NUMBER OF PROCEDURES PERFORMED
Since 1986, one obstetrical surgeon, Dr. James Sumers, in the Center for Prenatal Diagnosis has performed 206 TAC (transabdominal cerclage) procedures. Of these, 203 were prophylactic TAC procedures. "Prophylactic" refers to a procedure done prior to dilatation of the cervix. The outcomes data below apply to these prophylactic procedures. One hundred and ninty-four of the 203 have delivered, and 8 are ongoing. One of the two patients in whom the TAC was performed in the non-pregnant state has not achieved pregnancy.

Although good outcomes might be had with "emergent" procedures (done after cervical dilatation is evident), these emergent procedures are fraught with difficulties and are probably much riskier.

SURVIVING BABIES - PROPHYLACTIC TAC
In the index pregnancy (the one in which the TAC was performed) 193 mothers delivered 296 babies after 24 weeks gestation. Three individual babies from three different multifetal pregnancies and a full set of triplets died in the newborn ICU. There were fetal losses of a septuplet pregnancy at 21 weeks and of twins at 19 weeks from abruption.

GESTATIONAL AGE AT DELIVERY
Most, if not all, of these patients were at high risk of delivering very early, many having done so in their prior pregnancies. Neonatal survival and decreased risk of neurologic damage is tied to gestational age at delivery. Need for intensive care intervention is also related to gestational age at delivery. The following shows gestation at delivery for these TAC patients in the pregnancy in which the TAC was performed.

Gestational Age at delivery (wks)	Number of patients
14-24	7
25-28	5
29-30	9
31-32	12
33-34	35
35-36	37
37-40	88

One patient was lost to follow-up

OPERATIVE DAMAGE/NEED FOR TRANSFUSION/LOSS OF PREGNANCY PERIOPERATIVELY
No damage to pelvic organs has been encountered in our hands. One patient, early in the series, required transfusion for operative blood loss. One patient was taken back to surgery on the night after surgery for wound bleeding, but did not require transfusion. All babies have been alive immediately after surgery and at ultrasound exam two weeks later.

TAC IN MULTIFETAL PREGNANCIES
In the relatively small number of multifetal pregnancies in which TAC has been performed, the outcomes have been encouraging. In the twin pregnancies, TAC was done for usual reasons rather than twinning. Thirteen twin pregnancies have undergone TAC. All thirteen twin pregnancies delivered thus far have resulted in living babies delivered at 30, 31, 33, 34, 35(3), 36(3) and 37(3) weeks. One pregnancy ended recently at 19 weeks from an abruption (about five weeks after surgery).

Initially, the triplets and more underwent TAC for traditional reasons, but recently we have offered TAC as an option for management in these pregnancies at extremely high risk of early delivery. Still, some of the triplets undergoing TAC prophylactically had either a history of cervical incompetence, short cervix or deep cervical laceration. To this date, we have performed TAC on 44 triplet gestations, with 39 delivering so far. Surprising in the management of these pregnancies is that preterm labor seems less of a management problem than in the other multifetal pregnancies we manage. The reason for delivery has more frequently been related to fetal growth abnormalities and toxemia. Gestation at delivery is as follows:

Gestational Age at delivery (wks)	Number of patients
14-24	0
25-28	2
29-30	5
31-32	5
33-34	21
35-36	6
37-40	0

Three quadruplet and three quintuplet pregnancies underwent TAC at the patients' request. One quadruplet pregnancy (who lost twins at eighteen weeks in her only prior pregnancy) delivered at 35 weeks, the second delivered at 32 weeks, and the third delivered at 30 weeks. One patient (with a prior term delivery) with a quintuplet pregnancy delivered at 29 weeks for evolving toxemia. All five babies survived and did well. The second quintuplet pregnancy in a primigravid woman delivered at 29 weeks following prolapse of one baby's cord into, but not through, the cervical canal at sixteen weeks gestation. That baby had severely decreased amniotic fluid at eighteen weeks and passed away at 23 weeks. She was delivered at 29 weeks due to evolving preeclampsia. One of the surviving babies died in the NICU due to sepsis and RDS (respiratory distress syndrome). The third quintuplet pregnancy experienced severe oligohydramnios in one baby's sac at eleven weeks. She was delivered at 27 weeks due to nonreassuring fetal status of that baby on biophysical testing. That baby died in the delivery room and a second baby died three days later due to a large intracranial hemorrhage.

One septuplet pregnancy in a primigravida (patient's first pregnancy) underwent TAC at the beginning of the second trimester and suffered erosion of the cerclage through the cervical wall and labor followed by delivery at 21 weeks.