Innovative Surgery Improves Fetal Outcomes in Women with Cervical Insufficiency
February 27, 2023
Innovations in Obstetrics & Gynecology | Winter 2023
Patients with refractory cervical insufficiency are often unable to sustain a pregnancy past the second trimester and frequently experience spontaneous preterm births. Vaginal cerclage is typically the first-line treatment for these patients. However, for those women who fail vaginal cerclage, a laparoscopic abdominal cerclage may improve fetal outcomes and reduce maternal morbidities.
David Biats, DO, FACOOG, is an expert in Robotic-Assisted Transabdominal Cerclage (RATC). He joined University Hospitals Department of Obstetrics & Gynecology in October 2022.
David Biats,DO“Robotic abdominal cerclage is really a last resort for patients with recurrent pregnancy loss due to cervical insufficiency,” Dr. Biats says. “Maternal-fetal medicine specialists generally refer patients to me when the patient either doesn't have adequate cervix to do a vaginal cerclage or has failed prior vaginal cerclage.”
UH is one of only a few centers in the U.S. that offers RATC. Dr. Biats an expert and has developed his own surgical technique in his practice.
“I trained at a small hospital where I had to do everything,” he says. “When I started doing robotic surgeries, I got the idea to use this technique to perform needle-less transabdominal cervical cerclage. At that time, no one was doing these procedures.”
Instead of using a needle to place a stitch in the cervix, Dr. Biats makes small holes in the broad ligament on both sides of the cervix and feeds a 6-inch piece of Mersiline tape through the openings, tying the ends together at the level of the internal os, the opening into the uterus, much like the drawstring on a pouch.
“I don’t know of anyone who is doing it this way,” says Dr. Biats.
Advantages of Robotic-assisted Transabdominal Cerclage
Because RATC is performed laparoscopically, the surgeon only needs to make four to five 8 mm incisions in the abdomen, replacing the C-section length incision required with open laparotomy.
“The surgery is shorter, reducing patient exposure to anesthesia and the possibility of blood loss or tissue trauma,” says Dr. BIats. “Patients go home the same day, with faster recovery times and few, if any, maternal or fetal morbidities.”
Initial results are promising. Dr. Biats has performed 22 RATCs and has had only one pregnancy loss after placement, in a patient with a complex medical history.
A single-center, single-surgeon case study conducted between 2012 and 2019 reported 76 to 100 percent fetal success rates and better postoperative outcomes with RATC when compared to traditional laparoscopy, with a mean gestational age of 36.2 weeks and 100 percent survival rates.
Other studies have shown similarly good results. A large retrospective study with 300 women undergoing abdominal cerclage (open or laparoscopic) had a 98 percent neonatal survival rate compared to prior pregnancy, and 37-week gestational age (versus 24 weeks in the prior pregnancy).
UH Accepting New Patients
Cervical insufficiency affects an estimated 1 percent of pregnancies, leading to recurrent pregnancy loss. Dr. Biats recommends transabdominal cerclage prior to pregnancy, but says it can be done between eight and 13 weeks’ gestation. The cerclage is left in place so women can have additional pregnancies with C-section deliveries.
Because there are so few medical centers that perform robotic-assisted transabdominal cerclage, maternal-fetal specialists around the country refer patients to UH, and Dr. Biats says some patients self-refer due to increased awareness of transabdominal cerclage on social media.
“Physicians who care for patients with refractory cervical insufficiency should know this procedure is now available at UH,” says Dr. Biats. “If a patient loses a pregnancy, or if vaginal cerclage fails, you can refer them to UH, and our fetal-medicine specialists will confirm transabdominal cerclage is appropriate. The procedure is also effective for patients who’ve undergone multiple cervical surgeries due to abnormal paps and who don’t have enough cervix in which to place a stitch.”