Cervical Cerclage

Definition

What is Cervical Cerclage?

Cervical cerclage refers to a variety of procedures that use sutures or synthetic tape to reinforce the cervix during pregnancy in women with a history of a short cervix. The cervix is the lower part of the uterus that opens to the vagina.

Cervical cerclage can be done through the vagina (transvaginal cervical cerclage) or, less commonly, through the abdomen (transabdominal cervical cerclage).

When is Cervical Cerclage needed?

Your health care provider might recommend cervical cerclage if your cervix is at risk of opening before your baby is ready to be born or, in some cases, if your cervix begins to open too early.

Particularly, your health care provider might recommend cervical cerclage during pregnancy to prevent premature birth if you have:

• A history of second trimester pregnancy loss related to painless cervical dilation in the absence of labor or placental abruption (history-indicated cervical cerclage)
• Prior cerclage due to painless cervical dilation in the second trimester
• Painless cervical dilation diagnosed during the second trimester
• A short cervical length (less than 25 millimeters) before 24 weeks of pregnancy, in a singleton pregnancy

Precautions

What should you know before undergoing Cervical Cerclage?

Not everyone can safely undergo this procedure. Cervical cerclage isn’t appropriate for everyone at risk of premature birth. Your health care provider might not recommend a cervical cerclage if you have:

• Active vaginal bleeding
• Active preterm labor
• An intrauterine infection
• Preterm premature rupture of membranes — when the fluid-filled membrane that surrounds and cushions the baby during pregnancy (amniotic sac) leaks or breaks before week 37 of pregnancy
• Twin or higher order pregnancy
• A fetal anomaly incompatible with life
• Prolapsed fetal membranes — a condition in which the amniotic sac protrudes through the opening of the cervix

What are the complications and side effects?

The likelihood of risks occurring is very minimal, and most health professionals feel a cerclage is a life-saving procedure that outweighs the possible risks involved.

Possible risks could include:

• Premature contractions
• Cervical dystonia (inability of the cervix to dilate normally in the course of labor)
• Rupture of membranes
• Cervical infection
• Cervical laceration if labor happens before the cerclage is removed
• Some risks associated with general anesthesia include vomiting and nausea

It is important you understand the precautions and know the possible complication and side effects before having this Cervical Cerclage. If you have any questions, please consult with your doctor or surgeon for more information.

Process

How do I prepare for Cervical Cerclage?

Before cervical cerclage, your health care provider will do an ultrasound to check your baby’s vital signs and rule out any major birth defects. Your health care provider might take a swab of your cervical secretions or do amniocentesis — a procedure in which a sample of amniotic fluid is removed from the uterus — to check for infection. If you have an infection, a cerclage won’t be placed.

Ideally, a history-indicated cervical cerclage is done between weeks 12 and 14 of pregnancy. However, cervical cerclage can be done up until week 23 of pregnancy if a pelvic exam or ultrasound shows that your cervix is beginning to open. Cervical cerclage is typically avoided after week 24 of pregnancy due to the risk of rupturing the amniotic sac and triggering premature birth.

What happens during Cervical Cerclage?

Cervical cerclage is typically done as an outpatient procedure at a hospital or surgery center under regional or general anesthesia. Most cervical cerclage procedures are done through the vagina.

Cervical cerclage might be done through the abdomen if transvaginal cerclage is unsuccessful or anatomically difficult due to an extremely short, lacerated or scarred cervix.

During transvaginal cervical cerclage, your health care provider will insert a speculum into your vagina and grasp your cervix with ring forceps. He or she might use ultrasound for guidance. Your health care provider will likely use the McDonald operation or the Shirodkar operation. Data suggests no significant difference in outcomes between the two methods.

During the McDonald operation, your health care provider will use a needle to put stitches around the outside of your cervix. Next, he or she will tie the ends of the sutures to close your cervix.

During the Shirodkar operation, your health care provider will use ring forceps to pull your cervix toward him or her while pulling back the side walls of your vagina. Next, he or she will make small incisions in your cervix where it meets your vaginal tissue. Then, he or she will pass a needle with tape through the incisions and tie your cervix closed. Your health care provider might use stitches to reposition vaginal tissue affected by the incisions.

During transabdominal cervical cerclage, your health care provider will make an abdominal incision. He or she might elevate your uterus to gain better access to your cervix. Next, your health care provider will use a needle to place tape around the narrow passage connecting the lower part of your uterus to your cervix and tie your cervix closed. Then he or she will set your uterus back into place and close the incision. The procedure also can be done laparoscopically.

What happens after Cervical Cerclage?

After cervical cerclage, your health care provider will do an ultrasound to check your baby’s well-being.

You might experience some spotting, cramps and painful urination for a few days. Acetaminophen (Tylenol, others) is recommended for pain or discomfort. If your health care provider used stitches to reposition vaginal tissue affected by incisions in your cervix, you might notice passage of the material in two to three weeks as the stitches dissolve.

If you had history-indicated cervical cerclage, you’ll likely be able to go home after you recover from the anesthetic. As a precaution, your health care provider might recommend avoiding sex for a few weeks or more, depending on the reason for the cerclage.

If you had cervical cerclage because your cervix had already begun to open or an ultrasound showed that your cervix is short, you might need to remain in the hospital for observation. As a precaution, your health care provider might recommend limiting physical activity and sex until delivery.

Your health care provider will continue to monitor you closely for signs or symptoms of preterm labor.

Cervical cerclage removal

A transvaginal cervical cerclage is typically removed at around week 37 of pregnancy — or at the start of preterm labor.

A McDonald cerclage can usually be removed in a health care provider’s office without anesthetic, while a Shirodkar cerclage might need to be removed in a hospital or surgery center. After having a transvaginal cervical cerclage removed, you’ll typically be able to resume your usual activities as you wait for labor to begin naturally.

If you expect to have a C-section and plan to have children in the future, you might choose to leave a Shirodkar cerclage in place throughout your pregnancy and after the baby is born. However, it’s possible that the cerclage could affect your future fertility. Consult your health care provider about your options.

If you had a transabdominal cervical cerclage, you’ll need to have another abdominal incision to remove the cerclage. As a result, a C-section is typically recommended. Your baby will be delivered through an incision made above the cerclage. During the C-section, you can choose to have the cerclage removed or leave it in place for future pregnancies.

If you have any questions or concerns, please consult with your doctor or surgeon for more information.

Recovery

What should you do after Cervical Cerclage?

You may receive medication to prevent infection or preterm labor. For 2-3 days after the procedure, plan to relax at home; avoid any unnecessary physical activity. Your doctor will discuss with you when would be the appropriate time to resume regular activities.

Abstinence from sexual intercourse is often recommended for one week before and at least one week after the procedure.