Treatment

The standard treatment for incompetent cervix involves placing a cerclage, or a band made of synthetic material, around the cervix. The cerclage strengthens the cervix as well as stops the amniotic sac from coming out early. There are different types of cerclages available. In a transvaginal cerclage (TVC), doctors sew the cervix closed, usually during the 13th or 14th week of pregnancy. At 36 weeks, the stitches are taken out so the woman can deliver her child naturally. A few downfalls exist with this method: It requires bed rest for the remainder of pregnancy, many babies are still delivered prematurely, and it needs to be redone with each pregnancy thereafter. TVC has around an 85 percent success rate.

Since the cervix will not stay closed in patients with IC (incompetent cervix), treatment is to close it via intervention.  This is referred to as a cerclage.  There are many types of cerclages, all varying by method and height of placement.  I am going to discuss only the two main ones here with a mention to a third one.  This is a picture drawn by Dr. Davis to illustrate the different levels of cerclages.

TAC

Transvaginal Cerclage (TVC): a stitch (suture) which is placed through the vagina, within and around the cervix, much like a “purse string”.  This is placed at the bottom of the cervix or “as high up” as the doctor can get.  The method of placement is vaginal and the patient is given a spinal.  A TVC may be placed anytime from 12 weeks on.  Sometimes it is placed preventively before a problem seems to arise (aka a prophylactic cerclage).  Other times it is placed after the “wait-and-see” has demonstrated a problem with the cervix.   These are called a rescue or emergency cerclage. The two main stitches used, although there are variants on each: the Shirodkar and the McDonald. This is the procedure that most doctors recommend. Sometimes they will wait and watch your cervix for signs of funneling (when it starts to open at the top) or shortening.

A TVC requires pelvic rest, has an increased risk of infection as the stitch material itself can wick up vaginal bacteria, and is currently considered successful about 80% of the time.  Be sure you ask your doctor what the definition of success is!  Often times in discussing a TVC, their definition of success is a “live birth” regardless of prematurity.

The TVC is removed around 37 weeks to allow for a normal vaginal delivery.

Transabdominal Cerclage (TAC):  a band is placed around the OUTSIDE of the cervix and tied in place to disallow dilation.  This is placed at the very top of the cervix/bottom of the uterus.  It is placed via abdominal incision or laparoscopically.  The TAC may be placed prior to pregnancy or during pregnancy (around 12 weeks).  The TAC does not make the cervix smaller, it simply allows it from dilating.  If it is placed correctly, there is enough room left for all normal functions of the cervix (enough room for semen, menstrual blood, fertility treatments including IUI’s and IVF, even enough room to have a D&C if that is necessary). The band simply prevents the cervix from dilating beyond its normal state. Also, a TAC can be placed laparoscopically, either by hand or by DaVinci robot.

http://contemporaryobgyn.modernmedicine.com/news/prophylactic-laparoscopic-abdominal-cerclage-tips-success

A TAC is considered the absolute medical solution for IC.  Once a patient has a TAC, she can cross IC off her list of potential problems.  No bed rest or pelvic rest is required due to IC with a TAC.  It has a success rate of greater than 95% for a TERM delivery.

The TAC is permanent and requires delivery via c-section.

Transvaginal cervico-isthmic cerclage (TVCIC): The TVCIC is placed above the cardinal ligaments but isn’t quite as high as the TAC. It closes the cervix about 1/2 cm below the internal os.  It is NOT the same as the TAC.  It is placed vaginally and can be removed for vaginal delivery or left in place for future use if a c-section is required.

This information is from: http://beyondthisdesert.com/what-is-pprom/types-of-cerclages/

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