Have you ever experienced a mid-pregnancy miscarriage or premature birth without symptoms?

What is a cervical ligation?

Cervical cervical cerclage is a medical procedure used to treat cervical insufficiency, a medical condition in which the cervix becomes weak or short, which may lead to miscarriage or premature birth. In this procedure, surgical stitches are placed around the cervix (lower part of the uterus);

Types of cervical ligation

• Preventive ligation: Occurs before problems arise, usually in weeks 12 to 14 of pregnancy, for women with a history of miscarriage or premature birth.
• Emergency ligation: occurs when a shortening or opening of the cervix is ​​observed during pregnancy.
• Transabdominal ligation: It occurs in rare cases when vaginal ligation is not possible, and is performed through an incision in the abdomen.

When is it recommended to perform a cervical ligation?

Cervical cerclage is recommended in specific cases;

1. History of cervical insufficiency

• If the woman has a history of recurrent miscarriage in the second trimester, i.e. between weeks 14 to 28;
• In the case of a previous preterm birth before week 34 associated with cervical insufficiency, without contractions or labor.

2. Short cervix

Detecting a short cervix of less than 25 mm via ultrasound in the first or second trimester of pregnancy, especially if the woman is currently pregnant and has risk factors.

3. Opening of the cervix

Noticing an opening or dilatation of the cervix during Before the 24th week of pregnancy, it is usually detected by scan or ultrasound without pain or labor contractions.

It is not recommended to perform ligation in the event of severe bleeding, infection, rupture of membranes, or ongoing contractions, so consult the specialist doctors at Al Mousa Specialist Hospital first;

Read also: The shape of a cervical ulcer and signs of healing

How is the need for a cervical cerclage diagnosed?

Diagnosing the need for a cervical cerclage depends on an accurate assessment of the pregnant woman’s health condition, and is carried out in detail through the following steps.

1. Medical history 

The doctor reviews the woman's previous pregnancy history, such as:

• Repeated miscarriages in the second trimester between weeks 14 to 28 for no apparent reason.
• Previous preterm births before 34 weeks are associated with cervical weakness.
• History of previous procedures on the cervix, such as conization, or injuries that affected the cervix.

2. Ultrasound examination (sonar)

• Vaginal ultrasound: To evaluate the cervix, the length of the cervix is ​​measured in terms of its normal length, usually more than 25 mm in the second trimester, while a length of less than 25 mm, especially less than 15 mm, is considered short and causes concern.
• Openness or expansion: The presence of internal or external opening in the cervix is ​​checked, or the appearance of contractions at the internal opening of the cervix.

3. Clinical examination

• In some cases, the doctor manually examines the cervix through the vagina;
• This examination is often used if symptoms such as pelvic pressure or unusual discharge appear.

4. Clinical symptoms

• Symptoms such as heavy vaginal discharge, light bleeding, or a feeling of heaviness in the pelvis may indicate a problem with the cervix, which requires an immediate examination.
• In cases of cervical insufficiency, there are often no obvious symptoms, so follow-up depends on routine examination.

What are the cases in which the cervix is ​​ligated?

Cervical cerclage is performed in specific cases aimed at preventing premature birth, or recurrent miscarriage resulting from weakness or premature dilation of the cervix. Here are the most prominent of these cases:

1. Weak (micro) cervix, that is, when the cervix is ​​unable to remain closed throughout pregnancy, and often occurs without pain or contractions, and leads to the cervix opening early.
2. A previous history of miscarriage in the second trimester of pregnancy, especially if the miscarriage occurred more than once and was due to sudden dilatation of the cervix.
3. Previous preterm birth before week 34, especially if it was caused by cervical dilation rather than uterine contractions.
4. Short cervical length in the current pregnancy is less than 2.5 cm, and is diagnosed using vaginal ultrasound between the 16th and 24th week of pregnancy, especially in the presence of a previous history of premature birth.
5. Cervical dilation during second trimester screening is asymptomatic and is sometimes discovered during routine pregnancy follow-up.
6. After previous surgeries on the cervix, such as removing part of the cervix, or any intervention that affected the strength of its tissues.

However, we note that not everyone who has a short cervix needs a ligation, as the doctor determines this according to the length, medical history, and number of weeks of pregnancy, and here the role of the “Women’s Health Center” at Al Mousa Specialist Hospital is highlighted, as we have an integrated medical team equipped with the latest devices and technologies in the field of obstetrics and gynecology, which guarantees you comprehensive medical care.

Steps for the cervical ligation procedure

The cervical ligation procedure is performed with great care in a sterile medical environment, and includes several important basic steps. Below are the main steps for performing the procedure, with a focus on the most common type of vaginal ligation.

First: evaluation and preparation before the operation

• The need for the procedure is confirmed using vaginal ultrasound;
• Conducting tests such as blood counts and checking for infections;
• The woman may be asked to fast for several hours before the procedure, if general or spinal anesthesia will be used.

ثانيًا: التخدير

• Spinal anesthesia, such as epidural, or general anesthesia is usually used depending on the patient's condition and the doctor's recommendation.
• In some simple cases, local anesthesia may be used, but this is less common.

Third: The patient’s position

• The woman is placed in the laboring position on the surgical bed (pelvic position).
• The vaginal area is carefully sterilized;

Fourth: Surgical procedure (vaginal ligation)

• Accessing the cervix using a sterile medical instrument such as a vaginal spacer;
• Placement of sutures using strong, often non-absorbable sutures;
• Common techniques include the McDonald method, which is a simple suture around the cervix similar to a bag to close it, and the Shirodkar method, which is a deeper suture that requires more precise dissection.
• The threads are tightened so that they close the cervix without causing tissue damage, then ensuring that the cervix is ​​closed appropriately.

While in the case of transabdominal ligation (in rare cases)

• If vaginal ligation is not possible such as a very short or damaged cervix, ligation is performed through a surgical incision in the abdomen.
• Surgical tape is placed around the cervix during surgery, and this type is often permanent.

Fifth: Lockdown and initial recovery

• After the stitches are placed, the instruments are removed and the area is examined;
• The woman is taken to the recovery room;
• The woman is given prophylactic antibiotics to reduce the risk of infection, and medications to reduce cramping such as progesterone may be recommended.

Sixth: Post-operative care

• It is recommended to rest completely for several days, avoiding strenuous physical activity or sexual intercourse.
• Periodic visits to the doctor to examine the cervix with ultrasound, and to ensure the stability of the pregnancy.
• You should inform your doctor immediately if bleeding, cramping, abnormal discharge, or severe pain occurs.

Seventh: Removal of stitches

• In the case of vaginal ligation, the stitches are usually removed between weeks 36 and 37 of pregnancy, or immediately before birth if the birth was normal.
• إزالة الغرز تكون بسيطة وغالبًا لا تتطلب تخديرًا، وتُجرى في عيادة الطبيب أو المستشفى.
• While in the case of transabdominal ligation, the stitches may remain permanent, and delivery is usually performed by caesarean section.

The cervical ligation process requires great experience and precision.

When is the cervical ligation removed?

The cervical ligation is removed by removing the stitches in the following cases, depending on the type of ligation and the state of pregnancy.

First: in the case of vaginal ligation 

• Normal time: Stitches are usually removed between weeks 36 and 37 of pregnancy, if the pregnancy is stable and there are no signs of early labor. This timing allows the cervix to prepare for natural birth.
• Before premature birth: If labor begins or rupture of the membranes occurs before week 37, the stitches are removed immediately;
• In case of caesarean section: If the delivery is planned by cesarean section, the stitches may be removed during the procedure or left at the doctor's assessment.

Second: In the case of transabdominal ligation

• This type is often permanent and the stitches remain;
• Birth in this case is usually by caesarean section, and the stitches remain in place to support the pregnancy in future pregnancies.

Side effects of cervical ligation

Although cervical cerclage may be relatively safe, like any medical procedure, it may have side effects and potential risks. Below are the possible side effects and complications.

Common side effects

• A woman may feel mild pain or cramping in the pelvis or lower abdomen after the procedure, which is usually temporary.
• Light vaginal discharge, sometimes mixed with a little blood, may appear and continue for a few days after the procedure.
• Stitches may cause a feeling of irritation in the cervix, or sensitivity in the area.

Possible complications

• An infection of the cervix or vagina may occur as a result of the procedure, and symptoms include high temperature, foul-smelling discharge, or severe pain.
• Light vaginal bleeding may occur during or after the procedure, but severe bleeding is rare and requires immediate intervention.
• In rare cases, the procedure may rupture the membranes surrounding the fetus, which may cause miscarriage or premature birth.
• The procedure may stimulate contractions or contractions of the uterus, which can lead to premature labor if symptoms are not treated.
• If labor begins before the stitches are removed, the cervix may be torn or injured.
• In some cases, ligation may not prevent premature birth or miscarriage, especially if cervical insufficiency is severe.

Frequently asked questions about cervical ligation

How many days of rest after cervical ligation?

The pregnant woman is advised to rest for 3 to 5 days after the operation, and she may be asked to avoid stress and marital relations for several weeks, according to the doctor’s evaluation.

Is there an alternative to cervical ligation?

Yes, in some cases vaginal progesterone suppositories or complete rest can be used as alternatives, especially if the shortening of the cervix is ​​mild or there is no history of recurrent miscarriage.

Does miscarriage occur after cervical cerclage surgery?

Miscarriage after ligation is rare, but it is possible in cases such as infection, early water breakage, or ineffectiveness of cervical dilation.

What is the success rate of cervical ligation?

The success rate ranges from 85% to 90% in preventing premature birth and miscarriage associated with cervical insufficiency, especially when performed at the right time.

Ultimately; Al Moosa Specialist Hospital We provide you with precise care, continuous follow-up, and a specialized medical team to accompany you at every step of your pregnancy with confidence and safety, so book your consultation today and start your pregnancy journey in complete safety.

Sources:

Cervical Cerclage – my.clevelandclinic

Cervical Cerclage – ncbi.nlm.nih.gov

Cervical Cerclage Technique – emedicine.medscape