How to manage a second trimester abortion with a transabdominal (around the abdomen) cerclage (cervical stitch) in place?

Management of Second Trimester Abortion with Transabdominal Cerclage

For a second trimester abortion in a patient with a transabdominal cerclage in place, the recommended approach is dilation and evacuation (D&E) through the cerclage rather than performing a hysterotomy, as this preserves the cerclage for future pregnancies. 1

Understanding Transabdominal Cerclage in the Context of Abortion

Transabdominal cerclage is typically placed in patients with:

• History of failed transvaginal cerclage
• Anatomical limitations preventing transvaginal cerclage
• Severe cervical insufficiency

Unlike transvaginal cerclage, transabdominal cerclage:

• Cannot be easily removed
• Is designed to remain in place between pregnancies
• Typically requires cesarean delivery for subsequent births

Procedural Considerations

Medical vs. Surgical Options

1. Surgical approach (Preferred):

   • D&E is the procedure of choice for second trimester surgical abortion 2
   • Can be performed through the cerclage without removing it 1
   • Requires an experienced provider skilled in complex D&E procedures
   • Adequate cervical preparation is essential for safety 2

2. Medical approach (Alternative):

   • Less preferred with transabdominal cerclage in place
   • If used, a mifepristone and misoprostol regimen is recommended 2
   • Where mifepristone is unavailable, misoprostol alone can be used 2
   • May be more complicated with cerclage in place

Important Procedural Elements

• Ultrasound guidance: Essential during the procedure to visualize the cerclage and ensure safe evacuation
• Pain management: Adequate analgesia or anesthesia is crucial
• Specialized instruments: May require specific instruments to navigate around the cerclage
• Experienced provider: Should be performed by a provider with experience in complex D&E procedures

Post-Procedure Considerations

• Infection prevention: Prophylactic antibiotics should be administered
• Follow-up ultrasound: To confirm complete evacuation and cerclage integrity
• Future pregnancy planning: Counseling about the retained cerclage and its implications for future pregnancies

Clinical Evidence and Case Experience

The literature specifically addressing second trimester abortion with transabdominal cerclage in place is limited. However, case reports demonstrate that D&E can be successfully performed through a transabdominal cerclage without compromising the cerclage's integrity 1. In one documented case, a successful full-term pregnancy was achieved following a mid-trimester D&E performed through a transabdominal cerclage at 18 weeks gestation 1.

Common Pitfalls to Avoid

• Attempting cerclage removal: Unlike transvaginal cerclage, transabdominal cerclage should not be removed during the abortion procedure
• Performing unnecessary hysterotomy: Historically, hysterotomy was considered but is no longer recommended as the first approach 1
• Inadequate provider experience: This procedure requires specialized skills and should be performed by experienced providers
• Insufficient imaging: Lack of proper ultrasound guidance increases procedural risks

The evidence suggests that with proper technique and experienced providers, D&E through a transabdominal cerclage is feasible and preserves the cerclage for future pregnancies, which is particularly important given the specialized nature and surgical complexity of transabdominal cerclage placement.