- ATHENS OFFICE MED4WOMAN ATHENS
- VOLOS OFFICE MED4WOMAN VOLOS
Obstetrician-Gynecologist
PhD, University of Athens Medical School
Obstetrician-gynecologist Panagiotis Polyzos practices at the Institute of Life, the IVF Unit of IASO Maternity Hospital.
Cervical cerclage is a surgical procedure in which a stitch is placed around the cervix (the lower part of the uterus). It is typically performed between the 12th and 24th week of pregnancy, although in some cases it may be done later in gestation.
Babies born prematurely (before 37 weeks of gestation) are at higher risk for short- and long-term health complications.
There are many causes of preterm birth; one of them is cervical insufficiency, in which the cervix shortens and dilates prematurely. Cervical cerclage can help prevent this from occurring.
A group of high-risk pregnant women who may require close monitoring from the early stages of pregnancy includes those who:
If, in any of the above cases, the cervical length is measured by transvaginal ultrasound to be less than 25 mm, your doctor may recommend:
In certain situations, the potential risks of cerclage outweigh its benefits. These include:
Cervical cerclage is performed vaginally, in the operating room, under spinal anesthesia. The bladder is first emptied, and a vaginal speculum is inserted to visualize the cervix. The cervix is then held gently using a surgical instrument, and a suture is placed around it to keep the cervical canal closed.
The procedure usually takes no more than 30 minutes. Mild analgesia may be prescribed afterward, and most patients can go home the same day.
Cervical cerclage can also be performed transabdominally rather than vaginally. This method is rarely used and is generally reserved for women in whom a vaginal cerclage has failed in the past.
Abdominal cerclage can be done before pregnancy or during early gestation. It may be performed laparoscopically or through an abdominal incision.
In the case of an abdominal cerclage, the suture is not removed, and delivery is carried out by cesarean section.
Sometimes, cervical cerclage is performed as an emergency or rescue procedure after painless cervical dilation has already begun. This is considered a last-resort intervention to try to prevent miscarriage or preterm birth. However, the risk of failure in such cases is high.
Potential risks include:
Cervical cerclage is not always successful and does not guarantee prevention of miscarriage or preterm delivery.
Vaginal cerclage does not increase the likelihood of requiring a cesarean section.
After cerclage placement, you may experience mild vaginal bleeding or brownish discharge for one to two days. Bed rest is not recommended. You may resume sexual activity once all symptoms have completely resolved.
You should contact your doctor immediately if you experience any of the following:
The stitch is usually removed in the clinic between 36 and 37 weeks of pregnancy, unless labor begins earlier.
Under normal circumstances, anesthesia is not required. A vaginal speculum is inserted, the suture is located, cut, and removed.
The process takes only a few minutes and may cause minimal discomfort. You may notice slight vaginal bleeding for about 24 hours, though brownish discharge may persist a bit longer.
If contractions begin while the stitch is still in place, you must go to the clinic immediately for removal to prevent cervical injury.
If premature rupture of membranes occurs without the onset of labor, the stitch is usually removed due to the increased risk of infection.
International guidelines, such as those of the RCOG, divide cervical cerclage into three categories according to what prompts it. The category also determines when the procedure is done.
It is recommended for women with three or more previous second-trimester miscarriages or very preterm births where no other cause was found. It is done preventively, usually at 12 to 14 weeks, after first-trimester screening is complete.
It applies to women with a history of spontaneous preterm birth or second-trimester miscarriage, whose cervical length is measured regularly from week 14 to 16. If it drops to 25 millimeters or less before week 24, cerclage is recommended.
This is emergency cerclage, when the cervix has already started to open painlessly and the membranes are visible at the opening. The decision is made on an individual basis, after infection and contractions have been ruled out.
The first category is planned and calm. The third is a race against time. That is why early monitoring of women with a history matters so much.
Cerclage is not the only treatment for a short cervix. Vaginal progesterone has proven effective and in many cases is the first choice. The decision depends mainly on your history:
Sometimes the two treatments are combined. There is no one solution for everyone. Ask your doctor to explain why they recommend this particular option in your case.
Vaginal cerclage is done mainly with two techniques, named after the doctors who described them.
Studies have not shown a clear advantage of one technique over the other. The choice depends on the length and anatomy of the cervix, previous procedures and the surgeon's experience. When vaginal cerclage has failed or the cervix is very short, e.g. after an extensive cone biopsy, abdominal cerclage is considered, which today is often performed by laparoscopy.
A planned cerclage is preceded by a few simple checks so the procedure can be done safely:
Tell the team about every medication you take, especially blood thinners or aspirin. If you have contractions, fever or bleeding the day before, call. The procedure may need to be postponed.
Cerclage does not turn your pregnancy into “bed rest.” Most women carry on with their lives with a few adjustments:
After the stitch is removed at 36 to 37 weeks, the cervix does not necessarily open right away. Many women give birth days or even weeks later, when labor starts on its own. Vaginal cerclage does not rule out a vaginal birth.
With abdominal cerclage, the picture is different. The stitch stays in place and the baby is delivered by cesarean section. If the stitch is not removed during the cesarean, it can also protect future pregnancies.
For the next pregnancy, the plan depends on how the current one went. If the pregnancy reached term with a cerclage, it is usually recommended again. In women with recurrent miscarriage, a full workup before the next pregnancy helps determine whether the cervix is the cause or whether other factors, such as hormonal, anatomical or immunological ones, are also involved.
Write down the answers and keep them with your pregnancy documents, so you have them on hand at any emergency visit.
Not complete bed rest. Rest is recommended for the first few days, along with avoiding strenuous activity and heavy lifting. Prolonged bed rest has not been shown to help and increases the risk of blood clots. Your doctor will give you exact instructions.
They are rare. They include infection, bleeding, premature rupture of the membranes, uterine contractions and injury to the cervix if labor starts before the stitch is removed.
They depend on why it is done. With planned, history-indicated cerclage, most pregnancies reach an advanced week. With emergency cerclage, the rates are lower.
Abstinence is usually recommended for a period after the procedure, and in some cases for the whole pregnancy. Follow your doctor's advice.
Around week 36 to 37, in the office or at the maternity hospital, usually without anesthesia. It is removed earlier if contractions start or your water breaks.
Preventive cerclage is not recommended in twin pregnancies, because studies have not shown a benefit. In selected cases, when the cervix is very short or has already opened, the decision is made individually at a specialized center.
Not necessarily. For many women, labor starts days or even weeks after removal, when the time comes. However, if regular contractions start or your water breaks, go to the maternity hospital.
It depends on why it was done and how the pregnancy went. It is often recommended again, either preventively or after monitoring cervical length. Ideally, the plan is discussed before the next conception.
In an uncomplicated pregnancy, a short trip is usually allowed once the symptoms of the procedure have subsided. Discuss it with your doctor first and avoid destinations far from a well-equipped maternity hospital.
