Treatment for premature birth/cervical incompetence

Most preterm babies arrive early without warning. However, some pregnancies are known to be at risk of ending in preterm birth.

Monitoring – also known as the ‘wait and see’ approach.

This may be used if you are at risk of premature birth and should involve monitoring via transvaginal ultrasound to check the cervix for shortening (in length) or funnelling (where the cervix begins to open from the top (baby end) down) every two weeks from 14-28 weeks to ensure there is no change. Funnelling and shortening are signs that you may need treatment to prolong your pregnancy.

This is an important part of caring for women at high risk of preterm birth. Regular contact with a consultant can provide important reassurance. If a problem does develop, it will be picked up early.

Progesterone

Progesterone is a hormone that is known to be important in preventing contractions and in supporting a pregnancy to full term. However, there is mixed evidence on the use of progesterone supplements to prevent cervical shortening but it may be recommended by your consultant as well as or instead of a cervical stitch. Progesterone is given as either daily pessaries or weekly injections. These can be started in the second trimester or earlier. Pessaries are more commnly used and can be inserted vaginally or rectally until around 34 to 36 weeks. You will need to visit your local hospital or GP practice if you have progesterone injections.

Arabin Pessary

Diagram showing placement of Arabin Pessary

The Arabin Pessary is gaining popularity in the UK. Doctors in the Netherlands and Spain have considerable experience with using it to reduce the chance of premature delivery. It is a soft silicon ring that is inserted into the vagina by your obstetrician and moved into place so that the cervix sits inside it (see pic). Research is being carried out currently by Tommy's to see how effective this pessary is at preventing preterm birth in the UK, and as yet is not used in all hospitals.

The transvaginal cervical stitch/cerclage (TVC)

If you have had one or more premature baby or late miscarriage/s, or have had cervical surgery in the past and your cervix is getting shorter in early pregnancy, you may be offered a cervical stitch (also known as a cerclage or cervical suture) with the aim of keeping your cervix closed during pregnancy. You may also be offered this if you have had a number of premature deliveries without cervical shortening.

There are two types of cervical stitch:

  • Transvaginal cerclage (TVC), also known as the vaginal stitch. It is inserted via the vagina during day surgery with spinal anaesthetic
  • Transabdominal cerclage (TAC), also known as the abdominal stitch (see below). It is inserted through the abdomen using keyhole surgery or open laparotomy.

A vaginal cervical stitch can be placed at the beginning of the second trimester (around 12-14 weeks), based on your previous pregnancy history (history-indicated stitch), or later in the second trimester in response to your cervix starting to shorten (an ultrasound indicated stitch). 
Current research has not clearly shown one approach is better than the other, therefore some women can avoid having unnecessary surgery if they have ultrasound monitoring and only have a stitch placed when their cervix starts to shorten.

If, on monitoring, your cervix is seen to be open and your membranes are coming down into the vagina, an emergency vaginal stitch may be attempted. It is not always possible to have a stitch placed in this situation, for example if there was evidence of infection or if you were having symptoms of labour. The benefits and risks would need to be discussed carefully with you in this situation.

There are two different types of vaginal stitch:

  • Low vaginal stitch (sometimes called a McDonald Cerclage)
  • High vaginal stitch (sometimes called a Shirodkar cerclage or TVCIC – Transvaginal cervicoisthmic cerclage)

There is no exact positioning for these stitches. They will vary depending on your consultant.

It is difficult to put vaginal stitches into categories as each consultant’s technique and method can vary greatly. The experience of the surgeon will affect exactly how high a stitch is placed. The higher the stitch is placed within the cervix, the lower the risk of preterm delivery . However, exactly which type of stitch is best often depends on your personal situation, for example whether you have had cervical surgery to remove some of the vaginal portion of your cervix. All of these details can be discussed with your consultant prior to stitch insertion.

How is the vaginal cervical stitch put in place?

Both of these stitches are put in under regional anaesthetic, such as a spinal block, which means you are awake but can't feel anything. Usually you go home the same day.

After the operation you may have some mild cramps similar to period pains, and you may have bleeding and spotting for a few days. Both of these should settle after two to three days.

You may or may not be given medication to stop contractions and calm your womb and/or antibiotics. There is no strong evidence to suggest these drugs reduce the chance of early delivery of your baby.

When should I not have a vaginal cervical stitch?

A stitch may not be the best thing for you if you have any of the following:

When is the vaginal cervical stitch removed?

If you have a vaginal stitch placed, it is usually removed at around 37 weeks so you can give birth naturally. It is rare to go into labour as soon as the stitch is removed and your pregnancy may continue for weeks afterwards. However, if you do go into labour before 37 weeks and it cannot be stopped, the stitch will be removed to prevent cervical tearing.

If you have any contraction-like pains with a stitch in place, you should go to your local maternity unit as soon as possible for checks.

How effective is the vaginal cervical stitch?

The research into how well a vaginal stitch stops preterm birth is still inconclusive, but so far it has shown that women who have a stitch carry their babies for longer than those who do not . It is thought to reduce the risk of early delivery by between 30-50% .

In a small number of women, however, the vaginal cerclage does not prevent the waters from breaking and in this case various options will be discussed with you. It may be necessary to remove your stitch to prevent an infection developing inside the womb, which may put your own health in danger, as well as that of your baby.

Diagram illustrating position of cervical stitches (cerclage)

The transabdominal cervical stitch – TAC

This type of stitch involves abdominal surgery, which allows the stitch to be placed at the very top of the cervix. It is offered to women who have little to no cervix within the vagina to stitch or those who have previously been unable to carry a baby to a healthy point of pregnancy, even when they received a vaginal cervical stitch. Current experience suggests that many women who have previously lost a baby with a vaginal stitch in place were able to carry a normal full term pregnancy once an abdominal stitch was in place.

As this type of stitch is relatively new, it is only performed by a few obstetricians in the UK.

If you have had a failed transvaginal stitch, or know that you have very little cervical length to begin with, then ask to be referred to a transabdominal stitch specialist. A current list of specialists is available at the UK TAC Support group page on Facebook.

How is the abdominal cervical stitch placed?

The abdominal cervical stitch is preferably put in before you become pregnant but it can be placed during early pregnancy too. It is done either with a laparoscopy (where they make 3-4 small incisions in your abdomen and use a camera and long instruments to place the stitch) or an open laparotomy, which is a cut similar to a caesarean section cut.

If performed as an open procedure, this carries similar risks to a caesarean section.

Rare complications of the stitch can include infections or excessive bleeding . Ask your doctor to talk you through the risks.

Giving birth with a abdominal cervical stitch

If you have an abdominal stitch your baby will have to be delivered by caesarean section at around 38 weeks because the stitch cannot be safely removed during pregnancy to allow for a natural birth. It can however be left in place for further pregnancies as it does not prevent sperm getting into the womb or periods from happening as normal. IVF and IUI are also still possible.

What you can and cannot do during pregnancy with an abdominal cervical stitch.

This will very much depend on what treatment you have and the advice you’re given by your doctor. A very important part of monitoring during your pregnancy will be to reassure you that your pregnancy is progressing well. If the doctors or midwives have any concerns then, they will give you advice accordingly, this may be to reduce the amount you are working or to avoid certain activities. Your doctor may also advise you to refrain from sex if your cervix is short or your risk of early delivery has increased.

If at any point there is something you’re worried about then you should contact your doctor or midwife for advice.

The occlusion suture

An occlusion suture is sometimes used alongside a TVC or a TAC. It is placed at the very bottom of the cervix, at the tip, closing it completely. There is a theory that it could work to close the cervix completely to any bacteria and therefore prevents infection from getting into the womb, but an opposing viewpoint is that in itself it could create a breeding ground for infection. Research on the occlusion suture has not shown it to be effective.

Bed rest

Your doctor may recommend bed rest as part of your treatment. This has not been proven in research trials to be very effective but it is sometimes recommended as a safeguard. Bed rest can happen at home or in the hospital.

Warning signs of premature birth in pregnancy

Pregnancy for women at high-risk of premature birth can be a very anxious time. If you are worried about any signs or symptoms; then you should contact your midwife or hospital immediately. Here are some signs to look out for that could possibly indicate premature labour

  • an increase in pelvic pressure within the vagina or rectum
  • a change in your discharge, which may indicate a slow amniotic fluid leak or vaginal infection
  • bleeding or losing your mucus plug
  • period type pains in your abdomen or lower back. These may have a rhythm like contractions or be constant
  • your waters breaking (PPROM – preterm premature rupture of membranes)

What happens if the cervical stitch doesn’t work?

If you’re thought to be going into labour with a cervical stitch, there are a number of things that will need to be considered by your hospital. 
They may:

  • examine you to see if your cervix has shortened and dilated
  • perform a test called the fetal fibronectin test. This is a swab which checks for the presence of a protein within the vagina that has been found to be a predictor of labour. It is the glue that holds the amniotic sac to the walls of the womb. Finding it in the vagina is a good indicator of what is happening within the womb.

These two results will tell whether you are likely to go into labour within the next two weeks. Your doctor can then decide whether to administer steroids to help your baby’ lungs’ development if you’re far enough along in your pregnancy (minimum 23-24 weeks). Steroids are given over a 24 hours period in two injections. Timings are very important as they’re at their most effective if your baby is born within 24 hours to 7 days after administration of the second injection and multiple rounds are not advised .

If you’re at risk of imminent labour, you may be kept in hospital. You may have your bloods checked for signs of infection.

If you have a vaginal cervical stitch it will be removed to prevent cervical tearing. If you have an abdominal cervical stitch, you will need to have a caesarean section.

Read more about being at risk of premature birth

Read more about premature birth

Sources

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  2. Conde-Agudelo A, Romero R. (2016) Vaginal progesterone to prevent preterm birth in pregnant women with a sonographic short cervix: clinical and public health implications. Am J Obstet Gynecol. 2016 Feb;214(2):235-42. doi: 10.1016/j.ajog.2015.09.102. Epub 2015 Oct 9.

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  5. RCOG (2011) Cervical Cerclage. Green-top Guideline No. 60. Royal College of Obstetricians and Gynaecologists 
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  6. Liddiard A, Bhattacharya S (2011) Elective and emergency cerclage and immediate pregnancy outcomes: a retrospective observational study JRSM Short Rep. Nov 2011; 2(11): 91.

  7. Cochrane Database Syst Rev (2017) Cervical stitch (cerclage) for preventing preterm birth in singleton pregnancy. Jun 6;6:CD008991. doi: 10.1002/14651858.CD008991.pub3.

  8. Personal communication, Professor Andrew Shennan, Professor of Obstetrics at King's College London
  9. UpToDate, Transabdominal cervical cerclage http://www.uptodate.com/contents/transabdominal-cervical-cerclage [accessed 13/06/2017, updated Apr 2017]

  10. NICE (2007) Laparoscopic cerclage for prevention of recurrent pregnancy loss due to cervical incompetence, National Institute for Health and Care Excellence, London

  11. Brix N, Secher N, McCormack C et al (2013) Randomised trial of cervical cerclage, with and without occlusion, for the prevention of preterm birth in women suspected for cervical insufficiency. BJOG 2013;120:613–620.

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Last reviewed on April 1st, 2014. Next review date April 1st, 2017.

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