Types and Timing...

[diamondintherough]

Hi Laura,

I was wondering what you could tell me about the different types of cerclages? I've read about transabdominal, and transvaginal - - also about the option of having a cerclage placed prior to pregnancy?

Thanks in advance!

[vivc]

Diamond, I'll pop in here until Laura posts.

The transabdominal is the cerclage that's often used for a multiple pregnancy, or when vaginal cerclages have failed. This one is often left in place, and is the one that would be placed before pregnancy. I've only heard of that happening before multiple embryos are placed, since the weight of more than one baby would be awful for an incompetent cervix. There are several types of transabdominal cerclages - Laura's got them all memorized. But they all do the same thing - tie shut the top of the cervix so that funneling isn't even a possibility. This allows the entire uterus to support the baby's weight, rather than just the bottom.

There are a few types of vaginal cerclages. The MacDonald cerclage is rarely left in, due to the risk of infection, since parts of the stitch are outside of the skin. The Shirodkar can be left in place, since it's enclosed under the skin, and has been successful in preventing losses in up to 3 pregnancies in a row (I don't think I'd risk more than 2). A lot of doctors do a modified Shirodkar, which is under the skin except for the places where it's tied. Again, the risk of infection usually requires it to be removed around 37 weeks.

Most cerclages are MacDonald these days, since they're the easiest to place. If a cerclage is left in place, vaginal delivery is not possible. While I did deliver a 24-weeker through an intact stitch (idiot doctor), I REALLY don't recommend trying it!

[LaurAnnHere]

The type of cerclage you get depends on your needs and your diagnosis. If you have enough cervix then the MacDonald cerclage is really your best bet. You've probably already read about it. However, there are situation where other types of cerclages are necessary. I haven't actually met anyone who has had a cerclage placed prior to pregnancy. I have read about it. Some of the cerclages are permanent sutures. In this case they would be present for subsequent pregnancies as well. I personally would not want one placed prior to pregnancy because they eliminate the possibility of a vaginal delivery. You've probably already read the cerclage info on the website, but in case you haven't I'll paste it here...

A cerclage is a suture used to sew the cervix closed to reinforce a weak cervix. It is usually done between weeks 12 and 16. A cerclage will usually be removed between weeks 36 and 38 to prevent problems during labor and delivery. There are three different types of cerclage. They are the McDonald, the Shirodkar, and the Trans Abdominal (the Trans Abdominal cerclage can be done in a few different ways and may also be called the Hefner - or Wurm - procedure, the Uterosacral cardinal ligament, or the Lash). The McDonald and the Shirodkar are the most commonly used methods.

The McDonald cerclage is the most common, and the easiest to perform. It is done with a 5 mm band of suture placed on the cervix when there is effacement of the cervix or a history of prior incompetent cervix. It is usually removed at 37 weeks in an uneventful pregnancy (Certain problems, like infection, preterm labor or premature rupture of the membranes, make earlier removal more likely).

The Shirodkar cerclage is usually placed higher on the cervix than the McDonald cerclage. It is often used when a previous McDonald cerclage has failed or when the cervix is more likely to open up after suture. The cerclage is usually placed entirely under the skin, and because it was left in place, it originally required a cesarean delivery. Today, most physicians perform a modified Shirodkar, in which the stitch can be removed and a vaginal delivery can occur. Ask your practitioner which procedure they perform.

A Trans Abdominal cerclage is used when the cervix has been extensively biopsied, damaged, or removed. It is also used in cases of higher-multiple pregnancies. The suture is inserted through the abdomen above the pubic area. It is usually placed between weeks 11 and 12. Barring complications, the cerclage will then be removed at 37 weeks. If problems arise, the cerclage can usually be removed through the vagina. When the pregnancy continues to full-term, a cesarean section is performed and the suture left in place to protect future pregnancies. After two pregnancies, the cerclage may have to be replaced.

[diamondintherough]

Thank you both for your info on this. I've read about women who swear by the transabdominal, even as a first cerclage, because of failed transvaginal attempts. But I understand that majority of the time, the Macdonald has been sufficient.

I was curious, too, about my own situation. I'm not pg yet. But I've had two pregnancies in the past. My first was lost at about 18 weeks, and it was discovered that I had a very severe septum (Bicornuate uterus). I had that repaired, and conceived my son. IC came up, and that pregnancy had me on bedrest for pretty much the whole 9 months.

My infertility specialist said that sometimes the uterus has a 'memory' and still acts up, despite the repair. I know I should talk to her about it more in detail, but I left with the impression that the IC could have been a seconday result to a bad uterus. What do you ladies think?

She did say that next time around if my cervix began to shorten again, they would put in a cerclage. Personally, I am not going to wait until there is a problem, I will have a preventative cerclage put in. With my son, I was 22 weeks along before my cervix measured half a centimetre. By then it was too late to do a cerclage, and I ended up on my back in the hospital for 10 weeks (and then another 6+ weeks at home on bedrest). There is no way I can spend that kind of time in the hospital again, especially now that i have a toddler at home.

Is a cerclage good enough to keep me out of the hospital, and just take it extremely easy at home?

Sorry I know I've blasted you with q's - please take all the time you need. I know it isn't medical advise, and you are just giving your opinions on your own research.

[vivc]

Diamond, most women with preventative cerclages don't need bedrest at all after the initial cerclage healing time. I was on bedrest for a week after the cerclage, then I had two weeks of working halftime and resting the remainder of my day. During my freakout time, when I lost Rivi last time, I insisted on part-time work hours, even though my doc was sure it wasn't necessary.

Depending on the surgery they did to your uterus, I guess it's possible that some damage might have been done to your cervix. That might have caused your IC. Or, it might be totally unrelated. I would insist on a preventative cerclage around 13 weeks next pregnancy and cervical U/S at least every other week to make sure it's doing okay. I would also memorize the symptoms of PTL (preterm labor), just in case.

My worry about waiting for your cervix to shorten is that you'll lose valuable cervical length! A stitch will help hold it together...if you wait until something's wrong, the stitch might not be as effective (and you'll be more likely to end up on fulltime bedrest).