title: Abdominal versus vaginal cerclage after a failed transvaginal cerclage: a systematic review.
abstract: OBJECTIVE
  The purpose of this study was to compare the outcomes of pregnancy after transabdominal cerclage versus after transvaginal cerclage in patients with a failed transvaginal cerclage during a previous pregnancy.
  
  
  METHODS
  MEDLINE and EMBASE were searched in English. We included studies that reported perinatal and/or maternal outcomes in women who had a transabdominal cerclage or a transvaginal cerclage placed at or before 20 weeks of gestation, after having had a failed nonemergent transvaginal cerclage in a previous pregnancy. Data were included for individual patients if they met the inclusion criteria, and their outcomes were reported separately. We excluded patients with cervical amputation because transvaginal cerclage is not an option for these women because of technical difficulty.
  
  
  RESULTS
  Fourteen studies met the inclusion criteria. Thirteen of the studies were case series (12 retrospective and 1 prospective), and one study was a retrospective cohort study. In total, 157 women in the studies had a failed vaginal cerclage in a previous pregnancy; 117 women had a subsequent transabdominal cerclage; 40 women had a subsequent transvaginal cerclage. The likelihood of perinatal death or delivery at <24 weeks was 6.0% (95% CI, 3.8%-8.2%) after transabdominal cerclage and 12.5% (95% CI, 2.7%-22.7%) after transvaginal cerclage. The likelihood of serious operative complications after transabdominal cerclage was 3.4% (95% CI, 0.01%, 6.8%). There were no serious operative complications after transvaginal cerclage.
  
  
  CONCLUSIONS
  Transabdominal cerclage may be associated with a lower risk of perinatal death or delivery at <24 weeks of gestation, but it may be associated with a higher risk of serious operative complications. A multicenter randomized controlled trial should be conducted to address this question.
authors.affiliation: Department of Obstetrics and Gynecology, Sunnybrook and Women's College Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Veena
authors.initials: V
authors.lastname: Zaveri
authors.forename: Fariba
authors.initials: F
authors.lastname: Aghajafari
authors.forename: Kofi
authors.initials: K
authors.lastname: Amankwah
authors.forename: Mary
authors.initials: M
authors.lastname: Hannah
mesh_terms: D000005:Abdomen; D023802:Cerclage, Cervical / Q000379:methods*; D005260:Female; D006801:Humans; D007226:Infant Mortality; D007231:Infant, Newborn; D016013:Likelihood Functions; D011247:Pregnancy; D011256:Pregnancy Outcome; D019233:Retreatment; D017211:Treatment Failure; D014621:Vagina