What to do with a transabdominal cerclage if labor cannot be stopped?

Management of Transabdominal Cerclage When Labor Cannot Be Stopped

When labor cannot be stopped in a patient with a transabdominal cerclage (TAC), the cerclage should be left in place and delivery should proceed via cesarean section, as removal requires laparotomy and poses unnecessary risks to the mother.

Decision Algorithm for TAC Management in Labor

Assessment Phase

1. Confirm that labor is truly unstoppable:

   • Verify failed tocolysis
   • Assess cervical dilation and effacement
   • Evaluate contraction frequency and intensity

2. Determine gestational age:

   • If <24 weeks: Consider risks/benefits of intervention based on viability
   • If ≥24 weeks: Proceed with delivery planning

Management Options

Option 1: Leave TAC in place (RECOMMENDED)

• Proceed directly to cesarean delivery
• Benefits:
  • Avoids additional surgical procedure for cerclage removal
  • Reduces risk of maternal infectious morbidity
  • Preserves cerclage for future pregnancies
  • Minimizes operative time during active labor

Option 2: Remove TAC (NOT RECOMMENDED in active labor)

• Would require laparoscopy or laparotomy prior to delivery
• Significant disadvantages:
  • Increased surgical time during emergency
  • Additional anesthesia exposure
  • Increased blood loss
  • Higher risk of surgical complications
  • Loss of cerclage for future pregnancies

Evidence-Based Rationale

The Society for Maternal-Fetal Medicine (SMFM) guidelines recommend cesarean delivery between 37 0/7 and 39 0/7 weeks for patients with a transabdominal cerclage in situ 1. This recommendation acknowledges that TAC cannot be removed vaginally like transvaginal cerclage.

Unlike transvaginal cerclage, where there is reasonable evidence supporting either removal or retention in cases of preterm prelabor rupture of membranes (PPROM) 2, transabdominal cerclage requires a more invasive procedure for removal. The SMFM specifically notes that TAC requires cesarean delivery as it cannot be removed without surgery 1.

Important Considerations

• Future pregnancies: Leaving the TAC in place preserves it for subsequent pregnancies, which is particularly important given the high success rates of TAC in preventing preterm birth (92% delivery rate ≥32 weeks) 3.

• Surgical risks: Attempting to remove a TAC during active labor adds unnecessary surgical complexity and risk when cesarean delivery is already required.

• Maternal safety: The primary focus should be on safe delivery with minimal additional procedures during the emergency of unstoppable labor.

Pitfalls to Avoid

1. Do not attempt vaginal delivery with TAC in place as this can lead to severe cervical trauma, hemorrhage, and poor outcomes.

2. Do not delay cesarean delivery to attempt TAC removal, as this increases risks to both mother and fetus.

3. Do not confuse management protocols between transvaginal and transabdominal cerclage - they require different approaches due to their anatomical placement and surgical access.

In summary, when labor cannot be stopped in a patient with transabdominal cerclage, proceed directly to cesarean delivery while leaving the cerclage in place to minimize maternal morbidity and preserve the cerclage for future pregnancies.