Purpose: Cerclage related complications in patients after trachelectomy are rare, but can have an immense effect on fertility and obstetric outcomes. We aim to report on cerclage related complications after trachelectomy and to increase awareness and develop preventive strategies.

Methods: Retrospective case series from 2006-2021 in a single tertiary referral center, including patients who experienced cerclage related complications after vaginal or abdominal trachelectomy because of early-stage cervical cancer.

Results: Ten patients suffered from cerclage related complications after trachelectomy. The cerclage position was examined by transvaginal ultrasound. Cerclages were displaced after (i) trachelectomy (n=6), (ii) cesarean section following trachelectomy (n=2) and (iii) trachelectomy and cesarean section, complicated by a uterine niche (n=2). Five patients were pregnant at diagnosis of cerclage displacement: four patients presented with preterm prelabor rupture of the membranes (PPROM) in the second trimester and one patient underwent trachelectomy in the late first trimester, complicated by an intrauterine infection and cerclage migration to the vagina. All five pregnancies were terminated because of intrauterine infection and/or poor fetal prognosis after removal of the dislocated cerclage. Cerclages were removed vaginally (n=7), hysteroscopically (n=2) or laparoscopically (n=1). Five patients were not pregnant at diagnosis of cerclage displacement: three patients presented with gynecological symptoms and two patients presented with subfertility with the cerclage located in the uterine niche.

Two patients conceived without a new cerclage, both suffered from PPROM and second trimester fetal loss. A new cerclage was placed laparoscopically in nine patients. Seven patients conceived: five ongoing pregnancies resulted in a cesarean section at a mean gestation age of 37+ weeks, two patients experienced a spontaneous first trimester miscarriage after which they conceived again; one is currently in the first trimester and one is currently in the third trimester of pregnancy.

Conclusion: In this retrospective case series dislocated cerclages may result in poor fertility and obstetric outcomes. Dislocation might be related to a subsequent cesarean section. New laparoscopic cerclage placement resulted in favorable fertility and obstetric outcomes. We recommend to evaluate cerclage position prior to pregnancy or fertility treatment in patients after trachelectomy. This may prevent impaired fertility and obstetric complications.

Cerclage migration, Dislocated cerclage, Laparoscopic abdominal cerclage, Permanent cerclage, Trachelectomy