Cervical Cerclage is the closing of the cervix - the lower part of the uterus that opens to the vagina - via stitching. This surgery is performed during pregnancy to prevent premature birth or miscarriage.
Cervical Cerclage can be performed in 2 ways:
Transvaginal Cervical Cerclage - Procedure Is Conducted Through Vagina
Transabdominal Cervical Cerclage - Procedure Is Performed Via Abdomen
Cervical cerclage is a procedure in which sutures are used to close the cervix — the lower part of the uterus that opens to the vagina — during pregnancy to help prevent premature birth.
Cervical cerclage can be done through the vagina (transvaginal cervical cerclage) or through the abdomen (transabdominal cervical cerclage). Typically, the sutures are removed when a baby is considered full term — during week 37 of pregnancy. If necessary, the sutures can be removed earlier.
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
There are three types of cerclage:
A McDonald cerclage, described in 1957, is the most common, and is essentially a pursestring stitch used to cinch the cervix shut; the cervix stitching involves a band of suture at the upper part of the cervix while the lower part has already started to efface. This cerclage is usually placed between 16 weeks and 18 weeks of pregnancy. The stitch is generally removed around the 37th week of gestation or earlier if needed. This procedure was developed by the Australian Gynecologist and Obstetrician, I.A. McDonald.
A Shirodkar cerclage is very similar, but the sutures pass through the walls of the cervix so they're not exposed.This type of cerclage is less common and technically more difficult than a McDonald, and is thought (though not proven) to reduce the risk of infection. The Shirodkar procedure sometimes involves a permanent stitch around the cervix which will not be removed and therefore a Caesarean section will be necessary to deliver the baby. The Shirodkar technique was first described by V. N. Shirodkar in Bombay in 1955. In 1963, Shirodkar traveled to NYC to perform the procedure at the New York Hospital of Special Surgery; the procedure was successful, and the baby lived to adulthood.
An abdominal cerclage, the least common type, is permanent and involves placing a band at the very top and outside of the cervix, inside the abdomen. This is usually only done if the cervix is too short to attempt a standard cerclage, or if a vaginal cerclage has failed or is not possible. However, a few doctors (namely Arthur Haney at the University of Chicago and George Davis at the University of Medicine and Dentistry of New Jersey) are pushing for the transabdominal cerclage (TAC) to replace vaginal cerclages, due to perceived better outcomes and more pregnancies carried to term. A c-section is required for women giving birth with a TAC. A transabdominal cerclage can also be placed pre-pregnancy if a patient has been diagnosed with an incompetent cervix.
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 give birth prematurely.
Your health care provider might recommend cervical cerclage during pregnancy to prevent premature birth if you have:
A history of three second-trimester miscarriages or premature births or two second-trimester miscarriages with no other identifiable causes
A short cervix — as shown by ultrasound before week 24 of pregnancy — particularly if you've had a cervical injury, a history of premature birth or multiple miscarriages during your second trimester, or the length of your cervix is rapidly decreasing despite treatment with preventive medications
Cervical dilation with a visible amniotic sac before week 24 of pregnancy (emergency or rescue cerclage)
If you experience recurrent pregnancy losses despite treatment with preventive medications or cervical cerclage, your health care provider might recommend cervical cerclage before conception. It's possible, however, that the cerclage might reduce your fertility.
Cervical cerclage isn't appropriate for everyone at risk of premature birth. Your health care provider might discourage cervical cerclage if you have:
An intrauterine infection
Premature rupture of membranes — when the fluid-filled membrane that surrounds and cushions the baby during pregnancy (amniotic sac) leaks or breaks before labor begins
Prolapsed fetal membranes — a condition in which the amniotic sac protrudes through the opening of the cervix
A multiple pregnancy
A significant risk of miscarriage due to a severe fetal abnormality
A tear in the cervix (cervical laceration)
Inability of the cervix to shorten or open (cervical dystocia)
Permanent narrowing or closure of the cervix (cervical stenosis)
An abnormal connection between the bladder and vagina (vesicovaginal fistula)
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 labor begins and before week 37 of pregnancy
Movement of or loosening of the sutures (suture migration)
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 before week 37 of pregnancy if you have preterm premature rupture of membranes and a uterine infection.
Before cervical cerclage, your health care provider will likely do an ultrasound to check your baby's vital signs and rule out any major birth defects. Your health care provider might also 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, ideally you'll complete treatment before the cerclage is done. If your cervix has already begun to open or an ultrasound shows that your cervix is short, however, your health care provider might give you antibiotics shortly before the procedure to reduce the risk of infection. Also, your health care provider might recommend avoiding sex for at least one week before the procedure.
Ideally, an elective cervical cerclage is done between weeks 12 and 16 of pregnancy. An emergency or rescue cerclage, however, 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. Your health care provider might place a thin tube (catheter) in your urethra to fill your bladder and reposition the amniotic sac. Alternatively, your health care provider might insert a balloon-tipped catheter beyond the opening of your cervix and inflate the bulb to push the amniotic sac back into place.
Cervical cerclage is a relatively simple procedure. If cervical weakness is detected, a transvaginal ultrasound test is performed. This is followed by an anesthesia, which may be general, epidural, or spinal. Under anesthesia a strong thread is stitched around the cervical opening and is tightened to keep the cervix closed. The thread stitch is opened after completion of the pregnancy term in the 37th week.
Cervical cerclage is prescribed for women who are suspected of having a weak cervix due to previous damage sustained from miscarriage, abortion, or cone biopsy. The procedure is performed in the 12-14th week of pregnancy usually. In some cases a cerclage may need to be placed later in pregnancy in response to changes that may start to occur in the cervix. These are called emergent cerclages as they are used in response to emerging cervical changes such as its shortening and dilation before the completion of pregnancy term.
Expecting mothers who do not fall in the risk category for weak cervix are not eligible for treatment. Fit and healthy women with an ideal body weight also do not usually need cervical cerclage treatment if they do not belong in the risk zone.
A few days of rest after the procedure shall ensure complete recovery in about a week till the pregnancy term is completed and the cerclage needs to be removed.
Once the cervical cerclage is placed, it is advisable to take rest and avoid strenuous physical activity for a few days. It is also recommended to abstain from sexual intercourse for a week before and after the cerclage is placed.
The cervical cerclage cost in iran start from $250 for outpatient and for inpatient start from $550.