Cervical insufficiency and cervical cerclage

Cervical insufficiency is the medical term used to describe a short or weak cervix which is incapable of sustaining a full-term pregnancy. A pregnant woman with a weak cervix is likely to experience premature labour and childbirth—often as early as the 24th week of pregnancy, which involves huge risks for both mother and child. 

Some women who experience cervical insufficiency during one pregnancy do not experience it during consequent pregnancies. In other cases, women find cervical insufficiency to be a recurrent problem in all their pregnancies. Doctors and scientists believe this issue usually occurs due to a structural weakness of the cervix. The following issues are also likely to cause cervical insufficiency:

• Previous miscarriages: Women who have had previous miscarriages, especially recurrent miscarriages, are likely to have an increased risk of cervical insufficiency.
• Collagen disorders: Women who have genetic disorders that affect the production of collagen in the body might also have an incompetent cervix.
• Gynaecological lesions: Women with precancerous lesions on the cervix—even the ones who’ve had the lesions removed—may be at a higher risk of cervical insufficiency.

There is, unfortunately, no advance warning for cervical insufficiency, but a lot of women experience the following symptoms:

• Vaginal pressure
• Spotting or light vaginal bleeding during pregnancy (a type of abnormal uterine bleeding)
• Abdominal or lower back pain
• Vaginal discharge during pregnancy

If the above-mentioned symptoms show up, you should consult a doctor immediately. A simple pelvic exam can reveal if your cervix is soft, effaced or dilated. For women who might have a history or higher risk of cervical insufficiency, however, the doctor may begin monitoring the cervix’s condition from the 16th week of pregnancy, and might even give you a progesterone supplement early on to prevent cervical insufficiency. If the condition is diagnosed a little late, or if the risk of it getting worse soon is higher, then a cervical cerclage may be the best form of treatment for you.

Cervical cerclage is a simple surgical procedure where the doctor places a single stitch or a number of small stitches on the cervix to sew it close. The procedure is performed before the 25th week of pregnancy. The stitches remain in place until you get close to the full term of your pregnancy (which is the 36th or 37th week), and then the doctor removes the stitches. Removing the stitches doesn’t induce labour, but even if it does, you can safely deliver your baby by that point. 

This is a safe outpatient procedure performed under regional anaesthesia, and usually, women are able to go home within hours of it. In some cases, observation and hospitalisation may be required only if the risk of complications is high. There are two cerclage techniques that are used across the world:

• The McDonald method involves a needle which is used to place stitches through the cervix, and the ends of the sutures are tied in a purse-string knot.
• The Shirodkar method involves dissecting around the cervix and placing stitches around it to keep it closed.

Cervical cerclage is a simple surgical procedure that takes about an hour under local anesthesia. While in the operating room, the patient is put under regional anesthesia and a speculum is introduced into the vagina to access the cervix. The doctor then places the chosen type of stitch—which is either the McDonald method or the Shirodkar method—on the cervix to close it shut. The speculum is then removed and the patient is allowed to recover until they’re ready to go home within a few hours.

Your doctor may recommend at least two or three days’ bed rest after the procedure so that your body can heal. There might be a few post-procedure symptoms like mild cramping, light bleeding and vaginal discharge. Patients are usually able to get back home later in the day. Like with all surgeries, there is a risk of infections with cervical cerclage—which is why it’s important to keep a close check on a pregnant woman’s health after this procedure.

Even though cervical cerclage is a minor surgical procedure, it’s still a surgery, and you should take ample care after it. The following are some of the things you can expect after a cervical cerclage procedure.

• You might have to stay in the hospital for a few hours (or overnight, if your doctor recommends it) to ensure that you don’t have any severe complications or go into premature labour due to such issues.
• You might experience bleeding, mild cramping and vaginal discharge immediately after the procedure, which is likely to stop within a few days.
• You might be prescribed medications to prevent infections and the risk of other complications.
• You must rest for two-three days after the procedure and avoid physical activity. Your doctor will let you know exactly how long you need to rest for and when you can resume normal activities.
• You must abstain from sexual intercourse for a week before the procedure and for at least a week afterwards. Your doctor will recommend if and when you can resume sexual activity after the procedure. (Read more: Sex during pregnancy)

Cervical cerclage is the most effective way of treating cervical insufficiency and helps avoid premature labour and birth. According to the American Pregnancy Association, cervical cerclage is successful in 85-90% of cases. Women pregnant with twins or multiple foetuses are never recommended cervical cerclage, even though cervical insufficiency may be a bigger issue for them. This procedure is conducted only when necessary, and when true cervical insufficiency is confirmed by a doctor.

Read more: Twin pregnancy: symptoms, causes, types, complications, caring for a multiple pregnancy

There are minimal risks involved in the procedure of cervical cerclage. Most medical professionals will actually recommend that the life-saving benefits of this procedure far outweigh the possibility of some risks. However, since it’s a surgery, the following complications might occur after cervical cerclage:

• Premature contractions
• Infections
• Bleeding
• Ruptured membranes (Water breaking)
• Cervical laceration (if the delivery happens before the stitch is removed)
• Cervical dystocia or the inability of the cervix to dilate naturally prior to and during labour
• Miscarriage or stillbirth if the stitch fails

It’s important to contact your doctor immediately if there are any symptoms of a severe issue after the cervical cerclage procedure is conducted. The following are the symptoms you and your family should look out for:

• Contractions or cramping
• Lower abdominal pain or back pain that comes and goes
• Fever over 100 degrees Fahrenheit or 37.8 degrees Celsius
• Nausea and vomiting
• Foul-smelling vaginal discharge
• Water breaking or leaking
• Vaginal bleeding

Cervical cerclage is considered to be the best treatment for cervical insufficiency, according to modern medical science. There are times when cervical insufficiency is discovered after the 25th week of pregnancy and the cervical cerclage cannot be placed. In such conditions, doctors recommend bed rest and no/minimum physical activity. These measures, however, can delay the premature labour and birth only for a limited time and are unlikely to work till the end of the term.