Abdominal or Vaginal Cerclage? Dun dun dun….
I was 100% set in getting a vaginal cerclage and I decided I would leave it up to my Perinatologist as to whether I should get a McDonald or Shirodkar stitch placed (there are some things google cannot answer for you!). Then I read about women whose vaginal cerclages failed and were told, or independently determined, that an abdominal cerclage was the only way they were going to deliver a healthy, term baby.
An abdominal cerclage is done under general anesthesia and is a fairly intensive stomach surgery. The incision appears to be at least the length of a cesarean and the recovery time is approximately the same. As with any surgery, there are risks and the more exposed the internal structures of the body are, the higher the chances are an infection could occur. The abdominal cerclage can be done while pregnant or preventively before conception occurs. Many women who have cervical incompetence and opt for the abdominal cerclage, do so before they are pregnant.
Pros: The abdominal cerclage is placed above the internal OS (top of the cervix) so it is significantly stronger than a vaginal cerclage. It is possible to completely prevent or greatly reduce shortening or funneling of the cervix and most women do not have to go on bed rest since their cervical length stays within normal ranges. Since the abdominal cerclage does not need to be removed, you do not have to repeat the procedure with every pregnancy.
Cons: It’s an abdominal surgery and the recovery time is greater than a vaginal cerclage. Also, a cesarean section is required for the delivery of your baby. I would assume this means careful monitoring of your contractions, especially as you get closer to term, because you don’t want to risk causing your baby distress in the event your labor progresses without enough time to get to your hospital and prepped for surgery (if vaginal delivery was an option, your body would just deliver rapidly i.e. why some babies are born in cars).
The pro’s, at least on paper, seem to greatly outweigh the cons. So, why isn’t it as common? I think the problem lies with the fact that cervical incompetence is a fairly common diagnosis for anyone who experienced the loss of their baby between 16 and 24 weeks. If your bag of water dropped or you dilated prior to your OB tracking any cervical changes, they cannot say for CERTAIN that you have cervical incompetence until you are monitored in another pregnancy. If you jump right to an abdominal cerclage, but the problem was actually unrelated, you run the risk of going into preterm labor again and still having to deliver. The abdominal cerclage only helps with cervical incompetence.
The link I posted below shows a photograph of an abdominal cerclage and describes the surgical technique. What I found most helpful were all of the comments that were posted below including those of women who had abdominal cerclages but went into preterm labor and had to deliver their babies either a) by ceserean or b) by having the cerclage surgically removed and then inducing a vaginal labor. As you can read, some of them still experienced a loss if the preterm labor itself could not be prevented or stopped.
I suspect that many OBs and High Risk doctors feel that it is best to start with a vaginal cerclage because it is a well-known, established procedure with high success rates (over 70%). It is effectively a minimal, non-invasive procedure and if it is successful in one pregnancy it is likely to be successful in another.
At this point, I am leaning towards the vaginal cerclage because my cervical incompetence diagnosis is not 100% guaranteed. It is a difficult decision, and one I haven’t finalized, because I also do not want to run the risk of losing another baby because I made the wrong decision. If my cervix does shorten/funnel to unsafe lengths in my next pregnancy, if there is no evidence of any other problems related to preterm labor and if I have to go on bed rest, than I will likely choose to have an abdominal cerclage placed because I want to have several more children. If I have a propensity for funneling completely during the second trimester, I know I will face strict bed rest with all of my pregnancies. Since this can usually be avoided with an abdominal cerclage, it would benefit me to take the opportunity to avoid bed rest so I can have an easier time being pregnant and raising young children.
I’m anxious to hear what my Perinatologist suggests. My cervical incompetence diagnosis came from my OB but he will have had the opportunity to read all of my medical records and may have more insight and experience regarding what the best decision will be for me.
Click Here for a “How-To” link about an Abdominal Cerclage
Abdominal vs Vaginal is a truly hard decision indeed. Even after having 3 losses i struggled with the decision. I will say though that if you choose vaginal i’d trust a shirodkar rather than mcdonald ( and I may be a little biased b/c i had a failed mcdonald). But i chose to get an abdominal cerclage b/c when i do become pg again i have to know that i have done everything i can in order to hold the pregnancy. I know that i wouldn’t be able to bare having had a vaginal and then having a loss and thinking ” If only i’d done the abdominal” or hear the the doctor say “well next time we’ll do the abdominal”. I will say that even with my losses it was still a hard decision to make. The thought of having to deliver by c-section scared me a bit and i was a little upset at having to give up delivering my baby vaginally, but i had to sit and think about what was really important to me. I am sure that you will do what is best for you, but i just wanted to give you my train of thought. I hope that it helps and if you have any questions please feel free to email me.
Tough decisions! I was a staunch supporter of the TVC prior to my last pregnancy. I had the McDonald done and when that failed I said “why didn’t I just get the TAC?” In choosing the best cerclage, I think is important to know exactly what the cause of the previous losses were due to. Was it pre-term labor or cervical incompetence? For me, finding the exact reason meant reviewing both pregnancies, perusing dr reports and hospital reports, and talking to numerous drs. For me, I had painless dilation during both. During the 2nd pregnancy, every appointment I was funneling more and decreasing in length with no contractions.
The TVC works for some women and after my 2nd loss a dr said I could try the Shirdokar. I chose to do the TAC for many reasons. I wanted to keep working and I wanted the best possible chances of getting a baby to term.
Its a tough decision, and I say trust your gut and make the decision that is best for you. Good luck!
Thank you for all the personal stories! It’s a really difficult decision and I will know more once I have my appointment with my Perinatologist. I know that I should be grateful that there are things that can be done to treat cervical incompetence and that my next babies do have a better shot at surviving because of what happened with Claire.
I have had two losses of pregnancy At 24 AND 25WKS Respectively in the recent past after normal delivery of my first borne son.I recently went to see my gynecologist who prescribed for me cervical cerclage due to cervical incompetence according to him.am confused and would like to know more on C/I, question., 1.How many times can one get MacDonald stitch?
2.Are there chances of cervical cerclage fail? What are the precautions?