Cervical Cerclage

What is cervical cerclage

As your baby grows, he puts more pressure on the uterus, which may sometimes cause the cervix (the lower part of the uterus that leads to the vagina) to start dilating (shortening and opening) days or even weeks before the baby is ready for delivery, a problem often referred to as cervical insufficiency or an incompetent cervix ^[1]. A cerclage is a surgical procedure where a suture is placed around the cervix to prevent it from opening too soon during pregnancy, in women with a weak cervix ^[2]. It helps to carry a pregnancy to full term so the baby can develop properly ^[3], lowering the risks of having a miscarriage or premature baby.

Who needs a cervical cerclage

Women having suffered a second trimester miscarriage, or given birth to an extremely pre-term baby without proper labor and contractions in a previous pregnancy, are often suspected to have an incompetent cervix. Having a damaged cervix or a history of some surgery may also make it necessary to get a cerclage in any following pregnancy ^[2]. In such cases, the cerclage is often performed between weeks 12 and 16, when the risk of miscarriage reduces considerably ^[4] while the pressure on the cervix is still not too high to make it difficult to place the suture ^[5].

Those with a congenital malformation of the uterus or cervix may even opt for a pre-pregnancy transabdominal cerclage, where the cervix is stitched closed before conception, considerably reducing the chances of a complication or pregnancy loss ^[6].

Cervical cerclage types

The classification is based on the technique used for placing the stitch.

Transvaginal cerclage

It is usually done transvaginally ^[7] in one of the following procedures:

McDonald cerclage

The most common form of cerclage used by doctors today, a permanent suture is placed around the cervix in the McDonald cerclage ^[7].

Shirodkar cerclage

Another transvaginal surgery option, it involves making small incisions in the cervical and vaginal tissues to make the stitches that hold the cervix closed until full term ^[8]. It is usually made much higher than a McDonald cerclage so the cervix can be more securely closed ^[9].

Rescue cerclage

An emergency cerclage, it is performed when the cervix has already begun to dilate before term with few or no contractions while the amniotic sac begins to funnel into the cervical opening ^[5].

Transabdominal cerclage

Having a congenitally short cervix, a previous cervical surgery or a severe injury may make it too difficult to perform a cerclage transvaginally. In such cases, the doctor may opt for a transabdominal process where the cervix is tied shut through an incision made in the mother’s abdomen ^[10].

Cervical cerclage placement procedure

Before beginning the surgery, ultrasound scans are used to decide the type of cerclage to be opted for. The common method involves performing a local anesthesia before placing the suture through the vagina ^[5]. A speculum may be used to keep the vagina open during the surgery ^[11] while the cervix is held steady with a pair of ring forceps ^[10].

A thick band of thread ^[12] is then placed around the cervical opening in a manner resembling a purse-string ^[5] (Picture 2) and pulled tightly so it can be tied close ^[3].

Cervical cerclage aftercare

Once the surgery is over, your doctor may prescribe certain medications, including antibiotics and pain medicines. The painkillers help with any pain following the procedure while the antibiotics prevent any infectious conditions ^[13] as any infection at this time may be harmful to the baby as well as the mother.

Most women are put to bed rest for 2-3 days (may be longer in extremely high-risk cases). A little spotting or even a light bleeding after the surgery is considered normal. You may also notice a whitish/mucusy discharge for a few days ^[3]. Some women even report having a few occasional contractions for a few hours or days, but this usually goes away on its own.

Your doctor will explain all the restrictions and guidelines to follow before you go home after the surgery. Here are a few tips to help with the recovery process:

Avoid any strenuous activity like pulling something heavy or climbing the stairs too quickly ^[3]
Make sure not to strain too much during bowel movements
Drink lots of fluids (water, sugar-free fruit juices) and add plenty of fiber-rich foods (whole grain bread, cereals) in your diet as these can help prevent constipation ^[14]
Once your doctor allows you to shower, use mild soap and water to keep the area around the suture clean
Replace any bandages or pads you may be using as soon as they get dirty

Intercourse should be avoided for at least 7 to 14 days ^[11]. Make sure to talk to your doctor before beginning to follow any exercise schedule.

Cerclage removal

The cerclage suture is usually removed around the 37th week as the baby is generally mature enough to survive on his own by this time ^[3]. It may be removed earlier in case of an emergency like the water breaking or a premature labor ^[15]. Removal of a McDonald cerclage is usually a painless procedure performed without anesthesia, sometimes causing light bleeding ^{[3, 10]}. The stitch may be left in or removed after the delivery in case of a cesarean section birth ^[16].

However in case of a Shirodkar cerclage, the removal procedure has to be carried out in a surgery room. If you are planning to have a c-section delivery, a Shirodkar cerclage may be left in place to prevent any cervical complication in a future pregnancy ^[10].

Are there any risks and complications of a cerclage

Despite the fact that it helps women to carry a pregnancy for a longer period, there is some controversy regarding the safety of the procedure as it involves anesthesia, which may be associated with various complications ^[17]. It may also lead to certain other side effects or complications depending on when and how it is done, with the possible risks including:

Infection of the cervix or amniotic sac
Vaginal bleeding
Preterm premature rupture of the membranes (PPROM) ^[18]
Cervical laceration or a tear in your cervix ^[19]
A miscarriage
Preterm labor and birth ^[20]
Increased chances of a c-section

The minimally invasive nature of the McDonald cerclage, along with the lower amount of time required to perform it makes it preferable over the Shirodkar method for having a lower risk of infection and bleeding ^[9].

Planned cerclages performed earlier in pregnancy usually have lower risks of complications compared to surgeries performed in an emergency ^[21].

There are a few contraindications of a cerclage, including a placental abruption and severe vaginal bleeding ^[7].

Cerclage surgery success rate

Transvaginal cerclage has a success rate of around 80% to 85%, while over 95% women having undergone the abdominal procedure carry their pregnancy to full term ^[22].

Studies show no significant difference between the success/failure rates of the McDonald and Shirodkar methods ^[10]. According to certain studies, women carried their babies for 6 to 9 more weeks after receiving a rescue cerclage as opposed to those with non-surgical management (bed rest), who carried their pregnancy for 4 weeks longer since being diagnosed with an insufficient cervix ^{[23, 24]}.

Elective cerclages have a higher rate of positive outcomes compared to rescue cerclage ^[21]. The method is more effective in single pregnancies compared to multiple pregnancies as studies show no significant improvement in the outcome with a cerclage in women carrying twins ^[8].

When to call the doctor

Sharp pain in the lower abdomen or back at short intervals ^[25]
Severe bleeding
Odd or foul smelling discharge ^[11]
Fever and/or chills
Severe nausea along with vomiting
Clear or yellowish watery discharge (might indicate the waters breaking) ^[3]
Considerable or worsening pain at the site of the stitch

Pregnancy after a cerclage

Those who get a cerclage during one pregnancy usually need the surgery in all the subsequent pregnancies ^[3]. Due to this reason, some women may opt for a c-section delivery, keeping the stitch in place. However, make sure to talk to your doctor regarding the effects of the retained stitch on fertility.

Cervical cerclage ICD-9 code

Its ICD-9 code is 67.5 ^[26].

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