A cervical cerclage is a specialized surgical procedure performed during pregnancy in which a strong stitch is placed around the cervix, the lower part of the uterus that opens into the vagina. This stitch acts like a drawstring or a purse-string, reinforcing the cervix and helping to keep it closed. The primary purpose of a cervical cerclage is to prevent a premature birth or a late miscarriage for women who have a condition known as cervical insufficiency, sometimes referred to as an incompetent cervix. This is a condition where the cervix is weak and begins to shorten and open too early in the pregnancy, without the presence of contractions or labor. For women who have experienced the profound loss of a baby in the second trimester due to this condition, a cervical cerclage in a subsequent pregnancy can be a life-saving intervention.

The procedure is a proactive measure to provide mechanical support to the cervix, helping it to hold the growing weight of the pregnancy. It is typically performed between 12 and 24 weeks of gestation and is a decision made after a careful assessment of a woman's obstetric history and, in some cases, ultrasound findings. While the procedure carries some risks, for the right candidate, it significantly increases the chances of carrying the baby to term or to a viable gestational age. At Fortis Healthcare, our teams of high-risk obstetricians and fetal medicine specialists provide compassionate and expert care, guiding patients through this delicate procedure with the ultimate goal of achieving a healthy pregnancy and a healthy baby.

Understanding the Underlying Condition: Cervical Insufficiency

To understand why a cerclage is necessary, it is crucial to understand the vital role of the cervix during pregnancy and the condition that compromises its function.

The Role of a Healthy Cervix in Pregnancy

During a normal pregnancy, the cervix acts as a strong, protective gatekeeper for the uterus. It is a muscular structure that is designed to remain long, firm, and tightly closed for the full nine months. This strength is essential to hold the growing baby, the amniotic fluid, and the placenta securely inside the uterus. In the final days or weeks of pregnancy, the cervix begins to soften, shorten a process called effacement, and open up a process called dilation in preparation for labor and delivery.

What is Cervical Insufficiency?

Cervical insufficiency, or incompetent cervix, is a medical condition where the cervix is structurally weak and unable to remain closed under the increasing pressure of a growing pregnancy. In women with this condition, the cervix begins to efface and dilate painlessly and passively, typically in the second trimester of pregnancy between 16 and 24 weeks. This can happen without any of the usual signs of labor, such as contractions. This premature opening can lead to the bulging of the amniotic sac into the vagina, the rupture of the membranes, and ultimately, the loss of the pregnancy or an extremely premature birth, often before the baby is viable.

Causes and Risk Factors for Cervical Insufficiency

In many cases, the exact cause of a weak cervix is unknown. However, some known risk factors include:

• Previous Trauma to the Cervix: This can occur from a difficult childbirth that caused a cervical tear, or from certain gynecological procedures like a D&C (dilation and curettage) or a cone biopsy.
• Congenital Uterine Abnormalities: Some women are born with an unusually shaped uterus or a congenitally short cervix.
• Exposure to DES: In utero exposure to a synthetic estrogen called diethylstilbestrol DES, which is no longer prescribed.
• Connective Tissue Disorders: Certain genetic disorders like Ehlers-Danlos syndrome can affect the collagen that gives the cervix its strength.

The diagnosis is often made retrospectively, after a woman has experienced one or more characteristic second-trimester pregnancy losses.

What is a Cervical Cerclage? The Surgical Techniques

A cervical cerclage is essentially a reinforcing stitch placed in the cervix. There are several different techniques, chosen based on the patient's specific anatomy and obstetric history.

Transvaginal Cerclage

This is the most common approach, where the stitch is placed through the vagina.

• McDonald Cerclage: This is the most frequently performed type. The surgeon uses a needle to place a single, strong suture high up around the outside of the cervix, much like the way you would tighten the drawstring on a purse. The two ends of the suture are then tied together, cinching the cervix closed.
• Shirodkar Cerclage: This is a more complex technique that involves making small incisions in the vaginal wall to access the cervix at a higher level. The stitch is placed and tied, and the incisions are closed, often burying the knot beneath the vaginal lining. This technique is sometimes used if the cervix is very short or scarred.

Transabdominal Cerclage

This is a much less common and more invasive procedure, reserved for specific situations.

• The Procedure: This is a major abdominal surgery, similar to a caesarean section. The surgeon places a permanent band or stitch at the very top of the cervix, at the junction between the cervix and the main body of the uterus.
• Indications: A transabdominal cerclage is typically only recommended for women who have had previous transvaginal cerclages fail, or for whom a vaginal approach is not anatomically possible due to a very short or absent cervix. It is often placed before pregnancy or in the very early first trimester. A baby must be delivered via caesarean section with this type of cerclage, and the stitch is usually left in place for future pregnancies.

When is a Cerclage Recommended? The Types and Timing

The decision on whether to place a cerclage and when to place it is a critical one. There are three main scenarios.

• History-Indicated or Prophylactic Cerclage: This is a preventative cerclage placed based on a woman's past pregnancy history. It is offered to women with a classic history of one or more second-trimester pregnancy losses due to painless cervical dilation. It is performed proactively in the early second trimester, typically between 12 and 14 weeks of gestation, before any cervical shortening has occurred.
   
• Ultrasound-Indicated or Therapeutic Cerclage: This is for women who may not have a classic history of loss but have other risk factors such as a previous preterm birth. These women are monitored with frequent transvaginal ultrasound scans, usually every one to two weeks, to measure the length of their cervix. If the ultrasound shows that the cervix has started to shorten significantly typically to less than 25 millimeters before 24 weeks of pregnancy, a cerclage is then recommended to prevent further shortening and dilation.
   
• Rescue or Emergency Cerclage: This is performed when a woman presents for an examination in the second trimester and is found to have a dilated cervix, often with the fetal membranes bulging into the vagina. This is a high-risk situation, but if there are no signs of infection or active labor, a cerclage may be attempted to try to close the cervix and prolong the pregnancy.

Our Specialists

The placement of a cervical cerclage and the management of a high-risk pregnancy require the expertise of a specialist in Maternal-Fetal Medicine MFM or a high-risk obstetrician.

Dr. SEEMA THAKUR

SENIOR CONSULTANT FETAL MEDICINE | Fortis Shalimar Bagh

Dr. Jayati Dureja

CONSULTANT FETAL MEDICINE | Fortis La Femme GK

Dr. Joyce Jayasheelan

CONSULTANT OBSTETRICS & GYNAECOLOGY | Fortis BG Road

Patient Stories

"After losing our first baby at 20 weeks due to an incompetent cervix, we were heartbroken and terrified to try again. For our next pregnancy, our fetal medicine specialist at Fortis recommended a history-indicated cerclage. We had the stitch placed at 13 weeks. The procedure was quick and went smoothly. For the rest of the pregnancy, that little stitch represented so much hope. It allowed us to carry our daughter to term, and she was born healthy and strong. The cerclage was truly the anchor that held our pregnancy safe." - Kavya Nehra, 32, Gurugram

"Because my first baby was born prematurely, my doctor monitored my cervical length very closely with ultrasounds during my second pregnancy. At 22 weeks, the scan showed my cervix had started to shorten significantly. My doctor explained the situation and recommended an ultrasound-indicated cerclage. It was a scary time, but the team acted quickly. The procedure was successful, and with the cerclage and some activity restriction, I was able to carry my son for another 14 weeks. I am so grateful for that close monitoring; it made all the difference." - Radhika Kumar, 29, Delhi

The Cervical Cerclage Procedure: A Detailed Walkthrough

Preparation

• Evaluation: You will have a thorough evaluation, including a transvaginal ultrasound, to assess your cervix and to check for any signs of infection or uterine contractions.
• Anesthesia: A transvaginal cerclage is a surgical procedure performed in an operating theatre. It is typically done under spinal or epidural anesthesia, which numbs the lower half of your body, though general anesthesia may also be used.

The Surgical Procedure

• Positioning: You will lie on your back on an operating table with your feet in stirrups, similar to a gynecological exam.
• The Procedure: The surgeon will use a speculum to view your cervix. Using surgical instruments, a strong, non-absorbable suture is passed around the cervix and tied securely to cinch it closed. For a McDonald cerclage, this is done on the outer part of the cervix. For a Shirodkar, it involves small incisions and is placed higher.
• Completion: The procedure itself is usually very quick, taking about 30 to 60 minutes.

After the Procedure

• Immediate Recovery: You will be monitored in a recovery area for several hours after the procedure to ensure there are no contractions or other complications. You may be given medications to prevent infection and preterm labor.
• Hospital Stay: You may be able to go home the same day, or you may be kept in the hospital overnight for observation.
• At-Home Care: It is normal to experience some light spotting, cramping, and vaginal discharge for a few days after the procedure. Your doctor will give you specific instructions regarding activity restriction. This may range from taking it easy for a week or two, to more significant restrictions on physical activity and pelvic rest for the remainder of the pregnancy.
• Ongoing Monitoring: You will have regular follow-up appointments and ultrasounds to monitor your cervix and the well-being of your baby.

Cerclage Removal

For a transvaginal cerclage, the stitch is removed in the doctor's office or in the hospital at around 36 to 37 weeks of gestation to allow for a normal vaginal delivery. The removal is a quick procedure that does not require anesthesia.

Myths vs Facts

Take the Next Step

For women who have faced the heartbreak of a second-trimester loss or who are at high risk for preterm birth due to a weak cervix, a cervical cerclage can be a profoundly hopeful and pregnancy-sustaining intervention. It is a proactive surgical step that provides physical support when it is needed most, offering a much greater chance of bringing a healthy baby into the world.

The decision to proceed with a cerclage is a significant one, made with careful consideration and expert guidance. A detailed consultation with a fetal medicine specialist or a high-risk obstetrician is the essential first step to understanding your personal risk and determining if a cerclage is the right and safest path forward for you and your pregnancy.

CTA: Book a Fetal Medicine Consultation / Get a Second Opinion

Frequently Asked Questions

Q1. How successful is a cervical cerclage?

Ans. The success rate, defined as the ability to prolong the pregnancy and result in a live birth, is very good, especially for history-indicated prophylactic cerclages. Success rates are often reported to be between 85% and 90% for these patients. The success rate for a rescue cerclage is lower but can still be life-saving.

Q2. What are the main risks of a cervical cerclage procedure?

Ans. While generally safe, potential risks include premature contractions, premature rupture of membranes, infection of the cervix or amniotic sac chorioamnionitis, and bleeding. There are also risks associated with the anesthesia. Your doctor will discuss all potential risks with you in detail.

Q3. What signs or symptoms should I watch for after the procedure?

Ans. Your doctor will give you a list of warning signs. You should call your doctor immediately if you experience regular, painful contractions, a gush of fluid from your vagina which could indicate your water has broken, heavy vaginal bleeding, or a fever.

Q4. Can I have a normal vaginal delivery with a cerclage?

Ans. Yes. For a McDonald or Shirodkar cerclage, the stitch is removed around 37 weeks of pregnancy, specifically to allow for a normal vaginal labor and delivery to occur.

Q5. Is a cerclage always necessary in every pregnancy after one is placed?

Ans. Not necessarily. A diagnosis of cervical insufficiency can sometimes be specific to one pregnancy. However, if you have a classic history of painless second-trimester loss, it is very likely that you will be recommended to have a cerclage in all future pregnancies.

Q6. Will I need to be on bed rest after the procedure?

Ans. The recommendations for activity after a cerclage vary widely. While strict bed rest is rarely prescribed today, your doctor will likely recommend a period of reduced activity and pelvic rest meaning no intercourse or douching for the remainder of your pregnancy.

Q7. What is the difference between a cerclage and progesterone treatment?

Ans. Both can be used to prevent preterm birth. A cerclage is a mechanical, surgical solution to support a weak cervix. Progesterone is a hormonal treatment, usually given as a vaginal supplement, that is believed to help keep the uterus relaxed and may have anti-inflammatory effects on the cervix. Sometimes, both treatments are used together.

Q8. When is it too late to get a cerclage?

Ans. A cerclage is generally not placed after 24 weeks of gestation. After this point, the risks of the procedure, such as accidentally rupturing the membranes, are thought to outweigh the potential benefits.