Dizzy, your scan pic rocks!
So I am the cerclage girl, huh?? lol. Yes, I suppose I am the one to ask...
So what do you want to know?? There are 4 types, 3 are vaginal, 1 is abdominal. The most common type is a vaginal cerclage called a McDonald Cerclage, which is sewn in like a purse string at the very bottom of the cervix, on the portion that extends into the vagina. With this one they take a strong fibrous material, and they sew it through the cervix itself.
First and foremost, no matter what type of cerlcage you are getting, it should be done PREVENTATIVELY!! Which means.... 12-14 weeks, NOT 22 weeks. At 22 weeks, it is considered a 'rescue' cerclage, and it is placed AFTER the cervix has already started shortening or opening. In these situations the risk of infection during surgery are much higher, risk of rupturing the amniotic sac are higher as the sac is usually down in the birth canal already, and there is less chance of having it hold successfully, as many times, the sac is in the birth canal, and the pressue will just rip right through the stitch.
So no matter what, you MUST get them done preventatively, if you want the best chance of success.
The McDonald cerclage is the most common, however, it will have the highest failure rate. For most people it will be just fine, but you have to imagine that if you are sewn at the bottom of your cervix (for arguements sake, lets say your cervix is 5cm long). So if you are sewn at the bottom portion, you can still shorten, and funnel, right down to that stitch, meaning you will have preserved none of your cervical length. You also lose out on 5cms of cervical mucous, which is very important for blocking potential infectious bacterium from ascending up the birth canal. So, of all of the cerclages, this is the most common, but not the strongest, or the best, it is simply the easiest to perform.
So after this you have something called a Shirodkar. This is also a vaginal one, and it will go halfway up your cervix, so imagine it being 2.5cm up. In order to get there, because remember, only a little nubbin of your cervix extends into your vagina, they will actually have to cut and dissect the walls of the vagina away from the cervix (which is like a hollow long doughnut, and swells closed when pregnant and filles with mucous). So in this one, they will usually cut open your thigh muscle to remove some of the fibrous tissue located there, and it is this that they will use to suture your ceriv shut, 2.5 cms up. The theory is that since they are using a piece of your own body, you will be less likely to become inflamed or become infected. So once they have sewn the cervix shut using your thigh tissue, they will then sew the walls of the vagina back down onto your cervix, which will automatically enclose your stitches in your own tissue, and this is also a way of stopping inflamation and infections. Once again, since they are sewing through your cervix you are open to infection, and you can rip through this stitch as well. Also, since there is still 2.5 cm of cervix above, you can funnel down to this stitch. You have preserved a bit more cervical mucous though, which is good, but bacteria can still travel up that first 2.5cm which is kind of unprotected.
Next you have something called a CervicoIsthmic Cerclage (spellings vary). This one is the one that is probably done the least and is the least well known. It is actually very hard to find information on this one. This is a specialized one where they approach it from the vagina, but they are trying to place the stitch at the junction where the cervix meets the uterus. In reality, the cervix and the uterus are part of the same organ, its just the cervix is the lower portion which goes into the vagina. So with this one, they will open you up with clamps (just like the other ones), and they will try to use pliers etc to pull down muscles and ligaments that surround the top of the cervix. Once they have pulled these down, they sew the whole mess of things together. This is one of the strongest cerclages there is. It would be hard to funnle, shorten, thin, etc past this cerclage, as realisticly, there shouldn't be any way for the gestational sac to dip through this. Of course, this still can happen. With this cerclage you are also preserving the entire tube of cervical mucous, meaning, if a bacterial infection is trying to ascend, it has to get through 5cm of mucous before it can touch the gestational sac. With this cerclage thoug, they are working much closer to the Amniotic sac, and there is a greater risk of puncturing the sac and causing a miscarriage, however, miscarriages are a risk with any cerclage. For this reason, this surgery is usually taught only to, and by, surgeons who work with cervical cancers etc, as removing cancer from the cervix requires a fine hand and good technique.
The Cadillac of all cerclages is the only one that can be done abdominally, the Trans Abdominal Cerclage. This is also a very specialized surgery, and only a handful of surgeons are qualified to perform it. With this one, they will cut you open like you are having a c-section. They will locate your bladder, push it, or lift it up, and this will expose your entire uterus, cervix, etc. They locate the juncture of the cervix and the uterus, and in this surgery, the only one... they don't sew through anything. Instead, they place a 5mm band of material through and around the ports that surround the juncture of the cervix/uterus. They tighten this up, and cut away the excess material. They release the bladder, and it will settle down on top of the uterus, back in its regular position. They then sew you up, and you are done. This one is usually reserved for someone who has lost all or most of their cervix due to cancer etc, or who has failed one or more transvaginal cerclages. There is obviously a much greater risk of damaging the uterus as they are working cms away from it, and it is completely exposed. This is also the only permanent cerclage there is. The other ones will all be removed prior to delivery, allowing for a vaginal birth. With this one, it stays in for life. After the surgery, and due to the pressure of the uterus, the stitch actually becomes embedded below, and in order to remove it, they would have to dissect ALOT of tissue to find it. Most Drs don't want to do this, and it isn't neccessary, as your body has built up protective tissue around it, so it just stays in. BUT, you are committing yourself to a C-Section with this cerclage. This surgery can be done during pregnancy, or before pregnancy. Before pregnancy, you must make sure that the surgeon leaves enough of an opening so sperm can get in, and period blood can get out. Sometimes having it done before pregnancy can damage the crypts in the cervix which produce mucous, which can lead to a loss of CM, which means sperm will have a much harder time travelling to the uterus, and staying alive. So it can lead to secondary infertility. Strangely enough, when the surgery is done during pregnancy, it doesn't have this effect. After the baby is born, your tissues become less swollen, causing a natural opening to happen with the cerclage, which allows blood out and sperm in. This cerclage stays in place for subsequent pregnancies, and once you do become pregnant again, your tissues around it swell, closing the cerclage off fully once again.
With the TAC, it is serious surgery, and recovery can take 2-3 weeks, which some people are not happy with while pregnant. It can also be extremely painful, and obviously you are limited to the pain relievers you can use if you are pregnant. With this one, the rate of infection is drastically reduced as they are not actually sewing into your tissue, so you don't get that inflmatory process surrounding the other cerclages. You also preserve the entire length of cervical mucous. If done coreectly it is IMPOSSIBLE to funnel through this cerclage, so it virtually eliminates the need for a cervix altogether. However, if you have had prior operations to your uterus, such as one or more c-section, you are at a greater risk of uterine rupture if you do go into labour with this cerclage in place. As the uterus contracts and builds up pressure, it doesn't have a way to be released as you don't really have a cervix to open. So, to relieve pressure, it can rupture the uterus.
With all of these cerclages, there is a risk of miscarriage, blood loss, piercing of the amniotic sac by a needle, irritable uterus which can lead to PTL. So none of them should be taken lightly.
Recovery with the McDonald and Shirodkar cerclages are apparently similar. For me, the recovery with the McDonald was pretty easy. Of course I was nervous before, but they did an ultrasound to show me she was safe. You get into the OR, lay on the table, they put your legs in stirrups, and you are put to sleep. You wake up groggy, but as you get over that, of course there is some aching and pain, and concern that everything is okay. I think the fear that something has gone wrong makes any pain worse, so hopefully they will do a scan for you quicker than they did mine. Peeing burns to begin with, I will say that. And the worst part for me was the packing. They end up shoving a length of gauze up your vagina, probably about 10-15 feet long. This 'packing' is to help with post surgery bleeding. I wasn't bleeding alot at all, which was a good thing, but even still, the packing had to stay in for about 6 hours post surgery. It is this packing which can irritate the urethra and make it feel like you have a bladder infection constantly. It also hurts if you move, as the gauze is rubbing and tugging right where you were operated on. It is worse if the gauze starts coming out a bit as you will have this sort of tail hanging between your legs, and the weight of it coming out is awful on your surgery site. They will make you get up onto a bedside commode within the first 2 hours. You will have to use the bedside commode for about 2 hours after they have removed the packing, so about 8 hours. Removing the packing hurts, I will NOT lie about that. I was NOT in a maternity unit, so my nurse had never done this before, and didn't know what she was doing. She thought that since there was already 6 inches hanging down, it was pretty much all the way out. So she was slowly pulling the rest out, and I was crying and screaming because it was burning like you wouldn't believe. And she just kept pulling this stuff out, and I would ask her how much was left, and she would say, oh just a bit more, and she was wrong! It was bloody awful. Like I said, it was about 10-15 feet long in the end... The pain relief was IMMEDIATE once the packing was out. I was discharged the next day, and there was a bit of aching, but I didn't even need Tylenol for pain. It takes a couple of days to start feeling comfortable getting up and going again, but once I was confident things were good, I was fine with walking 2 or 3 kms at a time. There will be mild pulling and pinching as your uterus grows and pushs and pulls by your stitches.
My cerclage did end up failing. Not the stitch itself, but I contracted an infection at the site of the stitches at the end of my 21st week. It ascended the birth canal very quickly, not helped by the fact that my Dr didn't believe I had an infection, so he didn't treat me. By the 6th day of going untreated, I had started dilating through the stitch, meaning my stitch moved out of the way, but still remained closed, and instead, I tore a new opening to my cervix beside the original, sewn shut, opening. My labour was quick, and the stitch was NOT removed, which was the WORST thing the Drs could have done for me. They thought by leaving it in, they might be able to give my cervix a bit more help, but I think there is a point where they should have clipped it as it obviously wasn't helping. So I did deliver Devon through a hole that was ripped beside my cervical opening. After she delivered, I reminded them of the stitch, and that was when they snipped it.
When Trans Vaginal Cerclages DO fail, it is usually as a result of an infection. I believe the success rate of the McDonald cerclage itself is about 75-80%. And when it does fail, about 97% are as a result of infection.
I don't think there is anything I've missed out on...
xx
