Cervical cerclage is a procedure in which stitches are used to close the cervix during pregnancy to help prevent pregnancy loss or premature birth. 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). Typically, the stitches are removed at around week 37 of pregnancy.

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. However, cervical cerclage isn't appropriate for everyone. It can cause serious side effects and doesn't always prevent premature birth. Understand the risks of cervical cerclage and whether the procedure might benefit you and your baby.

Before pregnancy, the cervix is closed and rigid. During pregnancy, the cervix gradually softens, decreases in length (effaces) and opens (dilates) in preparation for birth. If you have an incompetent or weak cervix, however, your cervix might begin to open too soon. As a result, you could experience pregnancy loss or give birth prematurely.

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

  • A history of one or more second trimester pregnancy losses related to painless cervical dilation and in the absence of labor or placental abruption (history-indicated cervical cerclage)
  • Prior cerclage due to painless cervical dilation in the second trimester
  • Upon physical exam, painless cervical dilation diagnosed during the second trimester
  • A singleton pregnancy, a prior spontaneous premature birth at less than 34 weeks, and, upon ultrasound exam, a short cervical length (less than 25 millimeters) before 24 weeks of gestation

Cervical cerclage isn't appropriate for everyone at risk of premature birth. Your health care provider might discourage cervical cerclage if you have:

  • Vaginal bleeding
  • 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
  • A multiple pregnancy
  • A fetal anomaly incompatible with life
  • Prolapsed fetal membranes — a condition in which the amniotic sac protrudes through the opening of the cervix

Risks associated with cervical cerclage include:

  • Infection
  • Vaginal bleeding
  • A tear in the cervix (cervical laceration)
  • Prolapse of the fetal membranes into the vagina
  • Preterm premature rupture of the membranes — when the fluid-filled membrane that surrounds and cushions the baby during pregnancy (amniotic sac) leaks or breaks before week 37 of pregnancy
  • Preterm labor and premature birth
  • Miscarriage

Keep in mind that if you have cervical dilation in the second trimester, it's possible that you might experience these problems even if you don't have cervical cerclage.

After receiving a cervical cerclage, contact your health care provider immediately if you have leakage of fluid from your vagina, a sign of preterm premature rupture of membranes. Your health care provider might recommend removing the cervical cerclage early if you have preterm premature rupture of membranes and a uterine infection, depending on your stage of pregnancy.

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 that requires antibiotics, you'll complete treatment before the cerclage is done — if possible.

Ideally, a history-indicated cervical cerclage is done between weeks 12 and 14 of pregnancy. However, cervical cerclage can be done up until week 24 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. In some cases, cervical cerclage can be done before pregnancy.

If you have prolapsed fetal membranes — a condition in which the amniotic sac protrudes through the opening of the cervix — and your health care provider recommends cervical cerclage, he or she will treat the condition before doing the procedure.

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 the procedure

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 cerclage or the Shirodkar cerclage. Research suggests no significant difference in outcomes between the two methods.

To place the McDonald cerclage, 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.

In the Shirodkar method, 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.

After the procedure

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 at least one week and, afterward, using condoms during sex.

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 up to week 34 of pregnancy.

Your health care provider might recommend weekly or biweekly visits to examine your cervix until you give birth.

Cervical cerclage removal

A transvaginal cervical cerclage is typically removed at around week 37 of pregnancy — or at the onset 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 cervical 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 during week 37 through 39 of pregnancy. 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.

The effectiveness of cervical cerclage is a topic of debate.

Research suggests that cervical cerclage can reduce the incidence of premature birth in women at risk of recurrent premature birth. However, the timing of cervical cerclage can also affect the outcome. Emergency cervical cerclage done in the presence of advanced cervical change and prolapsed membranes has the worst outcome.

March 17, 2015