Cervical Cerclage Procedures

Tsega T.(BSc. MSc)

Menelik II Medical and health Science College

8 May 2023
 Outlines
• Objectives
• Introduction
• Pathogenesis
• Indications and contra indications
• Treatment options
– Non surgical and surgical approachs
 Objectives:
• By the end of this lecture students are able to
– Describe the risk factors for cervical insufficiency.
– Identify the indications for cervical cerclage .
– Outline the common methods of a cervical
cerclage procedure.
– Understand post op Complications
 Introduction
• Cervical incompetence has long been recognized as a
potential cause of preterm delivery & recurrent mid trimister
abortionns.
• Condition in which the cervix fails to retain the conceptus
during pregnancy.
• There are arguments about the occurrence and incidence of
incompetent cervix
• Cirvical encerclage is surgical reinforcement of the
incompetent cervix
• The Principle is The procedure reinforces the weak cervix by
a non-absorbable tape, placed around the cervix at the level
of internal os.
 Time of Operation
• In a proven case, prophylactic circlage should be done
around 14 weeks to 16th weeks of pregnancy.
• Emergency circlage can be done when the cervix is dilated
and there is bulging of the membranes.
• Why not to be Performed in First Trimester ?
– The first trimester abortions are usually due to germplasm
defect and cervical encerclage cannot prevent them .
– Therefore , the procedure is carried out only when viable
pregnancy is established .
– Cervical incompetence generally does not cause first trimester
abortions
 Prevalence
• Affects around1% of pregnant patients
• It is believed that cervical incompetence
is the cause of 20 - 25 % of all second
trimester losses
 AETIOLOGY
1. Idiopathic (most cases).
2. Congenital disorders (congenital mullerian duct
abnormalities eg. Septate uterus, Bicornuate uterus).
3. DES exposure in utero.
4. Connective tissue disorder (Ehlers- Danlos
syndrome).
5. Surgical trauma :
 Conization,( resulting in substantial loss of connective tissue) or
 Traumatic damage to the structural integrity of the cervix :
(repeated forced cervical dilatation associated with D&C).
 Pathogenesis
• The function of the cervix during pregnancy depends on the
regulations of connective tissue metabolism.
• Collagen is the principal component in the cervical matrix, others
are: (proteoaminoglycans, elastin and glycoproteins, like
fibronectin).
The biochemical events implicated in the cervical ripening
are:
1. Decrease in total collagen content,
2. Increase in collagen solubility and
3. Increase in collagenolytic activity.
 Symptoms
• Women with incompetent cervix typically present
with "silent" cervical dilatation (i.e., with minimal
uterine contractions) between 16 and 28 weeks of
gestation.
• Patient present with significant cervical dilatation (2
cm or more) and minimal symptoms.
• When the cervix reaches 4 cm or more, active
uterine contractions or rupture of membranes may
occur.
 Diagnosis
• It is a clinical diagnosis marked by gradual, painless
dilatation and effacement of the cervix with
membranes visible through the cervix.
• This history establishes the diagnosis, eventually,
women with this cervical status may develop
membrane rupture & labor.
• Short labors with the delivery of an immature fetus or
loss of the pregnancy at progressively earlier
gestational ages in successive pregnancies is
characteristic of reduced competence.
 Diagnostic Criteria

– Historical factors
1. History of painless cervical dilatation with preterm
delivery
2. History of forceful cervical dilatation and evacuation
3. History of obstetric trauma: cervical lacerations,
prolonged second stage followed by cesarean
4. Prior cervical surgery: cone, loop
– Cervical sonography
5. Short cervical length
6. Cervical funneling
 Sonographic findings
1. Funneling of the cervix with the changes in
forms T, Y, V, U (correlation between the
length of the cervix and the changes in the
cervical internal os). (Trust Your Vaginal
Ultrasound)
2. Cervix length < 25 mm
3. Protrusion of the membranes.
4. Presence of fetal parts in the cervix or
vagina
 Indication for cerclage
1. History compatible with incompetent
cervix AND
2. Sonogram demonstrating funneling
OR
3. Clinical evidence of extensive
obstetric trauma to cervix
ACOG Criteria Number 17 October 1996, ACOG
Criteria Number 18 October 1996
 Contraindications
• Rupture of membranes
• Uterine contractions
• Uterine bleeding
• Chorioamnionitis
• Cervix dilated > 4 cm
• Polyhydramnios
• Dead foetus
• .Abnormal foetus
• Lower genital tract infection
 PRECONCEPTIONAL MANAGEMENT
• Diagnosis
–Typical obstetric history of repeated midtrimester abortions .
–Dilator test ( Snap test ) : Hegar's dilator no . 8 can be introduced easily
without any resistance. Also while withdrawing it , no characteristic snapping
closure is felt .
–Hysterography : Funneling seen at the isthmus with the width of more than 8
mm at the internal os . Hysterography may be performed in midluteal phase
for this purpose .
• Place of the Preconceptional Encerclage
–Not performed as :
• Cannot judge the extent of tightness required , hence may become very tight
or may remain loose .
• Unexplained infertility is known after cervical encerclage done in a
nonpregnant state .
 Anaesthesia and preoperative evaluation

• General anaesthesia
• Ultrasonography to ensure live and normal foetus
• VDRL to exclude syphilis
• MS-AFP( Alpha Fetopritein) if appropriate
• Wet mount.( For vaginal infections).
• G Beta Streptococci, Gonococci, and Chlamydia
cultures.
Treat appropriately for infection.
 MANAGEMENT
NONSURGICAL MANAGEMENT
• Bed rest alone to avoid pressure on the
cervix.
• Injection of 17α OH progesterone
caproate 500 mg IM weekly is given as
cervical incompotence is considered as a
continum of preterm birth syndrome.
• Advanced cases , where encirclage is not
possible , may be treated by this
management .
 TREATMENTS

• Surgical repair of the cervix using a vaginal or

abdominal approach.
• The initial descriptions of cervical cerclage for
cervical incompetence came with Shirodkar and
McDonald in the 1950s, when both developed
techniques for physical support for what was
presumed to be a structurally weak cervix.
 Surgical Approaches
• Surgical approaches to cervical
incompetence is, at present, the
mainstay of treatment.
• Cerclage is not indicated solely based
on risk factors or prior cerclage
placed for doubtful indications.
 Cerclage

Prophylactic Emergency
 Prophylactic Cerclage
• Prophylactic cerclage sutures (Shirodkar,
McDonald )may be placed at 12 to 16 weeks'
gestation.
• Do not use tocolytics at the time of prophylactic
cerclage, but give perioperative antibiotics.
• Intercourse, prolonged standing (>90 minutes), and
heavy lifting are omitted following cerclage.
• Follow these patients with periodic vaginal sonography
to assess stitch location and funneling.
 Emergency Cerclage
• Care of the patient with newly detected reduced
cervical competence in the second trimester is both
difficult and controversial.
• When the diagnosis is made before cervical
dilatation has occurred and when there is still 10 to
15 mm or more of cervical length, admit the patient
for 24 hours of treatment with perioperative
indomethacin and broad-spectrum antibiotics
before placing the cerclage sutures, and observe the
patient for 48 to 96 hours postoperatively.
 Emergency Cerclage
In the case of advanced dilatation with bulging membranes,
several techniques may be helpful:
1. Pre cerclage amniocentesis to remove sufficient fluid to reduce the
bulging membranes can be helpful.
2. Overfilling the bladder with 1,000 ml of saline may help by elevating the
membranes out of the operative field, but may also obstruct the surgeon's
view.
3. Place a Foley catheter balloon inside the cervix, and overfill it with at least
50 ml of saline to gently push the membranes out of the lower segment.
The cerclage suture can then be placed and tied as the balloon fluid is
evacuated.
 Emergency Cerclage
• Cerclage is rarely performed after 24 to 25
weeks of pregnancy.
• The great risk of inducing PROM or preterm
labor and the ability to prolong gestation with
bed rest and suppressive medications argue
against surgical intervention in such cases.
• The cerclage is removed at 37 weeks' gestation
or at the onset of labor.
 Cerclage procedures
There are five different techniques for performing the
cerclage:
1. McDonald procedure
2. Shirodkar operation
3. Wurm procedure (Hefner cerclage)
4. Transabdominal cerclage
5. Lash procedure
The two most common are the McDonald and Shirodkar.
 MCDONALD'S OPERATION
• This is the simplified modification of Shirodkar's
encerclage operation .
• Here , the reinforcement stitch is taken below the
level of the internal os at cervicovaginal junction
without dissection of the urinary bladder .
• The McDonald technique requires no bladder
dissection, and the cervix is closed using four or five
bites with the needle to create a purse string around the
cervix.
 McDonald procedure
• The McDonald procedure is done with a 5 mm
band of permanent suture is placed high on the
cervix.
• This is indicated when there is significant
effacement of the lower portion of the cervix.
• It is generally removed at 37 weeks, unless there
is a reason to remove it earlier, like infection,
preterm labor, premature rupture of the
membranes, etc.
• It is also shown that this has very little impact of
the chance for vaginal delivery.
 Instruments
• Right - angled retractor
• half circle nontraumatic suturing needle
• suture material - braided black silk no . 1 or 2
or thick monofilament nylon .
 Steps of Operation
1. Cervix is exposed and the anterior lip of the
cervix is held by sponge holding forceps .
2. A purse string suture is taken starting
anteriorly and taking four bites through the
substance of the cervical tissue .
3. Knots of the two ends of the suture material
are tied anterior to the cervix taking care not
to tie them too tightly .
• Removal of the Stitch and Postoperative Care
– At 38 weeks of gestation or at the onset of labour - whichever is
earlier .
– Rest in head low position to avoid pressure of foetal head on
internal os
– Prophylactic tocolytic drugs like Isoxuprine , Salbutamol
– Sedation
– Patient can be discharged after the uterus has relaxed completely .
• Instructions
– Extra rest , preferably in head low position
– Avoid lifting heavy weights
– No travelling
– Fortnightly antenatal check up
– Continuation of tocolytic agents orally if indicated , particularly if
the uterus shows signs of irritability .
 Complications

1. Accidental Rupture of Membranes

– In such case , the abortion becomes inevitable .
– This can be prevented by taking care not to encroach into cervical canal during the
procedure .
2. Uterine Contractions
– Which can be prevented by :
• Avoiding the operative procedure till uterus is completely
• relaxed .
• Avoiding too much of manipulation .
• Strict bedrest in head low position postoperatively . Timely use of tocolytic agents , if the uterus
becomes irritable .
3. Failure to Prevent Obstetric Mishaps
– If diagnosis is incorrect
– If done too late when membranes are bulging .
4. Infection
– This can be prevented by proper case selection and following disinfection procedures .
– If Performed when the uterus is contracting
 Shirodkar operation
• The Shirodkar is also a frequently used technique.
• However, this was previously a permanent purse
string suture that would remain intact for life.
• There are physicians performing modified
techniques, where the delivery does not
necessarily have to be by cesarean, nor the suture
left intact.
 Shirodkar operation
• Place the suture as near the internal os as,
opening the anterior fornix and dissecting away
the adjacent bladder, before placing the suture
submucosally, tied anteriorly and the knot buried
by suturing the anterior fornix mucosal opening.
• The original intention with the Shirodkar method
was to leave the suture in place and aim for
delivery by caesarean section.
 Instruments
• Sim's / Auvard's speculum
• anterior vaginal wall rectractor
• sponge holding forceps
• right - angled retractors
• B.P. Handle no . 4 with blade no . 22
• Special aneurism needles - right - sided and left
- sided ( they are mirror images of each other )
• Mersilene tape , needle holder , scissors ,
catgut no . 1/0 on needle
 Steps of Operation

1. Patient's legs are tied in lithotomy position .

2. The cervix is exposed with the help of Sim's / Auvard's
speculum .
3. Anterior lip of the cervix is held with sponge holding
forceps .
4. Transverse incision of about 2 cm length is taken at
cervico vaginal junction in the anterior vaginal wall .
5. The bladder is pushed up with finger and gauze
dissection .
6. The internal os is identified by the attachments of the
bladder pillars .
 Steps…

7. Shirodkar's special aneurism needle is passed submucosally

on one side through the incision and brought out
posteriorly to the cervix at 6 O'clock position by taking a
vertical nick . Mersilene tape is threaded in the tip and the
needle is brought back along with the tape .
8. The needle is introduced similarly submucosally on the
other side and the tape is threaded in its tip . The needle is
brought out posteriorly through the same posterior incision
to bring the tape posteriorly and the needle is removed .
9. The two ends of the tape are tied posteriorly .
10.Both incisions are closed by few interrupted catgut sutures .
• At term mersilene tape can be divided and the patient can
be delivered vaginally .
 Comparison of Shirodkar's and McDonald's
cervical encerclage
Shirodkar's McDonald's
• Original surgery • Modification of Shirodkar's operation
• Technically skillful • Technically easy
• Requires more time • Requires less time
• More operative bleeding • No operative bleeding
• Suture material - Mersilene tape - • Suture material - Breaded black silk or
costly monofilament nylon much lower cost
• Special Shirodkar's encerclage • Oridnary nontraumatic curved suturing
needle required needle to be used Knot anteriorly
• Knot posteriorly • Cannot be performed in too short
• Length of cervix does not put cervix ( congenital or amputated ) , and
extensive cervical tears where reaching
limitations on procedure . Indicated
above the apex of the tear is not
when cervix is short , amputated or
possible
torn
 WURM PROCEDURE

• This is a procedure of cervical reinforcement suggested for

the treatment of cervical incompetence with effaced
cervix .
• The suture material used is braided silk no . 3.
• A stitch is inserted through cervical os from positions 12
O'clock to 6 O'clock and back to 12 O'clock position
• Another stitch is taken at right angles to this at positions
starting from 3 O'clock to 9 O'clock and back to 3 O'clock
position .
• The entry and exit points are approximately separated from
each other by 1 cm distance ; thus cervical tissue of 1 cm
each is incorporated at 12 , 3 , 6 and 9 O'clock positions
respectively .
 TRANSABDOMINAL ENCERCLAGE

• This is abdominal approach for

encerclage of the incompetent os of
the cervix where vaginal encerclage is
not possible due to too short cervix .
• Indications
–Congenitally short cervix
–Amputated cervix
–Marked scarring of the cervix .
 Procedure
• Mersilene strand stitch is taken to encircle the isthmial
region around 14 weeks of gestation . Elective
caesarean section is done at term and the stitch is left
in situ for the future pregnancies .
–Advantage
•Since the stitch is left in situ , no need to undergo
encerclage operation during every pregnancy .
–Disadvantage
•Since vaginal delivery is not possible in these cases ,
it involves two major surgical procedures - the
abdominal encirclage and the caesarean section.
 Lash procedure

• The last procedure, the Lash, is performed in the

non-pregnant state.
• It is typically done after cervical trauma that has
caused an anatomical defect.
• Lash described techniques aimed at the repair of a
specific anterior cervical structural defect.
• The cervical mucosa was opened anteriorly, the
bladder reflected and the cervical defect repaired
with interrupted transverse sutures before closing
the vaginal mucosa.
 ORDERS
• Admit for cerclage
• NPO after midnight
• Bed rest.
• Trendelenberg if cervix is effaced or dilated.
• Surgical consent
• A 100-mg dose of indomethacin may be given per
rectum during the operative period, followed by a
50-mg oral dose every 6 hours
 ORDERS
• McDonald cerclage
• Postop. ,Transfer to postpartum for
observation
• Regular diet
• Bed rest 12-24 hours
• May discharge if no uterine contractions,
vaginal bleeding, or rupture of membranes
during observation.
 Risks of Cerclage
1. Premature rupture of membranes (1-9%)
2. Chorioamnionitis (Infection of the amniotic sac, 1-7%) (This risk
increases as the pregnancy progresses and is at 30% for a cervix
that is dilated more than 3 cms.)
3. Preterm Labor
4. Cervical laceration or amputation (This can be at the procedure or at
the delivery, from scar tissue that forms on the cervix.)
5. Bladder Injury (rare)
6. Maternal hemorrhage
7. Cervical dystocia
8. Uterine rupture
 Efficacy of Cerclage

• Cerclage seems to be a
very effective treatment for
incompetent cervix.
• The success rates can be very high
(80-90%), particularly when done
earlier in a pregnancy.
 References
• ACOG Practice Bulletin No.142: Cerclage for the management of
cervical insufficiency. Obstet Gynecol. 2014 Feb;123(2 Pt 1):372-
379. [PubMed]
• Brown R, Gagnon R, Delisle MF., MATERNAL FETAL MEDICINE
COMMITTEE. Cervical insufficiency and cervical cerclage. J Obstet
Gynaecol Can. 2013 Dec;35(12):1115-1127. [PubMed]
• Gluck O, Mizrachi Y, Ginath S, Bar J, Sagiv R. Obstetrical outcomes
of emergency compared with elective cervical cerclage. J Matern
Fetal Neonatal Med. 2017 Jul;30(14):1650-1654. [PubMed]
• Wood SL, Owen J. Cerclage: Shirodkar, McDonald, and
Modifications. Clin Obstet Gynecol. 2016 Jun;59(2):302-10. [
PubMed]