompetence after large uterine cervical operations, such as RT or large conization. [ABSTRACT FROM AUTHOR]

Background: Second trimester short cervical length identifies women at increased risk for an early spontaneous Preterm birth (sPTB), hence raising a compelling needed for Cervical Assessment for prediction and possible Preventing Preterm Delivery. Objective of the study: to assess the implications associated with a short cervical length as well as the use of ultrasonographic-derived cervical length measurement in predicting preterm birth. Methods: the present review includes relevant randomized controlled trials (RCTs) that investigated the in Medline (via PubMed), Cochrane Library and Embase. Retrospective and Prospective Cohort studies, Case-control and Randomised controlled trials. There were no restrictions by outcomes examined, language or publication status. Results: The critical search results yielded 6 articles (randomized trials=2, cohort studies=3, casecontrol study=1) representing 653 patients . Five of the 6 presented similar pregnancy outcomes (spontaneous preterm birth or pregnancy loss < 24 weeks' gestation) between the ultrasound-indicated and the history-indicated cerclage groups. 45-69% of the patients followed with cervical ultrasound were able to avoid cerclage. Conclusion: Evidence from randomized trials supports that transvaginal ultrasound is predictive of preterm birth in women with prior preterm birth and a short cervix. The thresholds proposed vary from 15 mm to 28 mm and cerclage is thus recommended. [ABSTRACT FROM AUTHOR]

A cross-sectional study was conducted to evaluate the efficacy of rescue cerclage in patients with a dilated cervix and prolapsed foetal membranes. Thirty-five patients presenting with cervical dilatation and prolapsed foetal membranes were included in the study. A McDonald cerclage was placed in 27 patients. The duration of pregnancy prolongation and the number of deliveries after 28 weeks were evaluated. The median prolongation of pregnancy after cerclage placement differed significantly between the cerclage and bed-rest groups (64 days versus 13.5 days). Of the 27 patients who had cerclage, 17 (63%) delivered after 28 weeks of gestation, whereas all patients in the bed-rest group delivered before 28 weeks of gestation. The take-home baby rate was 63% in the cerclage group. When pregnancies were complicated by cervical dilatation with membrane prolapse into the vagina, placement of a McDonald cerclage in appropriately selected patients can be a beneficial therapeutic option. Impact statement Although the effectiveness and safety of rescue cerclage is controversial, our study provides strong support for the notion that cervical cerclage accompanied by long-term broad-spectrum antibiotics improves the perinatal outcomes in singleton gestations with membrane prolapsed into the vagina. Further prospective randomised trial is required to prove these findings. [ABSTRACT FROM AUTHOR]

Objective: To evaluate efficiency and safety of the new approach of laparoscopic cerclage.Study Design: Fifteen women were operated with our new technique. Their age ranged from 22 years to 35 years. Inclusion criteria included those with history of two or more second trimesteric abortions or early preterm labor. These women had at least two previous unsuccessful vaginal cerclage or vaginal insertion of cerclage is not possible because of congenitally short cervix, cervical conization or excessive cervical scarring.Results: Twelve of the participants delivered vaginally with the removal of cerclage, two had CS due to breech presentation and the cerclage was left in place and the last one has surgical evacuation. No intraoperative or postoperative complications were encountered namely; excessive bleeding, injury of uterine vessels or postoperative peritonitis. No technical difficulties upon doing the procedure or cerclage removal were met apart from one case where removal of the vaginal stitch was not possible [incision was done in the cervix over the tape and the Mersilene tape was cut followed by repair of the cervical tissue using (00) Vicryl stitches].Conclusion: The new approach for laparoscopic cerclage is a safe, effective and reasonable treatment after failure of vaginal cerclage. [ABSTRACT FROM AUTHOR]

We present a rare case of a complication after pessary insertion during pregnancy due to short cervix. A woman in the 35th week of gestation was admitted to the Department of Perinatology due to preterm labor. The patient's history revealed cervical pessary insertion during the 29th week of pregnancy due to a cervix of 18 mm in length. Because of threatened preterm labor, the pessary was removed. After pessary removal, a rupture of the cervix was diagnosed. Because of active labor and cervical rupture, a cesarean section was performed and a healthy newborn was delivered. After cesarean section the cervical rupture was sutured. Five days after the operation, the patient underwent surgery again due to a necrotically changed part of the cervix. This part of the cervix was removed. We present this case to emphasize that cervical pessaries can cause serious complications during pregnancy. Clinicians should take this into consideration before qualifying patients for pessary insertion. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study is to examine results of bacterial cultures of the cervix prior to cerclage placement and how these may be used to guide prophylactic antibiotics.Methods: All patients undergoing cerclage between 2000 and 2003 in a single, large community hospital were evaluated for indication for cerclage, signs and symptoms on presentation, transvaginal ultrasound cervical length findings, type of cerclage placed, type of anesthesia used, cervical culture taken, tocolytics given, gestational age at delivery, and complications surrounding delivery.Results: Sixty-five cerclages were performed between 2000 and 2003, 13 (20%) prophylactic, 47 (72%) therapeutic, and five (8%) emergent. Cervical cultures were obtained in 85% of patients, of which 40% were negative resulting in no antibiotics given. In the remaining 45%, one or more pathogens were isolated and antibiotics were given according to sensitivities reported. Fifty-five of 65 patients (84%) delivered after 32 weeks gestation and a latency > 60 d was seen in 84%. The incidence of chorioamnionitis and PPROM was low.Conclusion: Bacterial cultures of the cervix prior to cerclage show variable colonization and antibiotic sensitivities and, there is no single antibiotic, chosen empirically, that will cover all pathogens. [ABSTRACT FROM AUTHOR]

Aim The aim of this study was to evaluate outcome of pregnancies in women with rescue cerclage for cervical insufficiency. Material and Methods A retrospective study of all women who underwent rescue cerclage between 2002 and 2011 at an advanced tertiary care perinatal institute in India was conducted. Data retrieved from medical records was used to explore potential associations with prolongation of pregnancy beyond 28 weeks. Results The mean (standard deviation) gestational age at cerclage was 21.9 (2.7) weeks for the 74 women in the study. The McDonald technique was the preferred method for rescue cerclage (91.9%). All women received antibiotics; tocolytics were used in 35.1% and progesterones in 62.2% of women. The mean prolongation of pregnancy was 7.4 weeks with 42.0% women delivering after 28 weeks and 30.4% after 34 weeks. The take-home-baby rate was 50.7% (95% confidence interval: 38.7-62.6%). Postoperative vaginal infection was present in 16.2% of women, preterm premature rupture of membranes in 31.1% of women and neonatal sepsis in 5.8% of neonates. Cerclage placement after 20 weeks and negative pathogenic organisms in vaginal swab culture were significantly associated with delivery beyond 28 weeks. Conclusions Although half of the women had successful pregnancy outcomes after rescue cerclage, pregnancy extended from previability to prematurity in most of them. [ABSTRACT FROM AUTHOR]

Background: This study compared the changes in plasma oxytocin, intraoperative hemodynamics and postoperative uterine activity in patients who underwent elective Shirodkar cerclage for cervical incompetence with general or spinal anesthesia. Methods: Thirty-seven singleton pregnant patients were enrolled in this prospective, randomized, controlled comparison of general (n=17) and spinal anesthesia (n=20) for elective Shirodkar suture in the second trimester. Plasma oxytocin concentration was measured before, 1 h after, and 24 h after the procedure. Uterine activity was recorded by external tocography twice daily for 30 min over a three-day period. Results: Plasma oxytocin concentration did not change significantly after cerclage in either group. There were no significant differences between the two groups at any time. None of the patients reported painful contractions during study period. Two (11.8%) and four patients (20.0%) in the general and spinal groups, respectively (NS), showed increased uterine activity but these symptoms disappeared without treatment. The systolic blood pressure in the spinal group was significantly lower after anesthesia compared with the baseline and was significantly lower than in the general group during the procedure. Conclusions: Anesthetic method used for elective Shirodkar procedure did not affect the perioperative changes in plasma oxytocin nor postoperative uterine activity. [Copyright &y& Elsevier]

This editorial critically examines the definition of ‘cervical insufficiency.’ The definition, the clinical ascertainment, efforts to develop an objective method of diagnosis, as well as the nature of cervical disease leading to spontaneous mid-trimester spontaneous abortion and preterm delivery reviewed. The value and limitations of cervical sonography as a risk assessment tool for spontaneous pattern delivery arc appraised. The main focus is on the role of cervical cerclage to prevent an adverse pregnancy outcome. The value of assessing the presence or absence of endocervical inflammation in the outcome of cerclage placement is discussed. [ABSTRACT FROM AUTHOR]

The origin of incompetent cervix is multifactorial, and the success of rescue cerclage is unpredictable. We tested amniotic fluid from women who were preparing to undergo rescue cerclage for proteomic biomarkers and correlated their presence with clinical outcome. Study design: Amniocentesis was performed to facilitate rescue cerclage in 37 consecutive women with painless dilation (> 2 cm) and no detectable uterine activity for 4 hours (range, 1-24 hours) before cerclage. Thirty-nine consecutive women with a sonographically normal pregnancy and cervix who underwent amniocentesis for chromosomal testing during the same study interval at the same clinical site provided the control samples. A proteomic fingerprint was generated with the discarded sample and the Mass-Restricted score (MR score) for inflammation calculated. Peaks corresponding to free hemoglobin chains were sought as evidence of decidual hemorrhage or intra-amniotic bleeding. Results: Amniocentesis was performed at 23.5 weeks in cerclage (mean dilation, 4 cm) versus 19.5 weeks in control subjects. Cerclage subjects were delivered at 28.8 weeks; control subjects were delivered at 39.2 weeks. Thirty-two of 37 of cerclage subjects (86%) were delivered prematurely. Ten of 37 of cerclage subjects (27%), but no control subject, had a MR score that was indicative of inflammation (P < .001). Hemoglobin peaks were present in 12 of 37 of cerclage subject (32%), but no control subjects. Among cerclage subjects, those with a MR score of 3 to 4 were delivered earlier than those with a MR score of 0 to 2 (P < .001). Women with a MR score of 3 to 4 had a shorter latency period (days from amniocentesis to delivery; 3 days) and a shorter percentage of prolongation (1.8%) than women with a MR score of 0 to 2 (35 days; P < .05; 17.9%; P < .05). Women with hemoglobin had a shorter latency period (6 days) and a shorter percentage of prolongation (3.8%) than women without hemoglobin (38 days; P < .05; 21.8%; P < .05). Hemoglobin was present in 7 of 10 of the cerclage subjects (70%) with a MR score of 3 to 4. Women with both a MR score of 3 to 4 and hemoglobin had the shortest intervals to delivery. These findings illustrate 2 pathologic mechanisms that are associated with preterm delivery are also associated with incompetent cervix. Either an intrauterine inflammatory response or decidual hemorrhage predates surgery in one half the women whose condition requires rescue cerclage. The activation of either mechanism predicts cerclage failure. [ABSTRACT FROM AUTHOR]