Laparoscopic transabdominal cerclage: preconception versus postconception placement

Cervical insufficiency is a major contributor to spontaneous preterm birth and second-trimester pregnancy loss. Transabdominal cerclage is recommended for patients with a history of failed vaginal cerclage or when vaginal cerclage is not anatomically feasible. Laparoscopic transabdominal cerclage has emerged as a minimally invasive alternative to open transabdominal cerclage. However, data comparing obstetric and surgical outcomes based on the timing of laparoscopic transabdominal cerclage placement before vs during pregnancy.

Primary aims were to evaluate whether laparoscopic transabdominal cerclage placement before vs during pregnancy is associated with differences in delivery at or beyond 34 weeks' gestation and neonatal survival rates. Secondary aims were to evaluate other obstetric and surgical outcomes.

This retrospective cohort study included patients who underwent laparoscopic transabdominal cerclage for cervical insufficiency at 3 tertiary care centers within a single hospital system between January 1, 2008 and December 31, 2023. Patients were grouped by timing of cerclage placement: before pregnancy and during pregnancy. Prespecified primary outcomes were delivery at ≥34 weeks' gestation and neonatal survival at hospital discharge. Secondary outcomes included gestational age at delivery, birthweight, preterm prelabor rupture of membranes, spontaneous preterm birth, operative time, estimated blood loss, and perioperative complications. Statistical analysis included chi-square or Fisher's exact tests for categorical variables and t tests or Mann-Whitney U tests for continuous variables, with significance set at P<.05.

Sixty nine patients met inclusion criteria, including 40 who underwent laparoscopic transabdominal cerclage before pregnancy and 29 who underwent the procedure during pregnancy. The proportion of patients delivering at ≥34 weeks' gestation (30/40 [75%] vs 26/29 [90%]; P=.12) was similar between groups, as was neonatal survival at hospital discharge (35/40 [90%] vs 27/29 [93%]; P>.99). Median gestational age at delivery was slightly earlier in the preconception group (36.6 weeks vs 37.0 weeks, P=.02), although this difference was <7 days and thus not considered clinically meaningful. The incidence of spontaneous preterm birth was higher in the preconception group, while rates of preterm prelabor rupture of membranes did not differ. Operative time, estimated blood loss, and perioperative complications were similar between groups.

Laparoscopic transabdominal cerclage placement before or during pregnancy was associated with similar gestational age at delivery and high neonatal survival rates in this cohort. These findings support individualized counseling regarding timing of laparoscopic transabdominal cerclage placement while recognizing that limited power, particularly for rare outcomes such as neonatal death, restricts the ability to exclude clinically meaningful differences.