My Transabdominal Cerclage
This is a kind of off-the-wall topic compared to what I usually blog about, but I decided to share my story and experience and add to the chorus of women’s voices who have this issue. What’s the issue exactly? Well I have something called an incompetent cervix. This is a problem, where if I had live 50 years ago, I would have been considered barren and unable to bear a living child. Fortunately in this day and age, there is a way to address this issue. But unfortunately, a great number of medical professionals (doctors) do not address this issue properly or quickly enough.
In A Normal Pregnancy
In a normal pregnancy, the bottom portion of the uterus, called the cervix, remains stable while the uterus grows and expands to accommodate the growing baby. The cervix is comprised of connective tissue…like a tendon or a ligament, and has anywhere from 3 – 5 cm of length during pregnancy. Additionally a mucus plug develops in the cervical canal and acts as a barrier between the vagina (and any bacteria that may be lingering in there) and the interior part of the uterus where the baby is growing.
When labor begins, the cervix begins to shorten (efface) and open (dilate). This process is normally triggered by a drop in progesterone (a hormone) and contractions of the uterus (sometimes triggered by the rupture of membranes — the amniotic sack). Many times this dilation and effacement is painful. In some instances when labor stalls or a woman “fails to progress”, the cervix does not efface and dilate enough for delivery…which is another problem.
With Incompetent Cervix
With an Incompetent Cervix (sometimes called an Insufficient Cervix), the cervix fails to remain shut throughout pregnancy. This problem usually begins in the 2nd trimester (13 weeks +) of pregnancy when the baby and the amniotic sac have grown enough to fill the uterine cavity and start to place weight on the cervix. This causes an incompetent cervix to efface and dilate way before the baby has reached term; and many times forces the woman to deliver a severely premature baby (which will not survive if born before 22 weeks gestation…and in the US in many places, they will not place a fetus under 24 weeks gestation in the NICU).
Even if the cervix does not efface and dilate fully, then there is the risk of funneling with an incompetent cervix. Funneling is when the cervix begins to open a little bit; and the amniotic sac begins to slip into this opening. The pressure of the sac being compressed in such a small area as the cervical canal can cause the sac to rupture. This is called PROM (Premature Rupture of Membranes) and is potentially lethal to the fetus. In some cases the sac does not rupture…but comes through the cervix and begins to bulge into the vagina. This is bad too because it allows bacteria from the vagina to ascend into the uterus and cause infection there. Infection in the uterus and placenta during pregnancy can also trigger labor.
The Whys and Hows
Medical experts (a club were I am not a member of) estimate that about 1-2% of women suffer from incompetent cervix. But in my humble opinion, this is an underestimate. Truth is it is difficult to diagnose incompetent cervix. The length of a woman’s cervix in pregnancy can be measured via ultrasound. But this is not the standard protocol in pregnancy. Also many women with an incompetent cervix experience dynamic changes to it. So while laying down with pressure removed, the cervix may appear long and closed. But when standing or with pressure applied, it shortens and/or opens.
Many times, as was the case with me, if your membranes rupture…then a good amount of the pressure that you had on your cervix is gone once you lose your waters. Upon examination after my first loss, my cervix appeared long and closed when examined. So cervical incompetence was not suspected at first.
It is also not clear what exactly causes incompetent cervix. For sure if you’ve had any biopsies, cancers, surgeries or damage to your cervix prior; there is a chance that it will fail in pregnancy. But in many cases the cause is unknown. Some theorize that traumatic births and D&C can damage the cervix. But countless women have numerous D&Cs and vaginal births and their cervixes are just fine. Others theorize that genetic conditions such as Ehlers-Danlos syndrome and being exposed to DEX in utero can cause problems. In the end though my TAC surgeon advised me not to spend a second dwelling on what could have caused this issue since there is a fix that has nothing to do with the cause.
So What’s the Fix?
In spite of the fact that OB/GYNs…and even MFMs grow on trees, not many have a lot of experience with IC cases. They (MFMs especially) do have experience with dealing with pre-term labor (which IC can cause) and tend to treat IC like other high-risk, pre-term labor patients. This means ordering weekly progesterone shots, ultrasounds to monitor cervical length, and perhaps bedrest. If you start contracting early, tocolytics will be administered to stall it. Problem is with IC…many times it manifests too early or too suddenly for these methods to be effective.
A cerclage is a stitch or band placed in or around the cervix to prevent it from opening. It’s a similar concept to tying a knot at the bottom of a balloon. Like this:
It’s a simple concept but there are different types of cerclages placed in different types of circumstances. Something that the picture doesn’t really show is that the lower part of the cervix protrudes into the top of the vaginal canal (this is the part that the doctor can see and touch during gynecological pelvic exams); but the top part extends into the pelvis and sits behind your bladder (along with your uterus of course).
The more common type of cerclage is placed around the portion of the cervix that can be accessed through the vagina. For doctors, this is a pretty simple procedure. It’s like placing stitches around the cervix to close it shut. It can also be easily removed when it comes time to deliver the baby.
But there are downsides as well. Cerclages placed vaginally (also called a transvaginal cerclage, or ‘TVC’) are stitched into the cervix and sits as a foreign material in the vagina. The female vagina harbors many bacteria (which is normal…just like your mouth has bacteria) which are harmless if kept in check and if they stay in the vagina. However if they get out of control you can get a yeast infection (annoying…but ultimately ok for the baby); bacterial vaginosis (not necessary ok for the baby…but can be managed); and the worse case scenario is when the bacteria can creep up through the cervix, into the uterus…and that’s when real problems can occur.
In my case, I lost my mucus plug a few days after my TVC was placed. Why exactly this happened…no one knows for sure. However I do not think that running a stitch through my cervix helped keep the integrity of my mucus plug. But it also could have come out because I was beginning to dilate. But that also is not a good thing if you have a cerclage in place because it can tear through your cervix and cause damage and scarring.
Emergent vs. Prophylactic
Although a TVC is a relatively simple procedure, many doctors take the approach of “if it ain’t broke, don’t fix it”. A prophylactic TVC is placed before the cervix begins to shorten and has a higher success rate (72%). An emergent TVC is placed after the cervix has begun to shorten and/or dilate and is intended to buy a few more weeks of pregnancy. It’s success rate is not as high (< 60%).
The Transabdominal Cerclage (TAC)
A transabdominal cerclage is placed through the abdomen around the very top portion of the cervix (see the graphic below):
Having a band around the top, as opposed to the bottom, of the cervix greatly reduces the chances of what many of us call “funneling through the stitch” (which is not good). So basically the portion of the cervix above the cerclage begins to open. It doesn’t open completely…like it would if there were no stitch in there at all; but you still run the risk of PROM and infection. It really depends on how much you’ve funneled, or what bacteria is in your body (and how it migrates), etc.
In order to place the TAC, the surgeon needs to go through the abdomen to access the top portion of the cervix; hence the name “transabdominal”.
So if TACs have the best success rate, why are they so rarely done?
Well in my humble opinion, there are several reasons. Such as:
- Many doctors consider themselves scientists/clinicians more so than patient advocates. What this means is if the statistics look good, and there are clinical trials to back up a particular procedure or approach…then they take the path of less resistance. What this means is that while the success rate of a TAC is 20-20% greater than the TVC, is it worth the extra expense, increased recovery time, and required C-section in the end? Unfortunately insurance companies also take this approach…and if a woman either hasn’t been diagnosed with IC or had multiple 2nd trimester losses (sometimes with a history of a failed TVC), then they see the TAC as an unnecessary procedure.
- Not many doctors are trained on TAC placement. My surgeon, Dr. Sumners, explained this issue very well here. While the TAC placement is not extremely complicated, in order to be trained on how to do them…you need to have hands on training. Whether it’s because IC is so rare or perhaps because it seems “over the top”, many doctors have no experience with the procedure or exposure to it. Additionally there are only a handful of doctors in the entire United States who have done more than 100 of these procedures. It goes without saying that each woman and her uterus/cervix is different. TAC do fail and sadly many times it is because a doctor is inexperienced with placing them.
- Issues of miscarriage, fertility and viability. Having a TAC is generally a permanent placement and requires that the baby be born via C-section. However a D&C and an early miscarriage can still occur with a TAC in place. For TACs placed prior to pregnancy, there is some concern that it interferes with fertility…but this hasn’t been proven. If you have the TAC placed during pregnancy, the surgeon will often wait until viability of the fetus can be verified and you’ve passed the common miscarriage period of the early to mid 1st trimester. But of course it needs to be placed before the cervix begins to fail. This gives only a small window of time of when the TAC can be placed in pregnancy (usually between 9-15 weeks; but this varies by surgeon).
My Personal Feelings & Experience
Because it is not a common problem, I didn’t even realize what role the cervix played in pregnancy. Back in 2013 I conceived and the pregnancy was going well except for some spotting in the 1st trimester. Then, at 15 weeks I woke up in the middle of the night to what I could best describe as a charlie horse cramp in my uterus. The day before I had sneezed and then felt wetness in my underwear. However that didn’t concern me, in that I had read that pregnant women ‘leak’ when they sneeze (although now I know it was amniotic fluid and not urine). The cramp was concerning though because it was strong enough to keep me up for a while. I put some hot water on a towel and placed it on my tummy to deal with the cramp. It eventually let up and I went back to sleep.
The next morning I left to go to work. I arrived at my office, parked my car and got out. I might have taken 2 or 3 steps when I felt a sensation of a water balloon being in my vagina then ‘pop!’…a circle of wetness began to expand from the crotch of my jeans. I rushed to the bathroom in the lobby. The liquid was clear and there was tons of it, and I knew it wasn’t urine (I could feel it coming from my vagina). I informed my supervisor, then went back home, conferred with my midwife, then went into the hospital. An ultrasound confirmed it; I had lost all of my amniotic fluid. The baby was too young and underdeveloped to survive. Labor was induced and my son, Damian was born sleeping that evening.
The doctors made me feel that overall it was a fluke, and talked about PPROM. In my research of PPROM, I came across the issue of incompetent cervix. But I did not have any previous surgery or trauma to my cervix. Instead I thought my PPROM was caused by my 1st trimester bleeding making the amniotic sac week. In 2014 I conceived again. Looking at my history, the doctors decided to have me monitored by the high-risk pregnancy group (maternal-fetal medicine, or ‘MFM) beginning at 16 weeks. This made me pause, since my loss was at 15 weeks. However I met with them for a consult when I was 8 weeks along. They told me that they would scan my cervical length…and that the cervix rarely changes before that time. They would give me progesterone shots to calm my uterus and reduce the chances of preterm labor.
I trusted them…it was a mistake and I should have went with my gut.
The pregnancy was fantastic…no bleeding or cramping. Nothing felt amiss. I began to feel confident…and like a normal pregnant woman. 16 weeks came around and I went for my first cervical measurement. The ultrasound technician inserted the probe and remarked that my cervix had a cramp in it. That I should relax and they will try again in several minutes. When she tried again, I saw her measurement on the screen; it said 0.4 cm! I could see the baby’s head well above the bottom of my cervix though…so I figured that was good. The tech disappeared to consult with the doctor for a bit. I was whisked off to talk to MFM. They said my cervix was short but I wasn’t dilated. They would need to schedule a cerclage to be placed (vaginally) as soon as possible.
The next day (or maybe it was two days later) I went in. I had read up on cerclages and they seemed to have a good success rate. What I didn’t realize though is that the highest success rates on vaginal cerclages are the ones placed prophylactically. Since my cervix was almost totally effaced, mine was emergent. Emercency cerclages have a much higher failure rate. However, no one told me this at the time. I had my spinal and went in for the cerclage to be placed. Initially they told me the procedure went well. However the doctor did remark that he could see my membranes coming through my cervix and had to push them back in. I was to follow up in two weeks. I felt good….cervix sewn shut and baby was still in there!
Then it all started going downhill.
Two days after the procedure and went to the bathroom and saw a big glob of mucus in the toilet and on my toilet paper. I knew it was my mucus plug. I called in to the doctor’s office and the nurse told me not to worry…the mucus plug can regenerate. Then I kept having clear discharge…a lot of it. This worried me to the point where I went back to the hospital. They did an ultrasound and amniotic fluid levels were normal. They tested me for infection…came up negative. They remarked that the stitch was causing irritation and hence increased discharge. But one of the resident doctors did admit that in spite of the cerclage being there, I was dilated just by a fingertip. No one seemed concerned…but I knew that when the cerclage was first placed, I was completely shut.
I had a pre-scheduled OB/GYN appointment in a couple of days. I told her about the discharge. She tested it…and said the pH strip came back dark blue which was positive for amniotic fluid. She instructed me to go back to the hospital (again). Another ultrasound…fluid levels were ok….no infection, no contractions. Back home again. I had been to the hospital 3 times in one week at this point…my nerves were shot!
Over the course of the next week, I began to see mucus mixed in with the clear discharge. At first it was yellow…then it turned green. Yes…it was gross! But the nurse had told me my mucus plug would regenerate. But why was it coming out? Then one night I just sat in the living room and cried to my boyfriend. I was so tired of the hospital and looking at funky discharge and talking to doctors and nurses that seemed to be giving me the run around. But most of all I couldn’t believe that I was going through this again! 🙁 Something in my heart told me that I wouldn’t see this pregnancy to term. He told me that if the doctors didn’t say that, I shouldn’t think that.
But I knew…
The next day at work I was at my desk and could feel tightness in my back in the morning. The tightness seemed to move from my back to the front of my stomach. I was also feeling slightly feverish. I experience menstrual cramps and these weren’t nearly as painful. I was thinking that maybe I had eaten something to make me sick. However my lunchtime I began to realize that the cramping was coming in waves. I would feel tightness about 5-10 minutes apart. It would let up and then another wave would come. I finished the work day…and went straight to the hospital. I was hooked up to a machine and monitored for contractions. Nothing. But then a doctor came to examine me. She could see my membranes pushing through my cervix, in spite of my cerclage, when a contraction came. I was in labor and the cerclage was failing! The stitch had to come out due to the risk of ripping my cervix with the contractions. Within 5 hours my cervix dilated to 6 cm…my water broke and I delivered a girl, Iris, who was also too young to survive. I also had a bad infection…and had to remain in the hospital for another 2 days until I stabilized 🙁 .
Even after all of this, not one doctor or nurse officially diagnosed me with incompetent cervix. Not personally anyway. At some point, I believe it was noted in my medical records somewhere. But it didn’t matter…I knew. And I had resolved to stop letting nurses and doctors take the wheel of my medical care. I would do my own research and pursue the best course of action for me. If they don’t cooperate, then I move on. It’s my money…my body…and most importantly, my baby’s life!
I conceived again in 2016. I opted to change healthcare systems for my OB/GYN care. My record was reviewed and they suggested a referral to the MFM group at 12 weeks, and a vaginal cerclage placed early. Nope…not for me! I had decided that since my cervix tends to fail early, my best bet would be a TAC. Plus, I had a TVC and I knew that I didn’t want bedrest and the stress of feeling the stitch fail and getting another infection. I consulted with several TAC surgeons and opted to go with Dr. Sumners in Indianapolis. He’s one of the best TAC surgeons in the United States and plus my boyfriend has family in Indianapolis that we could stay with.
I had my TAC placed when I was 13 weeks pregnant. It was a more involved procedure than the TVC (which was outpatient…with the TAC, I spent 48 hours in the hospital); but the procedure and recovery went very well. My OB/GYN back home remarked 4 weeks later that you couldn’t even tell I had surgery….that’s how good the incision is! I’m currently 19 weeks pregnant and my cervix was measured to be 4.2 cm! Long and closed. No bedrest. No funky discharge. No pressure or cramping down there in the least! 😀
For other women out there battling with IC, I can’t tell anyone what they should do. All of our cases are different. But I will say that it is unwise to put blind faith in doctors and other medical professionals. Yes, they are supposed to be the experts. But there are a whole host of factors at work that may prevent you from getting the best possible care. Ultimately they don’t love your babies…you do. Do what’s best for you and your babies mommies!
I’ve spent countless hours reading and researching about incompetent cervix. It would be impossible for me to link everything…but here are some of the most valuable resources I’ve found:
Abbyloopers is a forum online that focuses on the TAC and helping women find doctors that perform the procedure. A map of their list can be found here. They also maintain data on TAC success rates of their members. Their Facebook group is also fantastic…filled with women who have or who are researching the TAC. For those who have had their babies, there is Abbyloopers Miracle Babies. 🙂
There are several other Facebook groups I like, such as Incompetent Cervix Awareness and Life After PPROM Loss. Due to the nature of these groups, you hear a lot of heartbreaking stories…but stories of hope as well.
On YouTube, there is Mona Hines. Like me, she’s had two losses due to IC, including a failed TVC. Unlike me though, she had her TAC placed before she was pregnant (by Dr. Davis…who is now retired). She has since had her rainbow baby and has uploaded many videos chronicling her journey….from her losses to her TAC pregnancy and beyond. She made the video below a week after her TAC was placed.
Dr. A. Haney works out of the University of Chicago and is one of the country’s premiere TAC surgeons. They have a great section of their website dedicated to the TAC…which can be found here. ObGyn.net has a good article on the procedure. Also Aetna (my current health insurance provider) has a page on the procedure as well.
Well I know this was insanely long, but hopefully someone out there will find it useful. As always, feel free to comment or message me if you wish with questions. Have a fabulous summer!