Carolinas HealthCare System

For those women whose pregnancy losses are determined to be due to cervical insufficiency we offer several surgical options. These include:

1) History Indicated (Prophylactic) Cerclage

This procedure is for patients who have at least one second trimester pregnancy loss with no other plausible explanation. We do not believe that patients need to suffer two or three second trimester pregnancy losses before prophylactic cerclage is offered. This operation is typically done between 12 and 16 weeks gestation in our One Day Surgical Center.

2) Exam Indicated (Emergency) Cerclage

This operation is done under emergency circumstances in which the cervix has become dilated without painful labor. This operation cannot be offered to women who are in active labor or who have intrauterine infection. Most often, a diagnostic amniocentesis (with results available in two to three hours) is necessary to exclude infection before this emergency operation can be performed.

While most specialists offer this operation to women at 15-22 weeks, we are comfortable considering and offering this operation up to 26 weeks gestational age. We will also consider emergency cerclage for patients with twins and triplets under appropriate circumstances.

For emergency patient referrals, physicians should call 704-512-7878 or 1-877-262-6397.

3) Transabdominal Cerclage (TAC)

This operation is generally performed on women with multiple second trimester pregnancy losses. In this operation, the cerclage is placed via laparoscopy (a small, camera aided incision through the abdomen) or laparotomy (an incision similar to cesarean section) around the upper most portion of the cervix. It can be done prior to pregnancy or between 10-14 weeks of a pregnancy. Classic indications for TAC are:

  • Prior failed transvaginal cervical cerclage or,
  • Anatomic defects or deformities of the cervix that prevent surgical placement of an effective transvaginal cervical cerclage.

A third indication was added for TAC which is when a patient has a history of prior cesarean section or myomectomy that requires cesarean section deliveries for all future pregnancies. When TAC is done for this indication, we prefer to do them outside of pregnancy whenever possible. Because traditional transvaginal cerclage is successful and effective 80-85 percent of the time, TAC is only offered to a small percentage of women with cervical insufficiency. Additionally, TAC carries additional risk of pregnancy loss due to the operation itself and requires all future pregnancies to be delivered via cesarean section.

4) Cerclage Revisions

This operation is done when a patient with a previously placed cerclage is referred from their obstetrician because the cerclage has either loosened or torn through the cervix and the cervix has become dilated despite the cerclage. A revision can be done up to 26 weeks gestational age. Because a failing cerclage can be a sign of an intrauterine infection, an amniocentesis to exclude infection is almost always done before we will revise (replace) an old cerclage.

Other Non-Surgical Consultations and Services We Offer

Preconceptual counseling and pregnancy planning
The best time to evaluate and do necessary testing is when you are not pregnant. This gives the specialists at our center the best opportunity to do a comprehensive evaluation, obtain and review past pregnancy records, and carefully develop a personalized plan of care for your specific situation.

Serial cervical surveillance
There is no diagnostic test that tells us with 100 percent certainty whether a patient has cervical insufficiency. That's why weekly cervical checks will be recommended to some patients with an unclear explanation for prior pregnancy losses. We do not believe in doing cerclages for pregnant women with an uncertain diagnosis because there are significant risks for pregnancy loss when an unnecessary cerclage is placed.

Instead, we follow patients very closely in conjunction with their obstetrician until we determine that they need cerclage or until they successfully reach 26 weeks gestation without a cerclage. Prior to 26 weeks, a cerclage may be performed if significant cervical changes occur.