Case Reports
Uterine Rupture After Uterine Artery Embolization for Symptomatic Leiomyomas Amanda Yeaton-Massey, MD, Megan Loring, MD, Shilpa Chetty, MD, and Maurice Druzin, MD BACKGROUND: There are few data regarding safety of pregnancy after uterine artery embolization. However, numerous women desire future fertility after this procedure. Uterine rupture without a history of cesarean delivery or uterine scarring is an exceedingly rare complication in pregnancy. CASE: We report a case of uterine rupture in a primigravid woman after uterine artery embolization. Her pregnancy was also complicated by placenta previa with placenta increta, resulting in a favorable neonatal outcome in an otherwise life-threatening situation for mother and fetus. CONCLUSION: Uterine artery embolization is a risk factor for abnormal placentation and uterine rupture in subsequent pregnancies. (Obstet Gynecol 2014;123:418–20) DOI: 10.1097/AOG.0b013e3182a46df9
T
he safety of pregnancy after uterine artery embolization has not been established. As a result, this procedure typically is reserved for women who do not desire future childbearing. Reported adverse outcomes after uterine artery embolization include miscarriage, preterm delivery, abnormal placentation, and malpresentation.1–5 In a study of 24 pregnancies after uterine artery embolization, there were three cases of abnormal See related editorial on page 415.
From the Stanford University Hospital and Clinics, Lucile Packard Children’s Hospital at Stanford, and the Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford California. Corresponding author: Amanda Yeaton-Massey, MD, Department of Obstetrics and Gynecology, Stanford Hospital and Clinics 300 Pasteur Drive, Mail Code 5317 Stanford, CA 94305-5317; e-mail: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/14
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placentation. This rate of abnormal placentation (3/24 [12.5%]) is much higher than rates in previously published studies of three to six per 1,000 pregnancies in the general population.2 Uterine rupture in women without a history of cesarean delivery or abdominal myomectomy is exceedingly rare, occurring in only 1 of 5,700 to 1 of 20,000 pregnancies.6,7 Risk factors for a uterine rupture include grand multiparity, advancing maternal age, dystocia resulting in protracted labor, macrosomia, multiple gestation, previous uterine surgery, and abnormal placentation, including placenta accreta, increta, or percreta.6 Diagnosis of uterine rupture can be difficult, with no pathognomonic signs or symptoms. The most reliable sign is development of bradycardia, with or without preceding variable or late decelerations in the fetal heart tracing.8 A suspected uterine rupture is a true obstetric emergency, necessitating immediate maternal surgical intervention and prompt delivery of the fetus.
CASE A 40-year-old woman with a 15-year history of symptomatic uterine leiomyomas and infertility presented to the emergency department of a community hospital with cramping and copious vaginal bleeding with clots. Initial work-up showed stable vital signs and a hematocrit level of 36. An abdominopelvic ultrasound scan revealed a 26-week intrauterine pregnancy with a posterior placenta previa. This was consistent with fundal height. She had never been pregnant and did not know she was pregnant. Surgical history was significant for hysteroscopic myomectomy 10 years previously, followed by uterine artery embolization 6 years previously and subsequent hysteroscopic removal of a retained necrotic leiomyoma 5 years previously. Since completion of these procedures, the patient had oligomenorrhea and was counseled that she would most likely be unable to conceive. The patient was transferred to our tertiary care facility for further evaluation and treatment. She received magnesium sulfate for uterine quiescence and betamethasone for induction of fetal lung maturity. A formal ultrasound scan was repeated at our institution and confirmed an intrauterine singleton pregnancy with normal fetal anatomy, normal amniotic fluid index, and a complete posterior placenta previa. In addition, this ultrasound scan raised a new concern for focal placenta accreta, which was supported by magnetic resonance imaging. Magnesium sulfate was discontinued 48 hours after the first betamethasone injection. The patient’s hospital course was uncomplicated until hospital day 10, when she began to experience painful uterine contractions as well as nonspecific abdominal pain. She was started on nifedipine for symptomatic contractions, with little relief. She then was switched to
OBSTETRICS & GYNECOLOGY
Indocin because of suspicion that degenerating leiomyomas were contributing to her pain and contractions. A repeat ultrasound scan was performed on hospital day 15 because of persistent abdominal pain. Ultrasound findings were significant for anhydramnios as well as dilated maternal bowel loops, consistent with a diagnosis of severe maternal constipation. Anhydramnios was attributed to Indocin use. The patient was started on a bowel regimen that included oral Colace and senna in addition to a bisacodyl suppository. Her abdominal pain improved after successful evacuation of her bowels. On hospital day 17, at a gestational age of 29 1/7 weeks, she had abrupt onset of severe abdominal pain that was unrelieved with narcotics. Fetal heart rate tracing progressed from category 1 to category 2, with intermittent mild variable decelerations but with moderate variability. An immediate fetal ultrasound scan demonstrated fetal parts adjacent to maternal liver edge with no discernible intervening myometrium and copious free fluid in the maternal abdomen. Clinical and ultrasound findings were suspicious for uterine rupture. The patient was transferred rapidly from the ultrasound suite to the operating room, where a midline vertical exploratory laparotomy was performed that revealed freefloating fetal limbs and body, with only the fetal vertex remaining in the uterus. The fetus was delivered easily, with Apgar scores of 5 and 7 at 1 minute and 5 minutes, respectively. Arterial cord gas showed pH of 7.29, pCO2 of 50.7, pO2 of 20, and pHCO3 of 24.8, with base deficit of 2. The placenta was uniformly densely adherent to the posterior uterine wall and thus did not spontaneously separate. Inspection of the uterus revealed two full-thickness myometrial defects consistent with a fundal rupture as well as an anterior rupture. An uncomplicated supracervical hysterectomy was performed for presumed placenta accreta, which was later diagnosed as placenta increta on surgical pathology. Blood loss was estimated to be 3 L. The patient was adequately resuscitated intraoperatively and observed in the intensive care unit for 24 hours postoperatively. She was transferred to the postpartum floor on postoperative day 1. On postoperative day 3, postpartum severe preeclampsia was diagnosed based on elevated blood pressure measurements and elevated liver function test results. She received magnesium sulfate for seizure prophylaxis for 24 hours and was discharged home on postoperative day 7. The newborn did well despite her gestational age of 29 weeks and was discharged home after a 3-week neonatal intensive care unit and 8-week intermediate nursery stay.
tion, with resultant compromise of endometrial perfusion leading to a focal or total absence of the decidua basalis.2 We hypothesize that in addition to leading to abnormal placentation, a compromised endometrium contributed to our patient’s uterine rupture. Uterine rupture has established risk factors as previously stated. Uterine artery embolization is less well-described in the literature as a risk factor for uterine rupture. A case report by Vidal et al9 describes a case of placenta accreta and uterine rupture after uterine artery embolization; however, this patient had a previous classical cesarean delivery. Of note, our patient did have other known risk factors for rupture, including advancing maternal age, abnormal placentation, and a history of hysteroscopic myomectomy. Her first hysteroscopic myomectomy was performed with the goal of maintaining future fertility while providing symptomatic relief from her menorrhagia and bulk symptoms. There is no mention in available records of entry into the uterine cavity or perforation. The patient subsequently underwent uterine artery embolization that was complicated by retained necrotic leiomyomas. Review of her magnetic resonance imaging performed 8 months after her uterine artery embolization demonstrated a retroflexed uterus measuring 93939 cm, which was largely replaced by a large central leiomyoma or conglomeration of leiomyomas. The endometrium was not clearly visualized secondary to compression by the leiomyomas. A hysteroscopy was subsequently performed and pieces of necrotic leiomyoma were removed with forceps. A resectoscope was not used. Although her initial myomectomy may have contributed to weakening her myometrium, we hypothesize that subsequent leiomyoma necrosis after uterine artery embolization led to minimal normal endometrium, thus putting her at high risk for uterine rupture. Additional outcome data after uterine artery embolization are needed before the safety of a subsequent pregnancy can be determined. However, this case points to uterine rupture as an additional risk, particularly in patients with a history of multiple or large leiomyomas given the likelihood of abnormal endometrium.
COMMENT
1. Goldberg J, Pereira L, Berghella V, Diamond J, Daraï E, Seinera P, et al. Pregnancy outcomes after treatment for fibromyomata: uterine artery embolization versus laparoscopic myomectomy. Am J Obstet Gynecol 2004;191:18–21.
REFERENCES Data regarding the safety of pregnancy after uterine artery embolization are limited. Case series have demonstrated increased rates of miscarriage (24%), preterm delivery (16%), postpartum hemorrhage (6%), and abnormal placentation (12.5%).1,2 The Ontario Multicenter Trial posits that the high incidence of abnormal placentation in their series could be directly related to the patient’s history of emboliza-
VOL. 123, NO. 2 PART 2, FEBRUARY 2014
2. Pron G, Mocarski E, Bennett J, Vilos G, Common A, Vanderburgh L. Pregnancy after uterine artery embolization for leiomyomata: the Ontario multicenter trial. Obstet Gynecol 2005;105:67–76. 3. Carpenter T, Walker W. Pregnancy following uterine artery embolization for symptomatic fibroids: a series of 26 completed pregnancies. BJOG 2005;112:321–5.
Yeaton-Massey
Rupture After Uterine Artery Embolization 419
4. Walker W, McDowell S. Pregnancy after uterine artery embolization for leiomyomata: a series of 56 completed pregnancies. Am J Obstet Gynecol 2006;195:1266–71.
7. Porreco RP, Clark SL, Belfort MA, Dildy GA, Meyers JA. The changing specter of uterine rupture. Am J Obstet Gynecol 2009; 200:269.e1-4.
5. Pabon I, Margret J, Unzurrunzaga E, Garcia I, Calatalan I, Vieco M. Pregnancy following uterine fibroid embolization: followup of 100 patients embolized using tris-acryl gelatin microspheres. Fertil Steril 2008;90:2356–60.
8. Leung AS, Leung EK, Paul RH. Uterine rupture after previous cesarean delivery: maternal and fetal consequences. Am J Obstet Gynecol 1993;169:945–50.
6. Walsh CA, Baxi LV. Rupture of the primigravid uterus: a review of the literature. Obstet Gynecol Surv 2007;62: 327–34.
Vaginal Erosion of an Abdominal Cerclage 7 Years After Laparoscopic Placement Eleanor Hawkins, MD, and Michael Nimaroff,
MD
BACKGROUND: With advances in minimally invasive approaches, laparoscopically placed abdominal cerclages are becoming more common. Although not meant to replace vaginally placed cerclages, one potential advantage is reuse in subsequent pregnancies. Their lifespan, potential remote complications, and long-term management remain unexplored. CASE: Reported is a patient with a laparoscopic abdominal cerclage who carried two pregnancies to term. Seven years after initial placement, 3 years after her last delivery, an abscess developed at the cerclage site. Erosion and subsequent expulsion of the cerclage followed. CONCLUSION: The longevity of abdominally placed cerclages is unknown. Placement in the peritoneal cavity reduces suture migration risk, yet tissue degradation may limit the lifespan. Patients with retained abdominal cerclages after completion of childbearing are at risk for remote complications. Closer long-term surveillance on an individual level and a collective level is warranted. (Obstet Gynecol 2014;123:420–3) DOI: 10.1097/AOG.0b013e3182a7114a See related editorial on page 415.
From the North Shore-Long Island Jewish Health System, Manhasset, New York. Corresponding author: Eleanor Hawkins, North Shore University Hospital, 300 Community Dr., 4-Levitt, Manhasset, NY 11030; e-mail: ehawkins@cal. berkeley.edu. Financial Disclosure The authors did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/14
420
Hawkins and Nimaroff
9. Vidal L, Michel E, Gavillon N, Derniaux E, Quereuz C, Graesslin O. Pregnancy after uterine-artery embolization for symptomatic fibroids: a case of placenta accrete with uterine rupture. J Obstet Biol Reprod (Paris) 2008;37:811–4.
C
ervical insufficiency, defined as painless effacement and dilation of the cervix before term, occurs in up to 1% of all pregnancies1,2 and in approximately 8% of patients with repeated midtrimester losses.3 The most common surgical treatment is transvaginal cerclage placement, for which McDonald and Shirodkar developed the two most popular techniques in the 1950s. Success rates of vaginally placed cerclages approach nearly 90%.4 For the subset of women with a short cervix (either congenitally or iatrogenically) or for those whom transvaginal cerclage has previously failed, transabdominally placed cervicoisthmic cerclage is an alternative.5 First described in 1965 by Benson and Durfee,6 the abdominally placed cervical cerclage has a quoted success rate of 81% to 90%.7,8 Recently, the laparoscopic technique for abdominal cerclage placement has gained popularity, reducing the morbidity associated with laparotomy. Blood loss, need for transfusion, and duration of hospitalization have been significantly reduced without compromising outcomes.9,10 The disadvantages of transabdominal placement include a more complex approach and need for cesarean delivery or, less commonly, the need for a subsequent laparotomy or laparoscopy to remove the suture. The unique issues encountered when dealing with second trimester pregnancy loss is another potential disadvantage, although uncommon. Proposed advantages include the ability to achieve closer proximity to the internal os, the ability to reuse the same cerclage in future pregnancies, a decreased risk of suture migration because of intraperiotoneal placement, and a theoretic decreased risk in suture-related infection because of lack of foreign body in communication with the vagina. This case reports a previously undocumented long-term complication of a successful laparoscopic transabdominal cerclage. A systematic Medline search was performed without restriction of publication period or language using the following terms: cervical; cerclage; abdominal; erosion; expulsion; and complication. No similar reports were found.
Laparoscopic Abdominal Cerclage Erosion
OBSTETRICS & GYNECOLOGY
Uterine Rupture After Uterine Artery Embolization for Symptomatic Leiomyomas Amanda Yeaton-Massey, MD, Megan Loring, MD, Shilpa Chetty, MD, and Maurice Druzin, MD BACKGROUND: There are few data regarding safety of pregnancy after uterine artery embolization. However, numerous women desire future fertility after this procedure. Uterine rupture without a history of cesarean delivery or uterine scarring is an exceedingly rare complication in pregnancy. CASE: We report a case of uterine rupture in a primigravid woman after uterine artery embolization. Her pregnancy was also complicated by placenta previa with placenta increta, resulting in a favorable neonatal outcome in an otherwise life-threatening situation for mother and fetus. CONCLUSION: Uterine artery embolization is a risk factor for abnormal placentation and uterine rupture in subsequent pregnancies. (Obstet Gynecol 2014;123:418–20) DOI: 10.1097/AOG.0b013e3182a46df9
T
he safety of pregnancy after uterine artery embolization has not been established. As a result, this procedure typically is reserved for women who do not desire future childbearing. Reported adverse outcomes after uterine artery embolization include miscarriage, preterm delivery, abnormal placentation, and malpresentation.1–5 In a study of 24 pregnancies after uterine artery embolization, there were three cases of abnormal See related editorial on page 415.
From the Stanford University Hospital and Clinics, Lucile Packard Children’s Hospital at Stanford, and the Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford California. Corresponding author: Amanda Yeaton-Massey, MD, Department of Obstetrics and Gynecology, Stanford Hospital and Clinics 300 Pasteur Drive, Mail Code 5317 Stanford, CA 94305-5317; e-mail: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/14
418
VOL. 123, NO. 2 PART 2, FEBRUARY 2014
placentation. This rate of abnormal placentation (3/24 [12.5%]) is much higher than rates in previously published studies of three to six per 1,000 pregnancies in the general population.2 Uterine rupture in women without a history of cesarean delivery or abdominal myomectomy is exceedingly rare, occurring in only 1 of 5,700 to 1 of 20,000 pregnancies.6,7 Risk factors for a uterine rupture include grand multiparity, advancing maternal age, dystocia resulting in protracted labor, macrosomia, multiple gestation, previous uterine surgery, and abnormal placentation, including placenta accreta, increta, or percreta.6 Diagnosis of uterine rupture can be difficult, with no pathognomonic signs or symptoms. The most reliable sign is development of bradycardia, with or without preceding variable or late decelerations in the fetal heart tracing.8 A suspected uterine rupture is a true obstetric emergency, necessitating immediate maternal surgical intervention and prompt delivery of the fetus.
CASE A 40-year-old woman with a 15-year history of symptomatic uterine leiomyomas and infertility presented to the emergency department of a community hospital with cramping and copious vaginal bleeding with clots. Initial work-up showed stable vital signs and a hematocrit level of 36. An abdominopelvic ultrasound scan revealed a 26-week intrauterine pregnancy with a posterior placenta previa. This was consistent with fundal height. She had never been pregnant and did not know she was pregnant. Surgical history was significant for hysteroscopic myomectomy 10 years previously, followed by uterine artery embolization 6 years previously and subsequent hysteroscopic removal of a retained necrotic leiomyoma 5 years previously. Since completion of these procedures, the patient had oligomenorrhea and was counseled that she would most likely be unable to conceive. The patient was transferred to our tertiary care facility for further evaluation and treatment. She received magnesium sulfate for uterine quiescence and betamethasone for induction of fetal lung maturity. A formal ultrasound scan was repeated at our institution and confirmed an intrauterine singleton pregnancy with normal fetal anatomy, normal amniotic fluid index, and a complete posterior placenta previa. In addition, this ultrasound scan raised a new concern for focal placenta accreta, which was supported by magnetic resonance imaging. Magnesium sulfate was discontinued 48 hours after the first betamethasone injection. The patient’s hospital course was uncomplicated until hospital day 10, when she began to experience painful uterine contractions as well as nonspecific abdominal pain. She was started on nifedipine for symptomatic contractions, with little relief. She then was switched to
OBSTETRICS & GYNECOLOGY
Indocin because of suspicion that degenerating leiomyomas were contributing to her pain and contractions. A repeat ultrasound scan was performed on hospital day 15 because of persistent abdominal pain. Ultrasound findings were significant for anhydramnios as well as dilated maternal bowel loops, consistent with a diagnosis of severe maternal constipation. Anhydramnios was attributed to Indocin use. The patient was started on a bowel regimen that included oral Colace and senna in addition to a bisacodyl suppository. Her abdominal pain improved after successful evacuation of her bowels. On hospital day 17, at a gestational age of 29 1/7 weeks, she had abrupt onset of severe abdominal pain that was unrelieved with narcotics. Fetal heart rate tracing progressed from category 1 to category 2, with intermittent mild variable decelerations but with moderate variability. An immediate fetal ultrasound scan demonstrated fetal parts adjacent to maternal liver edge with no discernible intervening myometrium and copious free fluid in the maternal abdomen. Clinical and ultrasound findings were suspicious for uterine rupture. The patient was transferred rapidly from the ultrasound suite to the operating room, where a midline vertical exploratory laparotomy was performed that revealed freefloating fetal limbs and body, with only the fetal vertex remaining in the uterus. The fetus was delivered easily, with Apgar scores of 5 and 7 at 1 minute and 5 minutes, respectively. Arterial cord gas showed pH of 7.29, pCO2 of 50.7, pO2 of 20, and pHCO3 of 24.8, with base deficit of 2. The placenta was uniformly densely adherent to the posterior uterine wall and thus did not spontaneously separate. Inspection of the uterus revealed two full-thickness myometrial defects consistent with a fundal rupture as well as an anterior rupture. An uncomplicated supracervical hysterectomy was performed for presumed placenta accreta, which was later diagnosed as placenta increta on surgical pathology. Blood loss was estimated to be 3 L. The patient was adequately resuscitated intraoperatively and observed in the intensive care unit for 24 hours postoperatively. She was transferred to the postpartum floor on postoperative day 1. On postoperative day 3, postpartum severe preeclampsia was diagnosed based on elevated blood pressure measurements and elevated liver function test results. She received magnesium sulfate for seizure prophylaxis for 24 hours and was discharged home on postoperative day 7. The newborn did well despite her gestational age of 29 weeks and was discharged home after a 3-week neonatal intensive care unit and 8-week intermediate nursery stay.
tion, with resultant compromise of endometrial perfusion leading to a focal or total absence of the decidua basalis.2 We hypothesize that in addition to leading to abnormal placentation, a compromised endometrium contributed to our patient’s uterine rupture. Uterine rupture has established risk factors as previously stated. Uterine artery embolization is less well-described in the literature as a risk factor for uterine rupture. A case report by Vidal et al9 describes a case of placenta accreta and uterine rupture after uterine artery embolization; however, this patient had a previous classical cesarean delivery. Of note, our patient did have other known risk factors for rupture, including advancing maternal age, abnormal placentation, and a history of hysteroscopic myomectomy. Her first hysteroscopic myomectomy was performed with the goal of maintaining future fertility while providing symptomatic relief from her menorrhagia and bulk symptoms. There is no mention in available records of entry into the uterine cavity or perforation. The patient subsequently underwent uterine artery embolization that was complicated by retained necrotic leiomyomas. Review of her magnetic resonance imaging performed 8 months after her uterine artery embolization demonstrated a retroflexed uterus measuring 93939 cm, which was largely replaced by a large central leiomyoma or conglomeration of leiomyomas. The endometrium was not clearly visualized secondary to compression by the leiomyomas. A hysteroscopy was subsequently performed and pieces of necrotic leiomyoma were removed with forceps. A resectoscope was not used. Although her initial myomectomy may have contributed to weakening her myometrium, we hypothesize that subsequent leiomyoma necrosis after uterine artery embolization led to minimal normal endometrium, thus putting her at high risk for uterine rupture. Additional outcome data after uterine artery embolization are needed before the safety of a subsequent pregnancy can be determined. However, this case points to uterine rupture as an additional risk, particularly in patients with a history of multiple or large leiomyomas given the likelihood of abnormal endometrium.
COMMENT
1. Goldberg J, Pereira L, Berghella V, Diamond J, Daraï E, Seinera P, et al. Pregnancy outcomes after treatment for fibromyomata: uterine artery embolization versus laparoscopic myomectomy. Am J Obstet Gynecol 2004;191:18–21.
REFERENCES Data regarding the safety of pregnancy after uterine artery embolization are limited. Case series have demonstrated increased rates of miscarriage (24%), preterm delivery (16%), postpartum hemorrhage (6%), and abnormal placentation (12.5%).1,2 The Ontario Multicenter Trial posits that the high incidence of abnormal placentation in their series could be directly related to the patient’s history of emboliza-
VOL. 123, NO. 2 PART 2, FEBRUARY 2014
2. Pron G, Mocarski E, Bennett J, Vilos G, Common A, Vanderburgh L. Pregnancy after uterine artery embolization for leiomyomata: the Ontario multicenter trial. Obstet Gynecol 2005;105:67–76. 3. Carpenter T, Walker W. Pregnancy following uterine artery embolization for symptomatic fibroids: a series of 26 completed pregnancies. BJOG 2005;112:321–5.
Yeaton-Massey
Rupture After Uterine Artery Embolization 419
4. Walker W, McDowell S. Pregnancy after uterine artery embolization for leiomyomata: a series of 56 completed pregnancies. Am J Obstet Gynecol 2006;195:1266–71.
7. Porreco RP, Clark SL, Belfort MA, Dildy GA, Meyers JA. The changing specter of uterine rupture. Am J Obstet Gynecol 2009; 200:269.e1-4.
5. Pabon I, Margret J, Unzurrunzaga E, Garcia I, Calatalan I, Vieco M. Pregnancy following uterine fibroid embolization: followup of 100 patients embolized using tris-acryl gelatin microspheres. Fertil Steril 2008;90:2356–60.
8. Leung AS, Leung EK, Paul RH. Uterine rupture after previous cesarean delivery: maternal and fetal consequences. Am J Obstet Gynecol 1993;169:945–50.
6. Walsh CA, Baxi LV. Rupture of the primigravid uterus: a review of the literature. Obstet Gynecol Surv 2007;62: 327–34.
Vaginal Erosion of an Abdominal Cerclage 7 Years After Laparoscopic Placement Eleanor Hawkins, MD, and Michael Nimaroff,
MD
BACKGROUND: With advances in minimally invasive approaches, laparoscopically placed abdominal cerclages are becoming more common. Although not meant to replace vaginally placed cerclages, one potential advantage is reuse in subsequent pregnancies. Their lifespan, potential remote complications, and long-term management remain unexplored. CASE: Reported is a patient with a laparoscopic abdominal cerclage who carried two pregnancies to term. Seven years after initial placement, 3 years after her last delivery, an abscess developed at the cerclage site. Erosion and subsequent expulsion of the cerclage followed. CONCLUSION: The longevity of abdominally placed cerclages is unknown. Placement in the peritoneal cavity reduces suture migration risk, yet tissue degradation may limit the lifespan. Patients with retained abdominal cerclages after completion of childbearing are at risk for remote complications. Closer long-term surveillance on an individual level and a collective level is warranted. (Obstet Gynecol 2014;123:420–3) DOI: 10.1097/AOG.0b013e3182a7114a See related editorial on page 415.
From the North Shore-Long Island Jewish Health System, Manhasset, New York. Corresponding author: Eleanor Hawkins, North Shore University Hospital, 300 Community Dr., 4-Levitt, Manhasset, NY 11030; e-mail: ehawkins@cal. berkeley.edu. Financial Disclosure The authors did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/14
420
Hawkins and Nimaroff
9. Vidal L, Michel E, Gavillon N, Derniaux E, Quereuz C, Graesslin O. Pregnancy after uterine-artery embolization for symptomatic fibroids: a case of placenta accrete with uterine rupture. J Obstet Biol Reprod (Paris) 2008;37:811–4.
C
ervical insufficiency, defined as painless effacement and dilation of the cervix before term, occurs in up to 1% of all pregnancies1,2 and in approximately 8% of patients with repeated midtrimester losses.3 The most common surgical treatment is transvaginal cerclage placement, for which McDonald and Shirodkar developed the two most popular techniques in the 1950s. Success rates of vaginally placed cerclages approach nearly 90%.4 For the subset of women with a short cervix (either congenitally or iatrogenically) or for those whom transvaginal cerclage has previously failed, transabdominally placed cervicoisthmic cerclage is an alternative.5 First described in 1965 by Benson and Durfee,6 the abdominally placed cervical cerclage has a quoted success rate of 81% to 90%.7,8 Recently, the laparoscopic technique for abdominal cerclage placement has gained popularity, reducing the morbidity associated with laparotomy. Blood loss, need for transfusion, and duration of hospitalization have been significantly reduced without compromising outcomes.9,10 The disadvantages of transabdominal placement include a more complex approach and need for cesarean delivery or, less commonly, the need for a subsequent laparotomy or laparoscopy to remove the suture. The unique issues encountered when dealing with second trimester pregnancy loss is another potential disadvantage, although uncommon. Proposed advantages include the ability to achieve closer proximity to the internal os, the ability to reuse the same cerclage in future pregnancies, a decreased risk of suture migration because of intraperiotoneal placement, and a theoretic decreased risk in suture-related infection because of lack of foreign body in communication with the vagina. This case reports a previously undocumented long-term complication of a successful laparoscopic transabdominal cerclage. A systematic Medline search was performed without restriction of publication period or language using the following terms: cervical; cerclage; abdominal; erosion; expulsion; and complication. No similar reports were found.
Laparoscopic Abdominal Cerclage Erosion
OBSTETRICS & GYNECOLOGY
