On rare occasions, a pregnant woman’s cervix may start to shorten and open early in pregnancy due to the increasing pressure of a growing baby, placenta and amniotic fluid. This serious condition, called cervical insufficiency (weakened cervix), can lead to very preterm delivery or pregnancy loss. A cervical cerclage may be recommended by your doctor to help delay the delivery and to decrease risks related to prematurity.
What is a Cerclage?
Cerclage is a surgical procedure performed during early or mid-pregnancy to decrease the risk of preterm delivery in cases of cervical insufficiency. It is an outpatient procedure performed in the operating room under spinal or epidural anesthesia. It involves placement of suture, or a stitch, in the cervix to help reinforce and support the cervix, The suture remains in the cervix during the pregnancy and is then removed in the late third trimester (this can usually be done in the office).
Types of Cerclage Procedures
There are different types of cerclage and different approaches for cerclage placement. The transvaginal approach is the most common, where the sutures are placed through the vagina. Your doctor will discuss the most appropriate management for your pregnancy taking into account your individual history.
A transvaginal cerclage is performed during the pregnancy, where the stitch is placed circumferentially around the cervix, through the vagina. There are two types of transvaginal cerclage techniques: McDonald or Shirodkar. Both techniques are considered equivalent in terms of pregnancy outcomes. The stitch is usually removed around 36-37 weeks, or earlier if contractions or other concerning symptoms are present. Vaginal delivery is possible after the removal of transvaginal cerclage.
A transabdominal cerclage procedure is an abdominal surgery that is performed either through an open incision (laparotomy), or laparoscopically (through small incisions and camera equipment). This procedure is typically performed in the interval between pregnancies, although sometimes may be done during the early part of pregnancy, and is considered a permanent stitch until childbearing is complete. Pregnancies after transabdominal cerclage placement are delivered via cesarean. Your doctor may recommend transabdominal cerclage placement if a previous transvaginal cerclage was ineffective, or if you have had previous cervical surgeries that make a transvaginal cerclage placement not feasible.
Who Can Benefit from Cerclage?
Cerclage can help prolong pregnancy and delay preterm delivery in some patients who have been diagnosed with cervical insufficiency.
Previous obstetric history suggestive of cervical insufficiency includes painless dilation (opening) of the cervix in the second trimester, multiple second-trimester pregnancy losses or preterm births. Cervical insufficiency can also be acquired, as can be seen post significant surgery on the cervix, or injury to the cervix during prior delivery.
When Is Cerclage Placement Recommended During Pregnancy? When is it removed?
A prophylactic transvaginal cerclage placement procedure is typically performed between 14 and 16 weeks of pregnancy, when the diagnosis of cervical insufficiency is suspected or known based on the patient’s prior obstetric history.
Transvaginal cerclage placement may also be indicated mid-pregnancy depending on the ultrasound or physical exam findings (this is called an ultrasound-indicated or physical-exam indicated cerclage).
The suture is typically removed between 36 and 37 weeks of pregnancy. An earlier removal may be recommended by your doctor, depending on symptoms you’re experiencing.
Most transabdominal cerclage placements occur prior to pregnancy. This is a permanent suture that remains in place until child-bearing is complete.
How Cerclage Helps Prevent Preterm Birth
The cervical stitches placed during a cerclage procedure help support the cervix and decrease the chance of the cervix opening. By providing mechanical support to the cervix and keeping it closed, cerclage can act as a barrier to infection and inflammation that can result from ascending infection from the vagina.
Risks and Considerations of Cerclage Placement
As with any surgical procedure, cerclage placement may carry risks such as bleeding and infection. There may also be an increased risk of premature rupture of membranes (water breaking early) and preterm contractions.
Cerclage does not prevent preterm birth in all cases. While cerclage is considered generally safe when placed prophylactically (before shortening/dilation of the cervix), unique clinical situations may make the procedure more high risk. Your doctor will discuss specific risks relating to your pregnancy.
Cerclage placement is contraindicated if preterm labor/contractions are present, and in other situations where there are signs of an infection, vaginal bleeding, etc.
What to Expect After Cerclage Placement
It is normal to experience some light cramping or spotting, or an increase in vaginal discharge, for a few days after a cerclage placement. You should avoid strenuous activity during that time.
You should seek immediate medical attention if you’re having significant pain not controlled with prescribed medication, heavy bleeding, or believe that your water has broken (gush of fluid, continuous fluid leakage).
Schedule a Consultation with Advantia Health Today
The maternal-fetal medicine specialists of MFM & Genetics of Advantia are available by referral from your provider for a consultation about cervical insufficiency or other high-risk pregnancy concerns. Call our office to schedule a consultation.
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If you have been referred by your primary care provider, OB-GYN or other healthcare provider, please call our office to schedule an appointment. Our dedicated team will help you understand what information to provide in advance to ensure you see the care best suited to your condition.