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Cerclage

Starting at: 12 weeks
Purpose: To reduce the possibility of preterm delivery or PROM.

If your previous PROM pregnancy was linked to cervical weakness or irritability (also known as “incompetent cervix” or IC), your health care practitioner may recommend preventative cerclage to stitch your cervix closed. A preventative cerclage can be put in place as early as 12 weeks, before any cervical change occurs.

Some women opt for preventative cerclage even if it is unclear whether their PROM was related to cervical weakness. Because of the risks associated with cerclage (see below), your practitioner will likely not recommend preventative cerclage if there is no evidence indicating that you have cervical weakness or that funneling is taking place. If you or your practitioner feel strongly that preventative cerclage is appropriate for you, make sure you both understand the reasons and the risks.

As an alternative to preventative cerclage, you can take a wait-and-see approach and opt for cerclage only if your practitioner identifies some cervical change. The cervix is a dynamic organ and can change very quickly so if you decide to take this approach, it is extremely important that you are monitored weekly to ensure that the emergency cerclage can be put in place in time to be effective.

The types of cervical change your practitioner will look for include:

  • Dilation: When the cervix begins to open. The opening can be anywhere from the size of a fingertip (approx. 1 cm.) or larger.
  • Funneling: When the internal portion of the cervix closest to the baby begins to open or change, allowing the amniotic sac to slip down into the cervix.
  • Effacement: When the cervix shortens in length, usually indicating approaching labor.
  • Ripening: When the physical makeup of the cervix changes from firm to soft or “ripe,” usually indicating approaching labor.

Regular monitoring is critical as your cervix can appear long and closed one week, only to show the changes described above at your next appointment. A cerclage can be done on an emergency or as-needed basis, except under certain circumstances such as if you are more than 4cm dilated or once PROM has already occurred. Members of the PROM list have found that cervical change is often detected between 15 and 24 weeks of pregnancy, perhaps from the growing weight of the baby and amniotic fluid. During this period, weekly (rather than bi-weekly) monitoring is ideal.

The general belief is that the earlier a cerclage is put in place, the more effective it is in addressing cervical weakness. There are two categories of cerclage: cervical (four variations) or transabdominal. The type of cerclage you receive generally depends on your practitioner’s expertise and the length of your cervix at the time of the procedure. Transabdominal cerclage is typically used if a woman has a very short or almost nonexistent cervix. A transabdominal cerclage is permanent and requires birth by caesarean section. A cervical cerclage is usually removed at the 37th week to allow for a normal delivery, unless there is a reason to remove it earlier.

There are some risks of cerclage, including infection, preterm labor, and even PROM. In addition, your cervix could be damaged either from the stitch or if you go into labor before the stitch is removed. There may also be some other risks depending on what type of anesthesia you choose for the procedure. Discuss types of cerclage available, risks, and long-term implications with your practitioner.

It is important not to dismiss cerclage as a viable form of treatment simply because you had a prior full-term pregnancy or because your cervix looked long and closed after PROM. As discussed in the monitoring section, the cervix is a dynamic organ and can change very quickly in a short period of time. Pressure from the growing baby and increased amniotic fluid can cause a weak or incompetent cervix to funnel, dilate, efface, or ripen (or some combination) leading to PROM. After the amniotic fluid is lost, the pressure on the cervix lessens and the cervix may return to its “normal” shape by the time of post-PROM examination, leading doctors to mistakenly rule out cervical weakness as the cause. If you are unsure whether a cerclage is necessary, talk with your practitioner about frequent monitoring.

For more information about cerclage, see this website: http://pregnancy.about.com/cs/incompetentcervix/a/aaincomp.htm

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