Cervical Cerclage during Pregnancy

As the baby grows during pregnancy, it puts a strain on the cervix. Under the pressure, a weak cervix may start to widen during the second or third trimester. This may lead to a miscarriage or a very premature delivery (preterm). To prevent harm to the foetus, a weak cervix may need to be sewn during pregnancy. This process is termed cervical cerclage, and takes place even before the signs of premature labour start to appear.

What is Cervical Cerclage?

Cervical cerclage is a minor surgical procedure which is used to treat a weak cervix. In this procedure, the cervix is stitched closed to prevent miscarriage or premature delivery.

While cervical cerclage lowers chances of a miscarriage or pre-term labour, other problems related to early labour may arise after the procedure. Any woman who has had a cerclage should get herself examined routinely to avoid other complications.

Most women who require a cerclage in one pregnancy will need to have it placed in future pregnancies as well. This procedure has helped some high-risk pregnancies last longer, but it is not risk-free. The good news is that a successful procedure can lead to a full-term pregnancy (37 weeks).

A cervical cerclage cannot be done if –

• The pregnant woman has vaginal bleeding
• The pregnant woman is having uterine contractions
• The membranes have ruptured early
• The stitches have to be taken out prior to labour
• The delivery requires a C-section to be done

Who Needs Cervical Cerclage and Why is it Required?

Cerclage cannot be performed for women who have dilated more than 4 centimetres, who have ruptured membranes or in cases where the foetus has died. However, cervical cerclage is required in the following cases –

• The mother-to-be had a history of late miscarriages because of abnormal uterus or damaged cervix. A damaged cervix will not remain closed during pregnancy.
• The mother-to-be had a previous 2^nd trimester pregnancy loss or a delivery that occurred with few or no contractions, suggesting that the cervix may not remain closed during pregnancy
• Exposure of the foetus to diethylstilbestrol (DES)
• The mother-to-be had any previous trauma or surgery of the uterus or cervix
• Hormonal influences
• Rupture of the membrane (water breaking)

What Are the Risks of Getting Cervical Stitch?

Cervical cerclage is generally a safe procedure. However, there might be some complications arising after the procedure. Emergency cerclages have a higher risk of complications. The risks of getting a cervical stitch during pregnancy are:

• Risks associated with anaesthesia
• Premature labour
• Rupture of membranes prematurely (water breaking)
• Chances of infections in the cervix
• Chances of the cervix getting torn (it occurs if the stitch is not removed at the start of labour)
• Excessive bleeding
• Chances of miscarriage increase in presence of cerclage
• Infection of the amniotic sac
• Cervical dystocia and failure to dilate requiring C-section
• A displaced cervix

Types of Cervical Cerclage

Prior to getting the cerclage, your medical history will be reviewed, including an examination of your cervix and transvaginal ultrasound. Your doctor will determine the procedure best suited for your case, and will pick one of three options

The three types of cervical cerclage are-

1. Transvaginal Cerclage (TVC) – TVC may be placed anytime within the 12^th week onwards. The TVC is removed around the 37^th week so that there are chances of normal delivery after cervical cerclage.
2. Transabdominal Cerclage (TAC) – TAC is a permanent procedure hence the delivery has to happen through C-section.
3. Transvaginal Cervico-isthmic Cerclage (TVCIC) – TVCIC can be removed for vaginal delivery or can be left if it is a C-section.

Benefits of a Cerclage

Cervical cerclage prevents miscarriage or preterm delivery or labour. The success rate of this procedure is about to 85% to 90%. This procedure is effective if there is truly a weak cervix, however the diagnosis of this can be inaccurate.

How to Prepare?

Before the procedure is performed a number of preparatory steps need to be completed –

• Complete medical history will be taken and analysed.
• Cervical examination will be conducted to assess the cervix.
• Ultrasound of the vagina will be performed and to check the baby’s vital signs and assess major birth defects.
• Your doctor may also do an amniocentesis. Amniocentesis is the procedure in which a small sample of the amniotic fluid is retrieved and tested to identify any chromosomal abnormalities the foetus might have.
• In case you have an infection that requires medication (antibiotics), you will need to complete treatment before the cerclage is done— if possible.
• You will not be allowed any food or drink after midnight of the previous day from the surgery to avoid nausea and vomiting during and after the cerclage.
• You will be advised not to have sexual intercourse, use tampons or douche for 24 hrs before the procedure.
• An intravenous catheter will be placed to administrate the fluids and medications.

A cervical cerclage is done between the 12^th and 14^th week of pregnancy.

Cervical Stitch Placement Procedure

In a cervical cerclage surgery stitches are placed in the cervix which is the outlet of the uterus to hold it closed. This is carried out using anaesthesia (general or regional). An instrument is used to spread the vaginal walls and the cervix is sewn in place. If you’re wondering about how long a cervical cerclage procedure takes, then the answer is about 30 minutes.

There are 3 ways in which the cervical stitches during pregnancy are done –

1. In this procedure, a stitch is placed through the vagina in and around the cervix like a purse string and placed at the bottom of the cervix as high as the doctor can reach. This is called Transvaginal Cerclage (TVC).
2. A band is placed around the outside of the cervix and then tied to control dilation. The band is placed either at the top or at the bottom of the uterus. It is placed laparoscopically or through an incision via the abdomen. In this procedure, the size of the cervix is not made smaller, the band stops it from dilating. This is called as the Transabdominal Cerclage (TAC).
3. A small incision is made in the cervix and a special tape is tied through it to close the cervix. This cerclage is placed above the cardinal ligaments, but not as high as the TAC. This is the third type of cerclage, Transvaginal cervico-isthmic cerclage (TVCIC).

The cervical stitch may cause some pain, spotting or painful urination. Your doctor may prescribe you Acetaminophen to help you get relief from the cervical stitch pain. If the doctor has placed stitches to reposition the vaginal tissues due to the incision in the cervix you may notice the passage of the material in 2 to 3 weeks as the stitches take time to dissolve.

The cost of a cervical stitch varies depending upon the medical clinic and doctor you are consulting.

Cervical Cerclage Aftercare

It is important that you recover well after the cervical stitches have been placed. Your doctor may keep you under observation for few hours to ensure that you do not go into premature labour, post which you will be allowed to go home with restrictions and guidelines to be followed. The process of recovery after cervical cerclage include medication, reduced or no physical activity, abstinence from sex, regular weekly or bi-weekly visits to the doctor.

• Constipation: After the cerclage has been placed, do not try to push the bowel movement too hard. You may want to make changes in your diet, like have high-fibre foods and more fluids. If required you may use over-the-counter stool softener medicines too.
• Rest: Ample rest will be required post the cerclage procedure.
• Vaginal care: The vaginal area should be carefully washed with soap and water. You should avoid placing anything inside your vagina during this time.

Seek medical assistance immediately if –

• You feel something bulging through the vagina
• Clear fluid starts coming out of the vagina
• If you have pain in the lower abdomen
• Foul smelling vaginal discharge starts coming from the vagina
• If you experience regular contractions
• If there is vaginal bleeding
• If there is pain while urinating

Cervical Stitch Removal

The removal of cervical cerclage happens in or around the 37^th week or at the onset of preterm labour. In case of any emergency, it may be removed earlier.

Removing the Transabdominal Cerclage (TAC) is a painless procedure which can be performed without any anaesthesia. It may cause light bleeding sometimes.

For Transabdominal Cerclage (TAC) removal a surgery has to be performed. The cerclage maybe left in place in case you plan to have a C-section.

You may go into labour (normal delivery) within 24 hours after the cervical stitch is removed. If you have had a Transabdominal Cerclage then you will need to go for a C-section.

What are the Results?

In a woman who has had a previous preterm delivery and who is pregnant and has a short cervix (less than 25 mm), result of cervical cerclage will be preventing a preterm delivery and reducing the chances of death and illness in the baby.

How Long is the Cerclage Left in?

The cervical cerclage procedure is performed between 12^th and 14^th weeks of pregnancy (at the beginning of the 2^nd trimester) before symptoms of premature labor begin. Emergency cerclages are those placed at a later stage in pregnancy when cervical changes have already begun.

The cerclage can be left till the 37^th week of pregnancy. Post which they can be removed. If you plan to go in for C-section then the cerclage can be left inside. It can be removed before your water breaks or contractions start.

Alternatives to Cervical Cerclage

Depending on the condition, a woman may have some alternative therapies available to her to avoid or delay premature labour instead of cervical cerclage. These include:

• Bed rest after cervical cerclage is prescribed so that there is less pressure on the cervix.
• There are drugs that are designed to stop or delay labor (Ritrodrine, terbutaline, and magnesium sulfate)
• Antibiotics may be prescribed to prevent preterm delivery.

Complications in Cervical Cerclage

Your doctor will explain all the risks and complications which may arise in the cervical cerclage procedure. If you experience any of the following symptoms after the stitch is placed then you should consult the doctor:

• Pain in abdomen or lower back
• Vaginal bleeding
• If you have fever of over 100 degrees
• Nausea or vomiting
• Foul smelling vaginal discharge
• Water breaking or leaking

Success Rate of Cerclage Stitch

Performing a cerclage stitch of a combination of procedures cannot assure a successful full-term pregnancy. The doctors at the most reduce the risk for you and your baby. Cerclages work best when they are placed early in pregnancy. The success rate for cervical cerclages is between 85% to 90%. The success rate is calculated by assessing the number of pregnancies delivered closer to the term with the procedure. Emergency cerclage has the lowest success rate.

Precautions to Take for Cervical Stitching During Pregnancy

Some precautions after a cervical stitch have been placed ensure the success of the procedure. Following precautions need to be taken if you have undergone cervical cerclage –

• Complete bed rest if you have undergone the cervical cerclage depending upon your medical condition.
• Reduced physical activity, along with no exercise is also recommended. In case you want to exercise, ensure medical supervision and/or approval.
• Refrain from heavy work for a short time.
• Avoid sexual activity for some time (up to the 34^th week) after the procedure.

It is advised to avoid climbing stairs after having a cervical procedure. However, there is no scientific evidence yet to prove that this could cause any issues. Since every case is different you may seek advice from your doctor about what your specific requirements are.

How Will it Affect My Pregnancy?

A cervical cerclage during pregnancy may affect you in the following ways –

• In most cases, a woman with a cervical cerclage will be able to complete the full term of pregnancy. The stitch is usually removed in the 37^th week.
• If you have undergone a Transvaginal Cerclage then you may go into labour within 24 hours of the stitch removal. You will not experience any pain.
• If you have undergone a Transabdominal Cerclage then you will need to have a C-section.
• In case you have to go in for premature labour and the drugs taken to delay the labour are not working then the stitch has to be removed as an emergency. This is done to avoid the risk of any damage to the cervix.
• If your waters break early and contractions do not start, it is recommended to remove the stitch within 48 hours. The reason is a high risk of infection if it is delayed.
• If you feel that you are going into labour before the stitch is removed, then you should immediately get admitted and inform the doctor. Leaving the stitch during the labour could lead to serious damage to the cervix.

Pregnancy After a Cerclage

There is no evidence that future pregnancies will be affected if you have had a cerclage before. However, in most cases, the doctor prefers putting a cerclage as a preventive measure if you have had one in your previous pregnancy.

10% of pregnancies end in preterm delivery (delivery before 37^th week). Premature birth is a cause of serious health problems, like respiratory issues, regulating body temperature and infections. According to statistics, preterm delivery causes more than 85% long-term disabilities and 75% death among newborns.

A weak cervix may pose a threat to the safety of your pregnancy. The Cervical Cerclage procedure will add a stitch of precaution to avoid any mishaps during the course of pregnancy.