Cervical cerclage represents a treatment for cervical failure, respectively in the case when the cervix starts to shorten and open too early during pregnancy, leading either to pregnancy loss or premature birth.
A weak cervix might be the result of:
- A history or miscarriages in the 2nd pregnancy trimester.
- An electrosurgical excision procedure or a cervical biopsy.
- The cervix being affected by a pregnancy interruption.
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What Is a Cervical Cerclage?
This medical procedure consists of placing a yarn in order to tighten the cervix. The technique is rather similar to squeezing a bag, which may open because of the high pressure produced by its content. While pregnant, the cervix has 2 functions:
- Pregnancy constraint.
- Dilation during delivery.
Thus, the normal state of a cervix is closed during the 9 pregnancy months and open at birth. In specific pregnant women, the cervix may open ahead of term, which may lead to premature birth. In this particular case, it`s recommended to perform a cervical cerclage. The procedure is performed in the first 6 months of pregnancy, and is a simple technique that uses a speculum. It`s made under general or local anesthesia (so, it won`t hurt), and involves sewing the cervix using a thick thread which will then be removed 3 weeks before the due date, or even earlier if it`s spontaneously triggered. The entire procedure takes roughly about 10 to 15 minutes.
Types of Cerclage
There are 3 different cerclage types:
- A McDonald cerclage: it was first described in 1947 and is considered the most common type of cerclage. It`s basically a pursestring stitch that is used to cinch the cervical shut. This involves a band of suture at the cervix`s upper side while its lower side has by this time began to efface. This particular cerclage is generally applied between 16 and 18 pregnancy weeks, and then it`s removed around the week 37.
- A Shirodkar cerclage: It`s quite similar to a McDonald cerclage, however, the sutures will now pass through the cervical walls, so they aren`t really exposed. This is a less common cerclage type and a bit more demanding than the previous one, and is thought to reduce any risks of infection, though it was never demonstrated.
- An abdominal cerclage: Also known as TAC (transabdominal cerclage), this is the least common type of cerclage and will involve applying a band outside and at the top of the cervix. This particular procedure is only performed if doctors deal with a cervix that is too short to try an regular cerclage, as well as if a vaginal cerclage isn`t possible or has failed, because of several pregnancies carried to their term or perceived better results. For pregnant women giving birth with an abdominal cerclage, a C-section is needed. A TAC can be applied before pregnancy if the woman has been diagnosed with a cervical insufficiency.
What Is Cervical Insufficiency?
Cervical insufficiency, also known as cervical incompetence, commonly manifests at the week 18 – 22 of pregnancy by painless cervical dilation, pelvic pressure or increase mucus removal. The cervical inability to maintain the pregnancy inside the uterus occurs if no contractions or labor is involved. If left untreated, cervical insufficiency may result in abortion, the conception product not being viable at such a low gestational age. Cervical insufficiency is frequently detected when the first trimester finishes, at an ultrasound examination that discovers a lengthened or short cervix.
A weakened cervix may be caused by either one of the below conditions:
- Previous cervical surgery.
- Abnormal uterus or cervix from a congenital malformation.
- DES exposure (diethylstilbestrol).
- Damage during a birth with complications.
- Previous cervical trauma, D&C from a miscarriage or a termination of pregnancy.
How Is a Cervical Stitch Done?
Cervical cerclage is performed by efficiently sewing the cervix, being programmed 12 to 14 weeks before it`s totally thinned (it`s seen as the optimal interval to be performed) or as an emergency measure after being already thinned (generally, in this case future pregnancies will also require this procedure). Rarely, cervical cerclage is performed after 24 pregnancy weeks. Specifically, a speculum is introduced into the woman`s vagina to remove the walls of her vagina. The procedure can happen in a few different ways:
- Sutures can be placed around the cervical opening.
- A special band may be placed around the cervix and sewn there.
- A tiny incision may be performed in the cervix. Then, a special band is tied around the woman`s cervix to close it.
It a cervical insufficiency has been diagnosed late during pregnancy, the amniotic sac might start to penetrate through the cervix. This particular inconvenience can be treated by simply inserting a very thin tube through the cervix, and then swelling a balloon at the tube`s end.
Another medical technique will involve filling the bladder with fluid using a similar tube inserted through the woman`s urethra. The full bladder will help push the amniotic sac back into the woman`s pelvis and the cervix can be closed by suturing.
What to Expect Before & After Cervical Cerclage?
- A specialized doctor in pregnancies with high risk will perform a thorough cervical investigation, which include a transvaginal ultrasound.
- The physician will explain the methods that he`ll use to control the pain during the procedure.
- You may want to note any questions you may have to ask the doctor.
- You may stay hospitalized for a few hours or even overnight in order to be supervised in the possible event of premature labor or contractions.
- Soon after the procedure, mild cramping or bleeding might appear, but which should stop in a couple of days. These may be followed by a vaginal discharge which may continue later on during pregnancy.
- You may receive drug treatment in order to prevent premature labor or infection.
- You will need to stay home and try to avoid any physical activity 2 or 3 days after this procedure.
- Your physician will explain when you are able to resume your usual activities.
- Abstinence from any sexual contacts is usually advisable about 7 days before and after this procedure.
How Do They Remove a Cerclage?
The cerclage is removed at 36 – 37 weeks with no anesthesia after the baby`s lungs has developed enough, but before the beginning of the spontaneous labor which may lead to suture avulsion.