04.21.11: A stitch placed in a weak cervix to help prevent premature delivery
Tara was 20 weeks pregnant with her first baby when she started bleeding. The cramps began within hours and by the time she got to the hospital, her pregnancy was over. Eight months later, she miscarried again, this time at 18 weeks. Tara counts these experiences as the most emotionally painful events of her life and said she’d never get pregnant again. Then her doctor mentioned a cerclage.
Katherine emailed that after successfully carrying a baby to full term, she miscarried three others in less than 13 months. Her doctor said she had an incompetent cervix and would need a “stitch” (cerclage) put in to keep from miscarrying a future pregnancy. She’s considering whether she’ll try getting pregnant again and wants to know how a “stitch” would affect the rest of her pregnancy. Will it work for sure? Will she have to stay on bed rest throughout the whole pregnancy? Can she work and take care of her three-year-old? After losing three pregnancies, she doesn’t want to risk another heartbreak.
Diana had very early stage cervical cancer many years back. She’s completely healthy today, but treatment damaged her cervix. When she became pregnant, her doctor knew Debra’s cervix might not be as strong as it should be and ordered frequent ultrasounds to keep an eye it. When ultrasound showed Diana’s cervix was beginning to shorten, her doctor recommended a cerclage to keep it from dilating prematurely. Diana carried her baby to term and delivered a healthy daughter.
There are several known reasons why some women have weak or incompetent cervixes including cervical trauma (Diana), a previous birth injury or Mom’s cervix simply didn’t develop properly. There are also lots of unknown reasons. Best estimates say about 25 percent of second trimester miscarriages are due to incompetent cervixes.
One way to prevent early dilation is with a cerclage - a minor surgical procedure that “stitches” the cervix (opening to the uterus) closed. There are several different techniques used to perform this procedure and it is usually done between 12 and 16 weeks of pregnancy. Cerclage was recommended for Tara and Katherine because of what happened to their previous pregnancies. Once their babies developed enough to put a little stress on their cervixes, they dilated and couldn’t hold their pregnancies inside any longer. Diana’s medical history gave her doctor a big head’s up that she might have a weak cervix.
Most women don’t need a cerclage because their cervixes are naturally sealed up as tight as Tupperware, and only begin dilating late in pregnancy. A few women, however, aren’t that lucky. Their cervix is more like a weak seal on a Ziplock baggie held upside down. When you put a little too much weight on it, the contents of that baggie spills out. A cerclage acts like a rubber band or duct tape to keep that baggie zipped.
If you need a cerclage, you’ll go into the hospital for a day or so. You’ll receive spinal or epidural anesthesia so you don’t feel any pain. You’ll be placed in a semi-upside-down position called Trendelenberg position, so your feet are above your head and there’s no weight on your cervix. Once you’re comfortable and positioned properly your doctor will get on in there and sew that thing closed. After the procedure, you’ll stay in the hospital for anywhere from a few hours to a couple days. You’ll get antibiotics and maybe some medicine to keep you from cramping. Then you’ll go home to rest.
It seems like this part ought to be common sense, but apparently some people are in short supply of that so I’ll just say it: Don’t stick anything in your vagina for at least a week (and maybe a whole lot longer) after you have a cerclage. No sex! I’m serious about this one. You’d be surprised how many people are caught with their pants down by this pesky rule. They come back in to their doctor’s office with cervical irritation or an infection and say, “You meant no sex at all or just not very much?” I don’t really want to know what they mean by “not very much.”
Katherine asks if she’ll need bed rest for the rest of her pregnancy. Probably not, Katherine. You might have to stay on the couch for a week or two, but once your cervix has gotten over the insult of being stitched, it ought to heal well and you should be able to go about your business. You should still take it easy (let this be your excuse to lay off the marathons and mountain biking) and baby your pregnancy, but you should be able to take care of your little boy and go to work.
Does a cerclage always work? Unfortunately, no. Cerclages carry a very low risk for causing miscarriage or premature labor and a high rate for success, but sometimes infection sets in, amniotic membranes rupture and other issues crop up.
Should Tara and Katherine have another try at pregnancy, this time with a cerclage? That’s not a question I can answer. I understand how fragile a mother’s heart is after she’s lost a pregnancy (or three). It’s hard to put yourself at risk for losing another one. If your doctor thinks a cerclage might solve the problem and you feel like you could stand up to that risk, it might be entirely worth it. As I’ve said so many times before: Every pregnancy involves risks and there are no guarantees things will turn out perfectly. Sometimes risks of the heart require more bravery, tenderness and thoughtful consideration than risks of the body. Good medical care, however, means we know what to do about a lot of those risks, should you choose to take them. I’ll be thinking about you, Katherine, no matter which direction you go.
Jeanne Faulkner, R.N., lives in Portland, Oregon with her husband and five children.
This Fit Pregnancy blog is intended for educational purposes only. It is not intended to replace medical advice from your physician. Before initiating any exercise program, diet or treatment provided by Fit Pregnancy, you should seek medical advice from your primary caregiver.