Cervical cerclage Procedure by Dr Aruna Ashok, Clinical Director, A4 Hospital and Fertility Centre, Chennai.

1. CERVICAL CERCLAGE

2. Introduction
• Prematurity is the leading cause of perinatal death and disability.
• Although preterm birth is delivery before 37 weeks, majority of
adverse outcomes occur when born before 28 week of gestation.
• Cervical cerclage was first performed in 1902 to provide a degree of
structural support to the weak cervix
• It also plays a role in maintaining the cervical length and maintains
endocervical mucus plug as a mechanical barrier to ascending
infection.

3. Other names - Cervical stitch, cervical suture,
internal os tightening.
• Previous terminology can be ambiguous (prophylactic/ elective/
emergency/ rescue/ urgent)
Indications
1. History indicated
2. Ultrasound indicated
3. Emergency cerclage
4. Transvaginal cerclage (McDonald’s)
5. High transvaginal (Shirodkar)
6. Transabdominal cerclage
7. Occlusion cerclage(Wurm’s)

4. HISTORY INDICATED
• Done electively at 12-14 weeks of gestation
• Offered to women with two or more previous preterm births and/or
second-trimester losses.

5. HIGH RISK FOR PRETERM BIRTH
• Multiple pregnancies
• Uterine anomalies – Mullerian anomalies.
• Cervical surgery/trauma – cone biopsy, large loop excision of
transformation zone, laser ablation or diathermy.
• Cerclage is not recommended as per guidelines – but prophylactic
cerclage can be considered in high risk group.

6. ULTRASOUND INDICATED CERCLAGE
• Therapeutic procedure done in asymptomatic women when TVS shows
short cervix between 14 and 24 weeks.
• In singleton pregnancy:
• Not recommended without h/o spontaneous preterm delivery or second
trimester loss with incidentally identified short cervix of 25mm or less.
• Recommended with prev. history of one or more spontaneous mid-
trimester losses or preterm births with cervix is 25mm or less before 24
weeks of gestation.
• Not recommended for funneling of cervix in the absence of cervical
shortening to 25mm or less.
• Serial sonographic surveillance will be offered to women with h/o prev. mid
trimester loss and not undergone history indicated cerclage

7. RESCUE CERCLAGE
• Done in case of premature cervical dilatation with exposed
membrane in the vagina
• Gestational age at presentation has to be taken into account.
• Rescue cerclage may delay delivery by a further 5 weeks on average
compared with bed rest alone.
• Two-fold reduction in chance of delivering before 34 weeks.
• Advanced dilatation of >4cm and membrane prolapse beyond
external os – high chances of cerclage failure.
• Even with rescue cerclage 50% chances of preterm labour can
happen.

8. TRANSABDOMINAL CERCLAGE
• Considered in previous failed transvaginal cerclage.
• Can be performed preconceptually or in early pregnancy.
• Can be done either laparoscopically or by laparotomy.
• In case of miscarriage/ fetal death with abdominal cerclage:
Upto 18 weeks – Suction evacuation/ D&E through the stitch
Delivery will require Cesarean.

9. TRANSVAGINAL CERCLAGE
• McDonald – commonly practiced, purse string suture at
cervicovaginal junction without bladder mobilisation.
• Shirodkar – above the level of cardinal ligaments, requires bladder
mobilisation, requires anaesthesia for removal.
• Occlusion Cerclage (WURM’S). Continous nonabsorbable suture is
placed at external os .
• Non- absorbable suture material will be used – mersilene tape or Silk

10. TRANSVAGINAL CERCLAGE
• Can deliver Normally .
• The cerclage is removed at 36 to 37 weeks , it is a out patient
procedure.
• Then can wait for Spontaneous Labour or Induce Labour.

11. CONTRAINDICATIONS
• Active preterm labour
• Clinical evidence of chorioamnionitis
• Continuing vaginal bleeding
• PPROM
• Evidence of fetal compromise
• Lethal fetal defect
• Fetal death.
RISK OF CERCLAGE – 2% chances of miscarriage following cerclage.

12. INFORMATION BEFORE CERCLAGE
• Patient to know before procedure that,
• Cerclage is not associated with increased risk of PPROM, induction of
labour or caesarean delivery.
• No apparent increase in chorioamnionitis.
• There is a small risk of cervical trauma, intraoperative bladder injury,
bleeding and membrane rupture in cerclage , Rescue Cerclage has
higher risk.
• If there is spontaneous labour later with suture in situ- risk of cervical
laceration/ trauma.

13. INVESTIGATIONS BEFORE CERCLAGE
• Apart from basic investigation, first trimester scan with screening to rule
out aneuploidy in history indicated cerclage
• For rescue cerclage – routine use of maternal WBC/CRP level to rule out
subclinical chorioamnionitis is not recommended. In the absence of clinical
signs of chorioamnionitis, rescue cerclage need not be delayed.
• No need for amniocentesis before cerclage
• No evidence to support need for genital infection screening before
cerclage.
• If detected, complete the antimicrobial course
• You will be asked to stop aspirin (5 days) and heparin(24hrs) injection (if
you are already on)

14. ON THE DAY OF PROCEDURE
• As the procedure is done under anaesthesia, 6hrs of fasting is
required
• Patient will be admitted in the morning on the day of procedure.
• IV fluids will be started as you are fasting.
• Just before procedure progesterone injection will be given to support
pregnancy.
• Prophylactic iv antibiotic will be given.

15. POST PROCEDURE INFORMATION
• Transvaginal cerclage can be performed as day care procedure - can be
discharged on same day.
• Those who are undergoing rescue/ ultrasound indicated cerclage can be
benefited by staying for 24hrs postoperatively.
• For transabdominal cerclage 48hrs stay is recommended.
• Antibiotics – initially IV, followed by oral antibiotics will be given
• Tocolytics will be given for 5 days post procedure along with your regular
medications.
• You can start aspirin and heparin 5 days post procedure.
• Ultrasonography will be done to confirm fetal viability before discharge.

16. AFTER DISCHARGE
• Bed rest after discharge should be individualised.
• Sexual abstinence.
• Serial sonographic surveillance is not recommended routinely, but
can be used in ultrasound indicated cerclage.
• Repeat cervical pessary insertion is required for some patients or in
rescue cerclage along with transvaginal cerclage .

17. Cervical pessary
• Feto Safe Cervical Pessary.
This is a perforated silicone pessary, designed to be used for
Pregnant patients with cervical incompetence. The silicone
pessary acts as a mechanical support to the cervix. It also
helps patients by making the direction of pressure toward
sacral bone. It helps to prevent second trimester
miscarriages due to cervical incompetence, preterm labour
and PPROM. It can be used along with cervical cerclage if
need be. And it is a non-invasive cost-effective alternative to
operative procedures.
Indications :
1. Short cervix < 2.5cm
2. Funneling of cervix
3. Previous history of cervical incompetence
4. Multiple pregnancy as prophylaxis
5. Signs of threatened miscarriage
How long can it be kept?
Can be kept in vagina till delivery. Since the pessary is
perforated the cervical secretions will not be accumulated.
For prophylaxis, vaginal suppositories can be used for 3 days
monthly. If in case need to be removed or expelled , can be
cleaned and reinserted.
Contact :
Ziller Medical Inc.
9791024002
India.

18. WHEN TO REMOVE CERCLAGE
• Transvaginal cerclage can be removed before labour between 36-37
weeks
• If elective caesarean is planned, can be delayed until caesarean.
• Shirodkar suture requires anaesthesia for removal
• Transabdominal cerclage requires caesarean section for delivery and
it can be left in place following delivery.

19. OTHER OCCASION
• If patient presented with established preterm labour, cerclage to be
removed to minimise trauma to the cervix.
• In case of PPROM, between 24 and 34 weeks, without evidence of
preterm labour/ infection, cerclage removal can be delayed until
steroids for fetal lung maturity is completed and/or in utero transfer is
arranged.
• Delayed removal is not recommended if risk of maternal/fetal sepsis
is expected.