Management of Twin Pregnancy Complications Amid COVID-19: Posterior Colpotomy Approach for Abdominal Cerclage Removal at 18 Weeks Gestation – A Case Report

Background

Recurrent mid-trimester loss and spontaneous preterm birth are complications encountered in 1% of couples that are seeking fertility [1]. Major causes of these complications include cervical incompetence and anatomical deformities, whether congenital or due to surgeries on the cervix, such as radical trachelectomy or conization procedures [2].

Abdominal cerclage is a surgical approach offered to patients with cervical incompetence to prevent these obstetrical issue [3–5]. The transvaginal approach is the primary approach and has been demonstrated to reduce delivery prior to 35 weeks of gestation in patients with an incompetent cervix [3]. The transvaginal approach is not always feasible in patients with a short or absent cervix with prior failed vaginal cerclage, and abdominal cerclage will become the preferable approach for these patients [6]. Abdominal cerclage was first introduced by Benson and Durfee in 1965 and allows the placement of a nonabsorbable suture at the cervicoisthmic junction. It is associated with a lower incidence of ascending infection or pre-term labor and premature rupture of membranes than the transvaginal route [6].

Transabdominal cerclage can be done either by laparotomy or with a minimally invasive technique, such as laparoscopy or robotics, which offer the opportunity to avoid a large abdominal incision and result in a much shorter hospital stay, a faster recovery, and better cosmesis [6–8]. Most of these laparoscopic procedures are reported to have been placed pre-conceptionally owing to concerns that laparoscopic manipulation of the pregnant uterus can increase the risk of post-procedure pregnancy loss [6]. Preconceptional or interval cerclage placement is preferred to conceptional cerclage and is technically less challenging because of the absence of the gravid uterus [6]. Abdominal cerclages could be left in place and used for future pregnancies, and the patient would deliver by cesarean delivery [6]. Some mid-trimester complications in pregnancy, including rupture of membranes, intrauterine infection, and fetal loss, require the removal of the cerclage and vaginal delivery to avoid the morbidity of a hysterotomy [6]. Many techniques have been described for removal of an abdominal cerclage, including laparotomy and laparoscopy, which can be challenging, especially with a gravid uterus, and carry higher morbidity [6]. A posterior colpotomy approach is an option. This technique has been performed in very few cases and requires surgical skills and a familiarity with the anatomical challenges [6]. This report presents the case of a 31-year-old woman with COVID-19 disease and chorioamnionitis at 18 weeks of gestation with a twin pregnancy who underwent abdominal cerclage for cervical incompetence and for whom a posterior colpotomy approach was used and was successful in the removal of the patient’s abdominal cerclage.

Case Report

A 31-year-old healthy patient G2P0010 was referred at 18 weeks + 3 days of gestation with a twin pregnancy (conceived by in vitro fertilization) for preterm premature rupture of membranes of the presenting fetus (fetus A). There were no drug allergies and no medical problems in her medical history. Her past gynecological surgical history consisted of a dilation and curettage for a missed abortion, a colposcopy, a conization of the cervix, and 3 laparoscopic surgeries, including laparoscopic cholecystectomy, laparoscopic ovarian cystectomy, and laparoscopic placement of a preconception abdominal cerclage.

Her laparoscopic abdominal cerclage was performed 2 months before her embryo transfer preconception due to a distortion in the anatomy of her cervix that resulted from the cervical conization procedure performed 4 years earlier for a CIN3 found on biopsy.

The patient arrived to our COVID Unit on day 4 of ruptured membranes with COVID-19 symptoms, including rhinorrhea and nasal congestion. She had a positive polymerase chain reaction test (CT 29) by means of an authorized nasal swab done in the COVID Unit. Upon presentation, the patient was hemodynamically stable and normotensive, with sinus tachycardia of 130 beats per min (bpm), no fever, and normal oxygen saturation. She denied abdominal pain and contractions. The review of systems was otherwise normal. Routine laboratory tests, urine analysis, and urine and vaginal cultures were sent. Intravenous (i.v.) cannula and hydration was started, a dose of the broad-spectrum antibiotic cefazolin 2 g i.v. was given, and the Infectious Disease team was consulted.

A few hours after admission, the patient started to experience high grade fevers and abdominal tenderness, with hypotension and persistent tachycardia. The working diagnosis at this stage became chorioamnionitis, and the patient was given gentamycin and ampicillin antibiotics. The patient was transferred to the ward after she was stabilized, the pain decreased, and fever had subsided.

On the same day of admission, when the patient was transferred to the ward, bedside ultrasonography was performed and showed an absent fetal heart rate (FHR) in the presenting fetus (fetus A) and positive FHR in the second fetus (fetus B). Speculum examination showed pooling of amniotic fluid of grey coloration, which was not foul smelling at this point, no bulging membranes, and closed irregular looking cervix. Laboratory test results showed the following values: white blood cell count 17.89, neutrophils 79.3, hemoglobin 11.6 g/dL, platelets 173×109/L, C-reactive protein 13.03 mg/dL, creatinine 0.58 mg/dL, lipase 22 U/L, D-dimer 6.86 mg/dL, procalcitonin 7.6 ng/mL, and potassium 3.3 mEq/L. Her urine analysis was positive, the urine culture showed E. Coli sensitive to gentamicin, and her vaginal culture had no growth.

On day 2 of admission, abdominal ultrasonography (Figure 1) was performed and revealed the following in fetus A (presenting fetus): intrauterine fetal demise with minimal amniotic fluid and a low posterior placenta in contact with the placenta of fetus B. Fetus B had a positive FHR and normal placenta with normal amniotic fluid. Upon returning to the ward, the patient felt pelvic pressure and upon urination and had a sudden sensation of a structure presenting from the vaginal introitus. On physical examination, a part of a cord was seen outside of the introitus, and a speculum examination was performed, revealing a distorted cervix with an extruding umbilical cord (Figure 2). Close monitoring was continued. Her laboratory test results that day showed the following values: hemoglobin 9.6 g/dL, platelets 123×109/L, C-reactive protein 15.4 mg/dL, and procalcitonin >100 ng/mL. Here vital signs were blood pressure 96/54 mmHg, heart rate 130 bpm, and temperature 39°C, corrected. At this stage we had a unclear diagnosis (COVID-19 complication vs chorioamnionitis), which is why a multidisciplinary decision was made to wait a bit before further intervention, especially because her fever was subsiding on medical treatment.

She experienced intermittent fever throughout her stay, and her inflammatory markers were trending upward. On day 3 of her stay, abdominal ultrasonography revealed oligohydramnios around the viable fetus (fetus B), which then progressed to anhydramnios on the next day, with a persistent and positive FHR. The patient was counseled about the low chances of fetal survival and the potential maternal morbidity and mortality. She opted for delivery. After discussing the abdominal cerclage knot placement, the decision was made to proceed with a posterior colpotomy approach to remove the suture.

Upon presentation to the operating room, the patient had tachycardia, with a heart rate between 115 and 130 bpm. Her blood pressure ranged between 120/65 and 145/90 mmHg, SpO2 was 97% on room air, and she was afebrile.

Spinal anesthesia was administered, and the patient was hemodynamically stable throughout the entire procedure. The patient was placed in the lithotomy position, and scrubbing and draping were performed. The posterior cul de sac was exposed using vaginal retractors. Some minimal fetal tissue of the presenting demised fetus was identified abutting from the external cervical os with a severely foul-smelling odor that was noted when the tissue was removed.

A vertical incision into the posterior vaginal fornix and peritoneum was done for better exposure, as was performed in the only reported similar successful cases, followed by opening to the pouch of Douglas. Then, digital identification of the cervical cerclage knot (prolene 1 suture) was performed. The suture was then cut and pulled out in its entirety. Hemostasis was secured and closure of incised parietal peritoneum and vaginal mucosa was done using vicryl 0 urologic resorbable suture.

The operative time was 25 min, and the estimated blood loss was 50 mL (Figure 3).

The cervix was closely examined and found to be 3 cm dilated. Intraoperatively, abdominal ultrasonography showed the second fetus B with a positive FHR, far from the cervical os, along with some retained parts of presenting fetus A noted below the living one.

The patient consented to proceed with termination of the pregnancy. An oxytocin infusion was started, 20 units in her i.v. line over 8 h continued as such, and 800 mcg of misoprostol (Cytotec) administered rectally was used. Then 400 mcg misoprostol was continued orally and rectally every 4 h.

Intravenous gentamycin (360 mg), ampicillin (2 g). and clindamycin (900 mg) were given preoperatively due to suspected chorioamnionitis and were to be continued postoperatively to prevent endometritis or pelvic peritonitis risk post chorioamnionitis.

The patient had a complete expulsion of the remaining fetal tissue a few hours after cerclage removal. The placenta of the second fetus were still in place until postoperative day 1. A manual revision was performed to extract the placenta in its entirety. Two units of blood were transfused due to 500 mL blood loss during expulsion and a hemoglobin level drop from 9.6 to 7.9 g/dL. Pelvic ultrasonography was done on postoperative day 2 to check for retained tissue; no retained tissue was present.

The decision was made to discharge the patient on postoperative day 3, since she had been afebrile for the last 48 h.

Discussion

An abdominal cerclage is performed when one or more previous vaginal cerclages have failed and has proven to be more efficient than repeated vaginal cerclage trials [9]. In some instances, an abdominal cerclage is placed when there is an extreme cervical deformity, either congenital or after cervical manipulations, that prevents the surgeon from achieving a successful vaginal cerclage [10]. Some of the advantages of an abdominal cerclage over a vaginal one include higher positioning of the cerclage stitch over the cervix, lower risk of slipping, more or less permanence, and consistency over multiple pregnancies without the need to remove it [11]. Studies have shown preconception cerclage placement to be superior to postconception cerclage placement due to the associated risks implicated on a gravid uterus and ongoing pregnancy [10].

Placement of an abdominal cerclage can be performed either by laparotomy or laparoscopy [12]. The latter approach is preferred owing to the lower morbidity and mortality, reduced blood loss, fewer wound complications, faster recovery, and better visualization of the pelvic anatomy, avoiding uterine vessel injury [12].

An abdominal cerclage can also be placed with robotic assistance of a laparoscopic approach, as presented in many case reports and case series that showed good outcomes [10,13]. Many variations of the technique in knot placement have been proposed for laparoscopic cerclage placement [11,14]. The first involves dissection into the vesicouterine peritoneum and exposing the uterine vessels anteriorly and bilaterally [11,14]. At the level of the uterine isthmus at 1.5 cm superior and 1 cm lateral to the insertion of the uterosacral ligament, a non-absorbable Mersilene polyester suture (used due to its minimal tissue reactivity and its durability) is used. It is passed medial to the uterine vessels posterior to anterior, the knot is tied anterior to the cervix around 6 squared knots, and the suture is cut 1 cm above the last knot [11,14]. Another variation used involves the same dissection of the vesicouterine peritoneum followed by anterior to posterior slipping of the cerclage tape, with the knot being tied posterior to the cervix [11,14].

Posterior is preferred in preconception cerclage and anterior in postconception cerclage, owing to impossibility of placing the knot posteriorly due to the challenges posed by visualization and the gravid uterus [14].

The benefits of posterior knot placement over anterior are the following: easier access if colpotomy removal of cerclage is considered, lower risk of adhesions to adjacent structures, and lower chances of erosion of suture into the bladder [14]. The benefits of the anterior knot technique over posterior technique include avoiding adhesions in the pouch of Douglas and easy removal by laparoscopy [14].

The need to remove an abdominal cerclage is determined on a case-by-case basis in patients with conditions including intrauterine fetal demise or chorioamnionitis [9,15]. There are different removal approaches described through laparotomy, laparoscopy, and colpotomy. Concomitant removal of the cerclage during cesarean delivery remains the most common approach; however in cases in which cesarean delivery is not essential, a minimally invasive option, vaginal or laparoscopy, is preferred [9,15]. The advantages of a laparoscopic removal are to avoid laparotomy and the need for a second trimester hysterotomy to deliver a fetus when needed [9,16].

On the other hand, the disadvantages are pulmonary stress due to pneumoperitoneum and hypercarbia, necessity of undergoing general anesthesia with its associated risks, possible CO2 embolization, and higher costs needed for this type of surgery [15,17].

Owing to these complications, another technique of removal of an abdominally placed cerclage has been recently implemented [6]. A more minimally invasive technique, colpotomy, is more favorable in terms of current and future maternal pregnancy outcomes [6]. Vaginal cerclage removal has an added value over laparotomy or laparoscopy approaches, during which general anesthesia is the only anesthesia type that can be done [6]. It is specifically important in COVID-19 cases, in which regional anesthesia is required for the patient’s well-being and to decrease intraoperative morbidity [6].

A colpotomy for abdominal cerclage removal has been rarely used thus far; however, this technique offers many benefits to the surgeon and the patient [6]. It is the least invasive of all approaches to remove the cerclage when chorioamnionitis, premature rupture of membranes, fetal demise, or failure of the cerclage in a second trimester of pregnancy are encountered and it can be done under regional anesthesia when needed (ie, COVID-19-complicated case) [6]. The advantages of such an approach are shorter surgical procedure time (minimal blood loss), one site incision, better cosmesis, lower risk of adhesions formation and pelvic organ injury, and better cost effectiveness, with very minimal material used [6]. Few cases of colpotomy have been reported to date, and spinal anesthesia was performed on all of these patients, which holds less risks than general anesthesia, which is inevitably done in laparoscopy. Most importantly, colpotomy can spare the patient a hysterotomy, and allows us to vaginally deliver the fetus when the situation demands [6]. This was the case in our patient, who underwent vaginal expulsion after abdominal cerclage removal by colpotomy, as was done in the few described cases of cerclage removal by colpotomy [6].

However, some disadvantages might prevent this procedure from being performed, including the need of a well-trained surgeon familiar with these vaginal surgery techniques, owing to the narrow operative field of view encountered and low exposure thus faced, risk of rectal injury with dissection posteriorly, difficulty of finding the suture when fibrosis of tissue around it is present, especially in previously placed long-term cerclage, and easier access to a posterior knot placement than to an anterior one, with which there is a higher risk of bladder injury [6].

Conclusions

An abdominal cerclage can be removed by posterior colpotomy, sparing all the risks of laparoscopic removal of abdominal cerclage, or by laparotomy/cesarean delivery, with faster recovery, lower cost, and fewer long-term adverse effects, such as abdominal adhesions [7,10]. This surgery requires a clear operative strategy and superior vaginal operating skills, which could be its limiting factors if not being done often [6]. Another point to keep in mind is that ideally a posterior knot placement should be considered when first placing an abdominal cerclage to be able to easily remove it by posterior colpotomy, thereby carrying fewer risks for the patient [6].