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Christina’s Question

Our first question is from Christina. “After finding I was 1.5 centimeters dilated at my anatomy scan, and then a subsequent 22-week loss, I was diagnosed with cervical insufficiency. Your podcast on cerclages was helpful as we met with MFM to determine how to move forward. Unfortunately, I went on to have two early miscarriages, but then got pregnant again and made it to the point where I got a cerclage at 13 weeks. I went in to have a full-term pregnancy and delivered a healthy baby at 37 weeks and 4 days after getting my cerclage out at 35 weeks and 6 days.

Is there data to support that now that I’ve had a successful pregnancy with the cerclage, is a cerclage likely to work again in a future pregnancy? This pregnancy was so stressful, even though I was being seen bi-weekly by my OB and MFM. Having three pregnancy losses before having a healthy baby was a lot to deal with. And at 38 years old, I know I don’t have a lot of time left to try again without interventions like IVF. Thank you, Dr. Fox.”

Dr. Fox’s Answer

All right, Christina, thank you for the question. I’m sorry you went through all that before you had your healthy baby. It is a lot. There’s a lot to unpack from your question. So first, in terms of cerclages, you, Christina, obviously know a lot more about this than some of our listeners might. As background, a cerclage is a type of stitch we place around the cervix in an attempt to maintain a pregnancy.

There are several reasons why we may or may not recommend and do that. However, if we categorize them by reasons, the first bucket is called a history-indicated cerclage, which is essentially placing a cerclage early in pregnancy before any complications arise due to factors from someone’s past, such as prior pregnancies or anatomical issues. But basically, it’s placed sort of… They used to be called something that’s prophylactic. And the idea is you’re putting it early in pregnancy to prevent something from happening later, and you’re doing that because of something in the past. So that’s history-indicated.

The second reason is something we call ultrasound-indicated, which occurs when a woman is pregnant and doesn’t have a cerclage, but then an ultrasound reveals a short cervix. An ultrasound, and for whatever reason, we decide that a cerclage is the right treatment to prevent pregnancy loss or preterm birth. And exactly how we decide which person with a short cervix does and does not need a cerclage is complex because it’s not everybody, and it’s not nobody.

Okay. The third reason, which is what you were, in theory, a candidate for, is when someone has a dilated cervix. If their cervix has dilated before 24 weeks, we refer to this as either a physical exam-indicated cerclage or an exam-indicated cerclage. Sometimes people used to call these rescue cerclages or emergency cerclages, which captures the feeling of the moment. It’s a pretty dire situation when your cervix is dilated in the second trimester and there’s a very high chance of pregnancy loss or very early preterm birth with no treatment. And then placing a cerclage at that time is a little more challenging surgically, and the data on it are pretty good, but it’s hard to have extensive studies with this. But basically, that’s a physical exam-indicated cerclage.

Okay. So going back to your question, you had a pregnancy loss where your cervix was dilated and then you lost the pregnancy, then you had, which could be a sign of a cervical problem, then you went on to have a few early miscarriages, which should not be related to the cervix, it’s other reasons. And then your doctors decided that you were a good candidate to have a history-indicated cerclage in the next pregnancy. And that’s the one you had at 13 weeks.

So, first, about that decision, because it does play into your question about future pregnancies. Whenever we see someone who comes to us and says, “Hey, in my last pregnancy, my cervix was dilated in the second trimester and then I lost the pregnancy,” or, “I had a preterm birth,” or maybe, “I had a cerclage,” whatever it is. They’re saying, “Do I need a cerclage in this next pregnancy, history-indicated?” You would think, “Yes.” You would think, “Okay.” You know, last pregnancy, your cervix was dilated. There was something wrong with your cervix. You needed a cerclage.

But the problem is it doesn’t work out that cleanly, meaning there are lots of reasons people could be dilated and lose a pregnancy in the second trimester or deliver early. One of the reasons is that you have this condition called cervical insufficiency, sometimes called cervical incompetence, where the cervix is, like, “weak” and needs a cerclage. However, there are many other reasons. Sometimes, people have a subclinical infection, a placental abruption, or an abnormality with the baby. And all of those can lead to a cervix opening or dilating and then losing the pregnancy, but there’s nothing wrong with the cervix.

So the decision to place a cerclage in the next pregnancy, a history-indicated cerclage, because of your first pregnancy, is complicated. And we never know 100% if it’s the right thing to do or not. Now I don’t disagree at all that you had one placed. It’s certainly a very reasonable thing to do. The other option would be, or would have been, I should say, instead of putting a cerclage at 13 weeks, to have your cervix monitored every week or two in the second trimester, and if the cervix remains nice and long, not to place a cerclage. Nothing wrong with your cervix. Or if the cervix becomes short, consider a cerclage, as it’s now straightforward that there’s an issue with your cervix.

And it’s interesting if you look at people like you who had a pregnancy loss with a dilated cervix, and then in the next pregnancy, if you don’t place a cerclage, it ends up being ballpark 50/50, whether your cervix would have gotten short. You would have needed a cerclage, or it might have been fine the whole time, and you wouldn’t have needed one. And that reminds us again how complicated this process is and how we don’t know 100% what the issue was.

So the decision was made during your pregnancy to have a cerclage at 13 weeks. Again, I don’t disagree with that decision. I’m just saying it could have gone either way in terms of what to do. The cerclage was “successful” because you got to 37 weeks and you had a healthy full-term delivery.

So now you’re asking me, “What about the next pregnancy?” And we’re left with the same question, right? We don’t know 100% if you have this condition, cervical insufficiency, or whether you don’t have it. Indeed, you could. Your story would fit the pattern of someone who does, right? In one pregnancy, your cervix is dilated and you lose the pregnancy, and then in another pregnancy, you have a cerclage placed and you don’t lose the pregnancy. So that certainly would be consistent with someone with cervical insufficiency.

But your story could also be consistent with someone who had a different condition in the first pregnancy. Maybe you had what we call a subclinical infection, where there was, for whatever reason, some infection and inflammation inside the uterus, and that’s what caused your cervix to dilate and lose the pregnancy. And then the next pregnancy, even if you didn’t have a cerclage, you would have gone to 37 weeks. Now nobody knows, right? You can’t go back in time and change what you did and see. You know, it just doesn’t work like that.

And so I would say at this point, it’s sort of the same decision that’s available to you. You can either say, “You know what, there’s a good chance I have cervical insufficiency. I went through a horrible pregnancy loss, then I had a cerclage, and it wasn’t such a big deal, so to speak, and I went full-term and everything went well.” Why rock the boat? Just place it again in the next pregnancy. The risk of the procedure is relatively low, and you’re likely to do well. And why not? In the worst-case scenario, you’re having a cerclage that is deemed “unnecessary.” Again, there might be some downsides, but they are likely not significant.

On the other hand, you might say, “You know what, I don’t want a cerclage if I don’t need one. I don’t want surgery if I don’t need it.” Or maybe, “I’m thinking of having five more kids and I don’t want to have a cerclage with five more pregnancies. I want to know for sure whether I have this issue with my cervix or not.” And so the alternative is not to place a cerclage and to do ultrasounds every week or two starting around 16 weeks, and see what happens with your cervix. And if it gets short, you know it’s probably the cervix. Have a cerclage then. And if it doesn’t get short and stays nice and long, you know what? It probably wasn’t an issue with my cervix in the first place.

And I have to tell you, this is something that comes up frequently when I see people who have a history of a loss rather than a cerclage. We go through this again, and I can take my best guess at what I think it is, but we have to have some level of humility, recognizing that we don’t always know. And we see people who have a story like yours and had a cerclage, and they decide not to have a cerclage the next time. Again, some of them end up needing a cerclage, and some of them end up not needing a cerclage, like, wow, she never had a cervical problem. And we have people who choose to have only the cerclage, which is quite reasonable again. And then we don’t know for sure what it was. Ultimately, if you have healthy babies, it doesn’t matter whether you know the cause.

And so, I would say the short answer to your question, I just gave you a long one, is that it’s not that you need a cerclage. We still don’t know. It probably would work out well if you got one. And if you didn’t get one and monitored very closely, I would tell you it’s ballpark 50/50 whether you would ultimately need one or not, based on your cervix getting short.

As an aside, thank you for your comments about the podcast and how it was helpful. It’s the single reason we do the podcast: so that people like you, going through these situations, have a place to go for good information that’s hopefully accurate, reasonable, and understandable. Okay, great question, Christina.

Maternal Fetal Medicine blogs are intended for educational purposes only and do not replace certified professional care. Medical conditions vary and change frequently. Please ask your doctor any questions you may have regarding your condition to receive a proper diagnosis or risk analysis. Thank you!