Cervical Cerclage: Why And How Is It Done During Pregnancy
- What is cervical cerclage?
- Why is cervical cerclage done?
- What is the right time for doing the procedure?
- What is the preparation process involved?
- What to expect during and after the procedure?
- When to call the doctor?
- When is cervical cerclage removed?
- What is the success rate of cervical cerclage?
- What are the risks involved?
Five to ten out of 1,000 pregnant women have an “incompetent” cervix (1). A normal cervix opens up at the end of your gestation for the baby to be born. But a weak cervix, which experts call an incompetent cervix, opens up much earlier during pregnancy, increasing the risk of miscarriage or premature birth.
So, is there a way to control premature birth due to a weak cervix? Momjunction explains what cervical cerclage is, how it is done, the risks involved and more.
What Is Cervical Cerclage?
Cervical cerclage or cervical suture is a surgical procedure done to prevent an incompetent cervix from opening up early during pregnancy. It is done by stitching the cervix to hold it and avoid premature delivery.
The procedure, which has been in vogue for more than 50 years, is usually done in the second trimester to hold the pregnancy until 37 weeks.
The cervical suture is done only if it is necessary and the necessity is determined by certain factors.
Why Is Cervical Cerclage Done?
The suture is done in the below cases (2) (3):
- Risk of miscarriage due to an abnormally shaped uterus or damaged cervix.
- Previous preterm labor or pregnancy loss in the second trimester due to cervical incompetence.
- Changes in the cervix that may lead to premature birth.
- A previous surgery or trauma to the cervix due to destructive forces or forced dilatation.
- History of inflammation or infection.
- Cervical shortening.
The above factors make you more prone to premature delivery and hence the stitch might be required. However, the procedure is not done too early in your pregnancy.
What Is The Right Time For Doing Cervical Cerclage?
Cervical cerclage is usually done at 12 to 15 weeks of pregnancy, i.e., before the cervical effacement (4). In some cases, this procedure is done at 24 weeks but seldom after that due to the risk of amniotic sac rupture.
Some women have to undergo emergency cerclage in the later stages if the cervix has already begun to open (2 to 4cm) (5).
The procedure is carried out only if the doctor diagnoses cervical issues during medical check-ups.
What Is The Preparation Process For Cervical Cerclage?
An incompetent cervix is diagnosed by the history of pregnancy losses and through an ultrasound scan. A scan helps determine the cervical dilation and short cervix (cervical length of less than 25mm).
Here is the preparation process for the procedure:
- An ultrasound scan is done to check the health of the fetus.
- A blood test checks for any infections.
- The mother should avoid having food or water for eight hours before surgery to prevent nausea and vomiting during the surgical procedure (6).
- The mother should avoid sexual intercourse for a week before the procedure.
- Stop taking any medications.
The preparation begins once the appointment is fixed for the cerclage procedure.
What To Expect During And After The Procedure?
Cervical cerclage is carried out by giving a general, spinal, or epidural anesthesia. A special instrument called speculum is inserted into the vagina to spread the vaginal walls apart to carry out the surgery.
One of the three methods is used for the cerclage (7):
- Shirodkar cerclage method: The doctor will pull the vaginal wall apart to pull the cervix towards her and make an incision into it. Then she will pass a needle with tape through the incision to tie the cervix. The sutures pass through the walls of the cervix. The cerclage is made farther from the junction of the vagina and cervix. These stitches often necessitate a C-section delivery.
- McDonald cerclage method: The doctor uses a needle to place the stitches around the outside of the cervix, i.e., around the intravaginal segment of the cervix. The cerclage is done nearer to the junction of the cervix and vagina. These stitches are removed on reaching full term.
- Transvaginal cerclage method: This is done if the cervix is too short for the above two procedures or vaginal cerclage has failed. The doctor places a tape around the cervical passage to tie it. In these cases, a C-section is done for the delivery.
Laparoscopic transabdominal cerclage method is being preferred to the other types because it does not require hospitalization, has less post-operative pain and is quick to heal.
If incompetence of cervix is diagnosed in the later stage then it can cause the amniotic sac to protrude through the cervix. In such cases:
- A catheter is inserted into the cervix. The balloon at the end of the catheter is inflated to close the cervix.
- Another method is to fill up the urinary bladder by inserting a catheter through the urethra. As the full bladder pushes the amniotic sac into the pelvis, the cervix is stitched.
After the procedure (aftercare)
- You will be under observation for several hours to ensure that you do not show up any sign of premature labor. The doctor will do an ultrasound scan to check the well-being of the fetus.
- You might experience cramps, spotting, or vaginal discharge for a few days after the surgery.
- The doctor may recommend antibiotics to fight infection and medication for pain relief.
- You may be told not to engage in physical activities or sexual intercourse for a few weeks after the surgery.
- In the follow-up visits, the doctor will check the stitch and look for any signs of preterm labor.
If you observe anything abnormal post-surgery, then call the doctor immediately.
When To Call The Doctor?
You need to talk to your doctor if you notice any of the following symptoms:
- Any signs of infection along with chills or fever
- Excessive vaginal discharge, bleeding, or pain
- Cramping or contractions
- Water break
- Persistent nausea or vomiting
- If any symptom gets worsened or a new symptom is noticed
You need to take proper care of yourself and avoid any physical and mental pressure for the procedure to be successful, and the sutures to be there until they are removed.
When Is Cervical Cerclage Removed?
The cerclage is usually removed at around 37 weeks or when you have preterm labor (contractions and water break) before 37 weeks of pregnancy.
The mean time between the removal of the stitch and delivery is 9.4 +/- 8.8 (mean +/- standard deviation) days (8).
A McDonald cerclage is removed at a hospital without any need for anesthesia while a transabdominal cerclage removal needs another incision in the abdomen.
What Is The Success Rate Of Cervical Cerclage?
The overall success rate of cervical cerclage in preventing preterm labor was found to be 80%. In case of women with cervical incompetence, the McDonald procedure increased the success rate of term deliveries to 95.4%.
The rate of fetal survival after cervical cerclage was found to be 85% and premature deliveries was 18.7% (9).
Although the cerclage helps decrease the chances of preterm deliveries, we cannot overlook the risks associated with it.
What Are The Risks Of Cervical Cerclage?
The risks of cervical cerclage include:
- Excessive vaginal bleeding
- Damage to the cervix during surgery
- Preterm premature rupture of membranes (PPROM), when the amniotic sac breaks before 37 weeks of pregnancy
- Preterm labor
- Tearing of the cervix (cervical laceration), when labor progresses with the stitches in place
- Permanent narrowing or closure of the cervix (cervical stenosis)
- Adverse reaction to anesthesia
- Another cerclage for future pregnancies
- Inability of the cervix to dilate during normal labor
Premature cervical dilation is a common reason for pregnancy loss. However, cervical cerclage can help carry a pregnancy for a few more weeks – how long it can be carried depends on your individual case. The alternative to a cerclage is total bed rest. Your doctor will assess your case and decide if or not you need the stitches.
Do you have any experience to share? Let us know in the comment section.