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Transabdominal Cerclage right place at the right time

Declaration of Interests. Act as NICE GDG member on pain and bleeding in early pregnancy (2010-2012)Executive Committee member, ESHRE (2011-)Chair, AEPU (2006-2011)No external funding/payments received from organisations or Pharma companies. Opportunityisnowhere. TVU of Open Cervix at 16 weeks. Lecture content Timeline.

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Transabdominal Cerclage right place at the right time

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    1. Transabdominal Cerclage right place at the right time Roy G Farquharson MD FRCOG Miscarriage Clinic Liverpool Womens Hospital, UK Contact: rgfarquharson@yahoo.com

    2. Declaration of Interests Act as NICE GDG member on pain and bleeding in early pregnancy (2010-2012) Executive Committee member, ESHRE (2011-) Chair, AEPU (2006-2011) No external funding/payments received from organisations or Pharma companies

    4. TVU of Open Cervix at 16 weeks

    5. Lecture content Timeline Prepregnancy assessments Early pregnancy Midtrimester loss recurrence Obstetric outcomes Achieving Optimal Standards Quality assessment

    6. Historical Perspective (Cervical Weakness) Described in 1658 by Grant: the orifice of the womb is so slack that it cannot rightly contract itself to keep in the seed; which is chiefly caused by abortion or hard labour and childbirth, whereby the fibres of the womb are broken in pieces from one another and they, and the inner orifice of the womb overmuch slackened.

    7. The Patients Journey following spontaneous or ART conception It is always a good thing to walk a mile in another mans shoes Nelson Mandela Long Walk to Freedom: The view from Robben Island Prison

    8. Clinical Event Sequence (CES) - relating symptoms & signs to pathology

    9. Standardised Investigation Protocol Consecutive cases of second trimester loss cohort Continuous Care provision by specialist team at one hospital (Liverpool Womens Hospital) Universal application of standardised investigation pathway BEFORE conception of index pregnancy Management plan constructed after completion of full investigation prepregnancy References: Transabdominal cerclage: the significance of dual pathology and increased preterm delivery, BJOG, 2005, 112, 1424-26 The incompetent cervix in The Cervix, Second edition, 2006, Editors Jordan, Singer, Jones and Shafi, Blackwell Publishing, p194-205 Recurring Miscarriage in High Risk Pregnancy, Fourth Edition, 2010, Editors James, Steer, Weiner & Gonik. Elsevier, p75-97. Late Pregnancy Loss in Early Pregnancy, 2010, Editors Farquharson & Stephenson, Cambridge University Press, p 277-286 The investigation and treatment of couples with recurrent first trimester and second trimester miscarriage. RCOG Green-top Guideline No 17,.RCOG Press, London. April 2011

    10. First Presentation with Midtrimester Loss (MTL) ~2% risk between 12 & 24 weeks gestation for general population

    11. Mid-trimester Loss consecutive cohort at Liverpool Womens 1988 -2010 (n=540)

    12. Investigation Protocols for MTL Non-uniform Inconsistent Restricted testing of important variables and causative factors Small cohort analysis & description Randomised trials - rare

    13. Investigation Protocols for Published Vaginal or Abdominal Cerclage Studies

    15. Standards for Testing APS Testing - Sampling to Lab transit time (LAC activity disappears after 4 hours) - Sample spun then frozen at -70C - Laboratory Quality control (between 5 and 15 % of RM cohorts have positive APS: does your lab under-report?)

    17. Next Pregnancy APS and BV screening essential SINGLE embryo transfer (SET) TVU of CLM at 16,20 and 24 weeks Cerclage choice (TVC or TAC) PTD risk assessment ?Antenatal steroid prophylaxis

    18. Cervical Length Measurement (CLM) and Funnelling Normal CLM circa 50mm Funnelling appears after 16 weeks if not before

    19. Next Pregnancy Outcome LWH (n=351 MTLs, 1995-2003) 90 (25%) women did not become pregnant again (Brigham et al, 1999, Hum Rep, 14, 2868-71) of 261 MTL cases, 58 cases miscarried (30 in T1(12%) and 28 in T2 (11%). of 203 deliveries, 41 (20%) delivered before 34 weeks and 56 (28%) before 37 weeks rate of PET (3%), IUGR (3%), Abruption (2.5%) and SB (1case)

    20. Comparison of vaginal (TVS) and abdominal (TAC) cerclage for treatment of cervical weakness for Midtrimester Loss based on consecutive cohort data from Liverpool Womens Hospital (2001-2008)

    22. Consent Procedure Full disclosure of procedure and pregnancy risks Timely discussion incl. Q&A Access to complete information set Worst case scenarios description Transparent process Reflection time prior to consent

    23. Reported operative complications Injury to bladder Small bowel injury (Mingione et al,2003) Large bowel fistula (Debbs et al,2007) Rupture of membranes, pregnancy loss Frequent large Haemorrhage (Lesser et al,1998,Zaveri et al,2002,Mingione et al,2003) ? Preconceptual (PC TAC) after 2005

    24. TAC patient characteristics

    25. Preconception TAC Cohort

    26. Index Pregnancy losses between 12 to 24 weeks (n=5) T1 n= 5 (12;14;19;23;24/40) PC n= 4 (8;9;12;19/40) No correlation between success and number of previous losses &/or number of previous vaginal sutures All 5 failures after 14 weeks associated with co-morbidity APS (n=3) or BV (n=2)

    27. Gestation at delivery

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