Age 41 – Cervical Cerclage

These photos show the cervix of a 41-year-old pregnant woman.

Relevant history

She has had two prior abnormal Pap tests (10 years ago and 3 years ago) that required biopsies; no HPV was ever detected. Three years ago, her treatment included cauterization of the cervix (view movie of her cauterization here).
She has had four previous losses (miscarriages/chemical pregnancies). This is her first pregnancy to progress past the first trimester.
She initially conceived twins, but one embryo stopped developing in the first trimester (a “vanishing twin”). This is a common occurrence in multiple pregnancies: the nonviable embryo usually stops growing and is reabsorbed or otherwise lost while the surviving embryo continues to develop.

Recent events and findings

At 22 weeks gestation she noticed loss of some of her mucus plug, as seen in the photograph on some toilet tissue. The mucus plug is a thick collection of mucus that seals the cervical canal during pregnancy and helps protect the uterus from bacteria. When the cervix softens and begins to open, the plug can loosen and pass out the vagina, often looking like a clump of clear or yellow jelly or stringy mucus sometimes tinged with blood. Losing the plug at term can be a welcome signal of imminent labor, but losing it earlier can mean the cervix is changing too soon.
She went to her provider the next day. Ultrasound showed the cervix had shortened rapidly (from 3.4 cm to 1.8 cm over 11 days) and the amniotic sac was “funneling” — bulging down into the cervical canal. These findings are consistent with cervical insufficiency (also called a weak or incompetent cervix), where the cervix cannot stay closed under the weight of the pregnancy and begins to shorten and open early.

Treatment given

To prevent further dilation and reduce the risk of preterm birth, an emergency (rescue) cervical cerclage was placed. A cerclage is a temporary stitch that closes the cervix. There are several types of cervical cerclage; in her case a McDonald cerclage (a purse‑string stitch) was used.
The procedure was done with a spinal block for pain control. The provider used small forceps to hold the cervix and placed a non‑absorbable suture near the internal os to cinch the cervix closed. These photos were taken on the day of the procedure.
She experienced mild cramping and light bleeding/spotting for a couple of days after the procedure, which is a common and expected response.
Her plan is for the cerclage to be removed at about 36 weeks and 5 days. After removal, many women go into labor spontaneously or continue to carry to a later gestational age; outcomes vary with each case.
Providers will monitor for signs of infection, contractions, or further cervical change. If labor starts or other complications occur, the cerclage may be removed earlier than intended.
At the time of this posting, she was 34 weeks and 2 days pregnant. She reports the stitch is intact and the amniotic sac remains funneling down to the level of the cerclage.

What you see in the photos

These photos were taken on the day that the cerclage was placed. Metal retractors hold the vagina open so the provider can see the cervix.
The cervix appears “puckered” because the cerclage pulls the os closed.
The slight bleeding visible was caused by the suture needle as it bit sections of cervical tissue to complete the stitching.
Some suture thread is visible surrounded by blood on the top left surface of the cervix.

Placed at 22 weeks gestation, the cervix appears puckered due to cerclage stitches pulling the os shut, like a drawstring

Cervical Cerclage stitch placed at 22 weeks gestation; suture strings visible on top left of cervix