What is cerclage? Cerclage is a surgical procedure performed in cases of cervical insufficiency (weakness of the neck of the womb) to stop the cervix from opening and the products of pregnancy (placenta and baby) from coming out, and to prevent miscarriage. Cervical insufficiency is a condition in which the tissue of the cervix cannot bear the weight of the products of pregnancy and, during pregnancy, opens without any symptoms (pain, contractions of the womb, etc.), causing the products of pregnancy to come out and miscarriage.
Miscarriage caused by cervical insufficiency usually happens in the second trimester of the first pregnancy, but in later pregnancies it may happen earlier.
Cervical cerclage is done under spinal anaesthesia or general anaesthesia, and a few hours after the operation, if the patient's general condition is stable, she is discharged. Cerclage prevents miscarriage and premature birth and has been successful in 85 to 90 per cent of cases of cervical insufficiency. Methods of cerclage: cerclage is done by three methods: McDonald, Shirodkar and abdominal cerclage.
The different methods of cerclage do not differ much from one another, and the choice of method for a patient usually depends on her condition and the treating doctor's opinion. In general, in cerclage the cervix is closed in a special way using a special suture thread.
When is cerclage done? (1) Cerclage is done when the cervix is short (less than 25 millimetres) before week 24 of pregnancy, in a singleton pregnancy. (2) In patients who have had several miscarriages in the second trimester of pregnancy where, according to the doctor's assessment, the cause of the miscarriages was cervical insufficiency.
(3) In cases where, based on the treating doctor's judgement, the operation is done as a preventive (prophylactic) measure, for example in patients who became pregnant after infertility treatment. These patients are among the relative indications for cerclage. (4) Multiple pregnancies with a risk of premature birth. (5) A previous cerclage because of painless dilatation of the cervix in the second trimester. In which patients is cerclage not recommended?
(1) Active vaginal bleeding (2) Active premature labour (3) Infection inside the womb (4) Premature rupture of the membranes (the amniotic sac leaks or breaks before week 37 of pregnancy) (5) A pregnancy with twins or more (6) Prolapse of the membranes, in which the amniotic sac bulges out through the opening of the cervix.
Benefits of cerclage surgery: (1) Giving birth to a healthy baby (2) Not having a premature birth (3) A normal length of time carrying the baby in the womb (4) No miscarriage. Complications and risks of cerclage: (1) Infection (2) Vaginal bleeding (3) Tearing of the cervix (4) Part of the baby protruding into the vagina (5) Early onset of labour and the birth of a premature baby (6) Miscarriage. Care after cerclage:
Some women need to stay in hospital after the cervix has been stitched and to follow post-operative care. Others, if their condition is stable, leave hospital but still need to follow post-operative care, which includes: (1) Taking the medicines prescribed by the doctor on time (2) Not doing daily activities for 7 days (3) No sexual intercourse for at least 7 days (4) Complete bed rest until the end of pregnancy.
If you notice any of the following signs, see a doctor immediately: (1) Fever above 38 degrees (2) Bleeding that does not stop (3) Pain in the lower back (4) Pain in the vagina or womb that does not improve with painkiller tablets. When are cerclage stitches removed? In general, these stitches are removed at week 37 of pregnancy. However, if the waters break or leak, or contractions start, the cerclage can be removed before week 37.
Most stitches are removed without any problems in the doctor's surgery. This is like having a Pap smear test and may cause slight bleeding. About future pregnancies: as mentioned earlier, most women who need a cerclage in one pregnancy also need it in their later pregnancies. What are the alternatives to this operation?
If changes in the cervix are seen late in pregnancy, or if the cervix has opened significantly, complete bed rest may be the best option. This depends on the pregnant woman's condition and the doctor's opinion.
What happens during this surgery? To control pain during the operation, general, spinal or epidural anaesthesia is given. Using a thread, the doctor places firm stitches around the cervix and closes the cervix completely.
Prepared and compiled by: Homa Yektapour – Education Unit
Source: Williams Gynaecology and Obstetrics