Cervical cerclage

Cervical cerclage is a surgical operation performed to close up / lengthen the cervix (which is the door to the opening of the uterus or womb). This is performed in the second trimester (usually between 12-24 weeks) with the aim to reduce the risk of second trimester miscarriages from cervical insufficiency or severe premature delivery.

Cervical cerclage may be considered in one of the following conditions:

  1. Past history of a pregnancy with PAINLESS dilatation of the cervix with eventual miscarriage from 12 weeks onwards. This would be highly suggestive of cervical incompetence.

  2. Past history of 3 or more midtrimester (12-24 weeks) losses or spontaneous preterm births (24-36 weeks).

  3. Short cervix < 25 mm with a history of one or more midtrimester (12-24 weeks) loss / spontaneous preterm birth (24-36 weeks)

  4. Severely short cervix <= 15 mm on scan at the second trimester scan.

  5. Shortening cervix to <=15 mm on scan <= 24 weeks despite treatment with vaginal micronized progesterone pessaries.

  6. Physical examination that shows painless dilatation of the cervix <= 24 weeks

Risks of cervical cerclage:

  1. Infection causing miscarriage or preterm labour

  2. Rupture of amniotic membrane - either from the inadvertent suturing of the membranes during the cerclage procedure or from infection after the procedure

  3. Less common risks include cervical laceration (i.e. if tearing from the suture occurs during labour before the suture has been removed) and cervical dystocia (i.e. inability of the cervix to dilate normally during labour because of the scarring caused by the suture)

  4. Rarely, it may not be possible to complete the cervical cerclage from the transvaginal approach if the cervix is so short that it is flushed with the rest of the vaginal vault.

Surgical approach:

  1. Transvaginal approach - this is the main approach for cervical cerclage. The commonest method used for cervical cerclage is known as the McDonald's cerclage. This is the approach with the lowest risks of the surgery and is the preferred method in most cases.

  2. Transabdominal approach - this may be the method of choice if previous transvaginal cerclage operations have failed or cannot be performed as the cervix is already flushed with the vaginal vault. This method is associated with higher risks as it involves either an open abdominal incision or a laparoscopic (or keyhole) approach. This is rarely performed.