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Cervical Cerclage Revisited

First performed in 1902, the cervical cerclage is the mainstay surgical intervention for the prevention of spontaneous preterm birth secondary to cervical insufficiency. Currently, it is performed during an estimated 1–2% of pregnancies, although evidence for the efficacy of the procedure is often lacking. The 1950s saw publications regarding surgical technique, while controlled trials were not performed until the 1980s looking at cervical cerclage effectiveness. These trials are limited by their populations, i.e., have often been carried out in women with previous preterm birth and so are difficult to generalize to women with specific risk factors. There are still many questions to be…

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 Cervical stitch (cerclage) for preventing preterm birth in singleton pregnancy

Cervical cerclage reduces the risk of preterm birth in women at high‐risk of preterm birth and probably reduces risk of perinatal deaths. There was no evidence of any differential effect of cerclage based on previous obstetric history or short cervix indications, but data were limited for all clinical groups. The question of whether cerclage is more or less effective than other preventative treatments, particularly vaginal progesterone, remains unanswered.

 Common method of preventing early births may be causing more

New research has found a commonly used method of preventing early or preterm birth (delivery of a baby before 37 weeks) may in fact be causing more to occur, and leading to further problems. The “cervical cerclage” is a surgical procedure involving stitching the neck of the womb (the cervix) closed in pregnancy. The cerclage stitch prevents preterm birth as it provides support to a weakened cervix. This prevents the cervix from opening too early in pregnancy, and also acts a barrier, protecting the baby from vaginal infection.

Articles of Interest

Complications from cervical cerclage

Cervical insufficiency, a condition where the uterine cervix fails to retain pregnancy in the second trimester, is a common cause of spontaneous preterm birth. Cervical cerclage was developed in the 1950s to treat women with cervical insufficiency, mechanically improving the cervix’s tensile strength for increased support.

Current controversies in cervical cerclage

Cervical incompetence is defined as the inability to support a full-term pregnancy because of a functional or structural defect of the cervix. It is characterized clinically by acute, painless dilatation of the cervix usually in the mid-trimester culminating in prolapse and/or premature rupture of the membranes with resultant preterm and often previable delivery. Cervical cerclage has become the mainstay for the management of cervical incompetence, but remains one the more controversial surgical interventions in obstetrics.

Emergency Cervical Cerclage

Despite the progress of medicine in the last decades, recurrent pregnancy loss, premature birth, and related complications are still a vast problem. The reasons for recurrent pregnancy loss and preterm delivery are diverse and multifactorial. One of the main reasons for these complications is cervical insufficiency, which means that the cervix is weak and unable to remain closed until the date of delivery. It manifests as painless softening and shortening of the cervix without contractions.

Learn About Cerclage Placement Due to Cervical Insufficiency

Sometimes the cervix isn’t strong enough to stay closed as a pregnancy grows. Formerly called an’ incompetent cervix’, this condition is now called ‘cervical insufficiency’. By definition, it is “the inability of the cervix to retain a pregnancy in the absence of the signs and symptoms of clinical contractions, or labor, or both in the 2nd trimester.” In addition, there must not be any evidence of preterm prelabor rupture of membranes (PPROM), placental abruption, or infection. Diagnosis is based on a history of painless cervical dilation in the 2nd trimester with subsequent delivery of the fetus in the 2nd trimester, typically before 24 weeks of gestation.

Should I have a cerclage procedure?

Ideally, a cervical cerclage procedure is done between 12 and 14 weeks of gestation (after 14 weeks the procedure is called an emergent cerclage). The procedure can be performed up until week 23 if an exam demonstrates that the pelvis is beginning to open. The operation is typically avoided after week 24 because of the potential danger of nicking the amniotic sac and triggering premature rupture of membranes.

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StatPearls

Cervical cerclage is performed as an attempt to prolong pregnancy in certain women who are at higher risk of preterm delivery. Cerclage placement may be indicated by a history of cervical insufficiency or by certain sonographic or physical exam findings in a current pregnancy. The McDonald and Shirodkar techniques, or modifications thereof, are the most commonly used methods for placing a cerclage.