Uterine Evacuation in the Setting of Transabdominal Cerclage

INTRODUCTION: Cervical insufficiency is associated with preterm delivery and recurrent pregnancy loss. Transabdominal cerclage, a more effective treatment alternative to transvaginal cerclage with >90% efficacy in preventing preterm delivery, is also permanent and requires delivery by cesarean. Patients with a transabdominal cerclage may require uterine evacuation via dilation and curettage (D&C) or dilation and evacuation (D&E) in subsequent pregnancies. The cerclage could limit cervical dilation. Alternatives, including hysterotomy or laparoscopic cerclage removal, are invasive and carry higher morbidity. Previously published literature on uterine evacuation with transabdominal cerclage in place includes older case series with few D&Es. OBJECTIVE: We aimed to identify and describe demographic and clinical variables, cervical preparation and surgical techniques, and uterine evacuation outcomes among individuals with transabdominal cerclage requiring uterine evacuation via D&C and D&E in a modern dataset. METHODS: This case series includes patients with transabdominal cerclage who underwent uterine evacuation at an academic medical center between March 2018 and August 2025. Eligible patients and clinical variables (gestational duration, indication), surgical techniques (cervical preparation and dilation), and outcomes (estimated blood loss [EBL], operative time, complications) were identified through chart and operative report review. Data were deidentified and stored in REDCap. Descriptive statistics were used for analysis. This study was approved by the institutional review board. RESULTS: Twelve uterine evacuation procedures met inclusion. Mean gestational duration was 12 weeks (range 8–20 weeks), with 58% undergoing D&C (n=7) and 42% undergoing D&E (n=5). The most common indication for D&C was therapeutic termination and for D&E was fetal anomaly. All procedures were performed by complex family planning physicians. Among D&C procedures, no cervical preparation was used. Intraoperative mechanical cervical dilation achieved sufficient dilation, to an average 27 French, with cannula sizes ranging from 7 to 12 mm. Mean EBL was 30 cc, and mean operative time was 16.5 min (range 12–24 min), and no complications occurred. Among D&E procedures, all received osmotic dilators (n=5) for cervical preparation; In addition to laminaria, two received mifepristone, and one received misoprostol and mifepristone. Mean preoperative cervical dilation achieved was 1 cm (range 0.5–1.5 cm). Four patients required additional intraoperative dilation, up to 59 French. Mean EBL was 230 cc (range 50–600 cc), and mean operative time was 45 minutes (range 16–92). Both 20-week procedures were prolonged by challenging cervical dilation (80 and 92 minutes). One 20-week D&E had two complications: a superficial posterior cervical laceration and delayed retained products requiring hysteroscopic removal. CONCLUSIONS: We describe D&C and D&E techniques and outcomes in patients with transabdominal cerclage. Our findings support the safety and feasibility of utilizing standard practices for cervical preparation with transabdominal cerclage in place, which can reassure clinicians and patients. Compared with more invasive alternatives such as hysterotomy or cerclage removal, D&C and D&E with experienced surgeons offer a feasible, lower morbidity alternative. However, the prolonged operative time and complications described in both 20-week D&Es highlight the need for more data at more advanced gestations.