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BackTable / OBGYN / Article
Vaginal vs Abdominal Cerclage: Sustaining Second Trimester Pregnancies
Evangeline Adjei-Danquah • Updated Jul 20, 2025 • 40 hits
Second trimester pregnancy losses can be devastating, and an increasing number are being attributed to cervical insufficiency. Pregnant and non-pregnant patients who have experienced at least one second trimester pregnancy loss are ideal candidates for cerclage to manage cervical insufficiency. Current clinical practices have found vaginal cerclage to have lower success rates than laparoscopic abdominal cerclage, with most candidates having failed a vaginal cerclage prior to the abdominal surgery.
Gynecologic surgeon Dr. Craig Soboleski draws on his years of surgical expertise treating pregnant and pregnancy-planning patients to explain the evolving field of OB/GYN laparoscopy and its impact on cerclage procedures. Historically considered a last-resort "rescue" procedure due to its invasiveness, abdominal cerclage via minimally invasive laparoscopic techniques is now gaining traction for its high success rates. The renewed viability of cerclage underscores a potential shift in cervical insufficiency management, with abdominal cerclage increasingly considered earlier, especially in cases of prior unexplained second trimester loss.
This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable OBGYN Brief
• Abdominal cerclage via laparoscopy is increasingly preferred in cases of failed vaginal cerclage and significant cervical insufficiency. It provides durable support and high success rates, with evolving techniques improving safety and visualization.
• Laparoscopic abdominal cerclage offers enhanced precision through innovative techniques that minimize guesswork and improve surgical tool placement, especially in pregnant patients with challenging anatomy.
• In pregnant patients, the enlarged uterus limits pelvic space and visualization. Techniques such as broad ligament fenestration and uterine elevation tools (e.g., liver retractors) are used to improve access and minimize risk during laparoscopic cerclage.
• Determination for cerclage, particularly abdominal cerclage, typically focuses on risk management and patient specific needs or requirements. The field is largely trending toward earlier consideration of abdominal cerclage after a single unexplained second-trimester loss.
• While standard surgical protocols for infection and VTE prophylaxis remain unchanged, pregnancy requires key adjustments—like fetal monitoring, altered trocar entry, and patient positioning.
Table of Contents
(1) Vaginal vs. Abdominal approaches to Cerclages
(2) Advanced Techniques for Abdominal & Cervical Cerclage
(3) Cerclage in Pregnant vs. Non-pregnant Patients
Vaginal vs. Abdominal approaches to Cerclages
While vaginal cerclages are less invasive and not often used as a first-line intervention for cervical insufficiency, the procedure has somewhat variable success rates compared to abdominal cerclages, particularly in patients with recurrent pregnancy loss or prior failed cerclage.
Although abdominal cerclages historically carried greater morbidity due to open surgical techniques, the adoption of laparoscopic approaches has significantly reduced surgical risks, making it a safer and more accessible option. The tradeoffs include the need for cesarean delivery and a more technically demanding procedure, but it's consistently high success rates, often exceeding 95% in select populations, make it an increasingly preferred option to vaginal cerclages in specialized care settings.
[Dr. Craig Sobolewski]
I can't, without reviewing our data, swear by this, but the overwhelming majority of patients have had at least one vaginal cerclage that failed before.
[Dr. Mark Hoffman]
Oh, wow. Okay. Why is that? Again, I'm not up-to-date on what's out there. 10 years ago, last time I looked at it, they just weren't great vaginal cerclages. Honestly, around here, that's all they do. It's not anything that-- to your point, it's an MFM-driven program at times, or maybe REI. We don't have an REI group here. You got to go have a pretty significant volume of patients who need those, and I've never done one in my practice. It's not that anyone's asked me and I said I couldn't, it's not come through our OB programs at all.
[Dr. Craig Sobolewski]
At least my sense is that it's a factor of the fact that abdominal cerclages, the other terminology that was used to describe that procedure was a rescue cerclage. Typically, abdominal cerclages, because they were laparotomies, were reserved for patients in whom all other options had been tried and failed and exhausted. It was truly a rescue operation because it was such a potentially morbid procedure.
[Dr. Mark Hoffman]
These days, laparoscopically, I know you said you guys do a bladder flap. I've seen 50 of them in residency, and not one of them involved a bladder flap, and the numbers from his cases were pretty impressive. I know there's a lot of different ways to do that procedure, but I would say a lot of the ones I see are arguably less morbid than a vaginal cerclage.
[Dr. Craig Sobolewski]
No, I think so, too. I don't know. I don't know if they're less morbid, but maybe not necessarily more morbid-
[Dr. Mark Hoffman]
Not more … I can see it both ways. The success rate for abdominal cerclage in terms of maintaining pregnancy till term is phenomenal. It's one of the most successful procedures that we do, right?
[Dr. Craig Sobolewski]
Yes, I really feel like that we are on the right path of making vaginal cerclage as a thing of the past. I'm just not familiar enough with what the obstetric algorithm is to decide-- to answer your question. To Cap Haney's point, I think that if you had one second trimester loss and there was no other explainable reason for it, why not? I will say what it does do is confines all those patients to a C-section.
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Advanced Techniques for Abdominal & Cervical Cerclage
Vaginal cerclage typically involves sutures placed transvaginally around the cervix or just above at the cervicovaginal junction. They can often be placed electively or emergently and removed to allow for vaginal delivery. However, their effectiveness may be limited in certain high-risk patients, particularly those with prior failed cerclage.
In contrast, abdominal cerclage involves transabdominal placement of a suture at the cervicoisthmic junction. This technique requires dissection around the bladder and uterine vessels for precise placement, offering a more robust structural support. Ultimately the choice between vaginal and abdominal approaches depends on individual patient history, risk factors, and clinical judgement, with abdominal cerclage increasingly being considered earlier in select high-risk cases.
[Dr. Craig Sobolewski]
Amy Broach really has spearheaded this in our division, and she has developed this pretty slick technique. I suspect that we do some things probably uniquely different than some other places. One is that we use just the cup, a colpotomy cup-- a colpotomizer cup. We just use the cup to delineate the apical vagina, the vaginal fornix. We take some ring forceps, put them on a colpotomy ring, the 4-centimeter one, the large one, and we just have somebody down below just pushing up on the vaginal apex. It really helps to make sure that we're putting the stitch at the true internal loss instead of just guessing.
[Dr. Mark Hoffman]
Oh, that's great. I use a curved baby needle driver on the cup. Gives you a little bit of an angle to push up, but yes, same idea. When I'm doing a trachelectomy or something, where they don't have a manipulator attached. Yes, it's a great technique.
[Dr. Craig Sobolewski]
Yes, we do that for the cerclages. Then she developed a technique where we actually make a fenestration in both the posterior and anterior leaf of the broad ligament. We put our needle driver below the round through that space to throw our stitches from posterior to anterior. The angle that you get from that is so nice. It's so perfectly aligned. We do it for all of them, but especially for the pregnant uterus, where sometimes trying to see that space or feel comfortable that you're putting your suture in the appropriate position, not having the visualization that you can get because you can't see there because the broad is intact. It's a little tricky, I think, probably to envision what we're talking about.
[Dr. Mark Hoffman]
You make a window in the broad so you can see through it?
[Dr. Craig Sobolewski]
Yes.
[Dr. Mark Hoffman]
Do you close it back up?
[Dr. Craig Sobolewski]
Yes, we do. Just a barbed suture. We do make a bladder flap, and we tie the knot down anteriorly. We don't suture it down like I used to back in the day, like you said that Dr. Haney did. Every time we throw the stitch, Amy always jokes that she gets another gray hair because in those pregnant patients, it is still, you got to hold your breath when you're doing it.
Cerclage in Pregnant vs. Non-pregnant Patients
When performing cerclage in pregnant patients, standard VTE prophylaxis, including the use of sequential compression devices and heparin when needed, are still appropriate. Similarly, infection prophylaxis is expected to be the same for pregnant and non-pregnant patients. Pre-viable pregnancies require fetal heart tones via Doppler, while viable pregnancies require both fetal heart and contraction monitoring. Routine use of tocolytics is not supported by evidence.
However, specific pregnancy physiologic factors require attention. Anesthetic planning and surgical entry needs to account for gestational anatomy, and collaboration with anesthesiologists experienced in managing pregnant patients is critical. For cerclage procedures in pregnant patients, a bedside ultrasound is performed pre- and postoperatively to document amniotic fluid volume and confirm integrity of the membranes. In non-pregnant cerclage cases, cervical manipulation and dilation using uterine manipulators provide an estimate of the cervical opening, helping to guide placement tension.
[Dr. Craig Sobolewski]
When I think about it, if I think about what's different about operating in a pregnant patient compared to a non-pregnant patient, I think there are some things that when you are making the decision to operate, whether any day of the week, you're in your clinic and you see a patient and you're making a decision to operate, and now you've made that decision, then you go through your list of what you do to plan for that procedure. All that's going to be the same in a pregnant patient, but there's going to be some things that might be a little bit different. Pregnancy is a hypercoagulable state. Do I need to do anything differently about my VTE prophylaxis? The answer is no, it really isn't.
Even though there are physiologic changes in terms of the coagulable factors, most of the increased PTE risk comes from venous stasis. I think being efficient in the OR, SCDs, if the patient-- if you have a scoring system that you use to determine VTE risk and that person scores at a level that would require perioperative heparin is safe in a pregnant patient. Whatever your VTE management is, it shouldn't change based on a pregnant patient. You're going through your order list. Do you have to prophylax them against infection differently? The answer there is no. You use standard guidelines for whatever antibiotic prophylaxis based on the procedure that you're doing.
When they're in the hospital in pre-op, there are some things you might do differently. At least we do. If it's a pre-viable pregnancy, we'll get fetal hearts by Doppler, and that's it. We'll do that both pre- and post-procedure. We don't do anything for tocolysis. There's no evidence to support routine tocolytics in any manner. If it's a viable pregnancy, they should have both electronic fetal heart monitoring as well as monitoring for contractions, both pre- and post-procedure. That's different. That's not going to be in your ERAS order set for whatever procedure you're doing.
Think about your trocar entry or your site of entry, how you're going to get in. Think about how you're going to position the patient throughout the operation. Make sure you have an anesthesiologist who's comfortable managing a patient during pregnancy. Post-operatively, other than fetal hearts, and based on gestational age, with whichever way you're going to do it, there's really no guidelines or need to manage those patients differently in the immediate post-operative timeframe.
[Dr. Mark Hoffman] Are you keeping them overnight? You're sending them home?
[Dr. Craig Sobolewski]
Yes, sending them home. There's no evidence to support this necessarily, but for our cerclages, we just document the deepest amniotic fluid pocket in pre-op and post-op. We do just a quick bedside ultrasound, look at fluid, and then we do a quick bedside ultrasound and look at fluid afterwards just because we're putting a needle that sometimes goes into the stroma of the uterus, just to document that we didn't rupture them so that if three or four days later, God forbid, they rupture, we know–
[Dr. Mark Hoffman]
You know that they ruptured three or four days later or not?
[Dr. Craig Sobolewski]
We know that it didn't happen as a consequence of the procedure that we did, yes.
[Dr. Mark Hoffman]
Cerclage loose enough that you can do a DNC?
[Dr. Craig Sobolewski]
Yes
[Dr. Mark Hoffman]
When you're doing these on non-pregnant patients, are you making them a little looser or, again, just feel and see and–
[Dr. Craig Sobolewski]
You know what? On the non-pregnant patient, you have a manipulator in, so you know that you can at least-- that your cervix is at least dilated to the degree that your manipulator's there. That's probably-
[Dr. Mark Hoffman]
Like a seven, right?
[Dr. Craig Sobolewski]
-a seven or eight, yes. At least the first trimester miscarriages, you can manage that way for sure.
Podcast Contributors
Dr. Craig Sobolewski
Dr. Craig Sobolewski is a minimally invasive GYN surgeon at Duke University in Durham, North Carolina.
Dr. Mark Hoffman
Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.
Cite This Podcast
BackTable, LLC (Producer). (2025, March 11). Ep. 79 – Laparoscopy in Pregnancy: Key Considerations for Surgeons [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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