At the end of presentation, the participants should be able to understand the following: Definition of Cerclage Types of cerclage Indications Pre operative Preparations Removal of Cerclage

1. CERVICAL CERCLAGE
MODERATOR: Dr. Rehana Mushtaq
PRESENTER: Dr. Rahul Shah
PGY1
Department of Obstetrics & Gynaecology
1/9/2024

2. OBJECTIVE
• At the end of presentation, the participants should be
able to understand the following:
• Definition of Cerclage and Types
• Types of cerclage
• Indications
• Pre operative Preparations
• Removal of Cerclage
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3. CERVIVAL CERCLAGE
Provide structural support
to “weak” cervix.
Maintain cervical length and
the endocervical mucus plug
as a mechanical barrier to
ascending infection.
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Principle: The procedure reinforces the weak cervix by
a nonabsorbable tape, placed around the cervix at the
level of internal os.

4. • Cerclage remains one of the standard options for
prophylactic intervention in the care of women at risk of
pretermbirth and second trimester fetal loss and is used by
most obstetricians, despite difficulties in identifying the
population of women who would most benefit.
• The procedure, a stitch inserted into the cervix, was first
performed n 1902 in women with a history of second
trimester loss or spontaneous preterm birth suggestive of
cervical insufficiency, with the aim of preventing recurrent
loss.
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5. Types of Cerclage
• History Indicated cerclage
• Ultrasound Indicated Cerclage
• Cervical Cerclage in increased risk cases of preterm
delivery
• Transabdominal cerclage
• Rescue Cerclage
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6. HISTORY INDICATED CERCLAGE
• Prophylactic in asymptomatic women
• Elective in 12-14 WOG
• Indications: >2 previous preterm birth and/or second trimester losses
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Not helpful in the decision for a history indicated cerclage.
• Painless dilatation of the cervix.
• Rupture of the membrane before the onset of contraction.
• Cervical surgery.
• Pre-pregnancy diagnostics tests: Cervical resistance Index,
hysterography or insertion of cervical dilators.

7. ULTRASOUND INDICATED CERCLAGE
• Indication: Previous one or more spontaneous mid-trimester
loss or preterm birth and cervix is 25mm or less before 24
wog
• Not recommended for funneling of the cervix in the absence
of cervical shortening
• Not indicated in women who have an incidentally identified
cervix of 25mm or less with no history of spontaneous mid-
trimester loss or preterm birth.
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8. Serial surveillance? +- USG indicated cerclage
• Women with one or more second trimester loss or pre term delivery
• Those who experience cervical shortening are at an increased risk of
subsequent second trimester loss/preterm birth may benefit from US
indicated cerclage.
• Those whose cervix remain long have a low risk of 2nd trimester
loss/premature delivery
• Because the majority of women with a history of second trimester
loss/preterm delivery will deliver after 33 WOG, no evidence to
support serial sonographic surveillance over expectant management.
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9. Transabdominal Cerclage
•Indications: Previous failed Transvaginal Cerclage
•Associated with increased Maternal Morbidity
•Can be performed before or in early Pregnancy
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10. Rescue Cerclage
• Even with rescue cerclage the risk of sever preterm delivery
and neonatal mortality and morbidity remain high.
• Delay delivery by 5 weeks on average compared with
expectant management (bed rest) alone
• A/W 2 fold reduction in the chance of delivery before 34
weeks of gestation.
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Advanced dilatation of the cervix (>4 cm)
Membrane prolapse beyond the external OS.

11. CERVICAL INSUFFICIENCY
• Cervix starts dilating and effacing before her pregnancy has reached
term, usually between 16–28 weeks of gestation, without any
associated pain or uterine contractions.
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12. • Cervical incompetence is probably responsible for causing 20% to
25% of miscarriages in the second trimester.
• The woman gives history of recurrent second trimester pregnancy
losses, occurring earlier in gestation in successive pregnancies and
usually present with a significant cervical dilatation of 2 cm or more in
the early pregnancy.
• However, usually there is absence of any other symptoms. In the
second trimester, cervix may dilate up to 4 cm in association with
active uterine contractions.
• This may be associated with rupture of the membranes resulting in the
spontaneous expulsion of the fetus.
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13. • On clinical examination, the cervical canal may be dilated
and effaced. Fetal membranes may be visible through the
cervical os.
• Sonographic serial evaluation (every two weeks) of the cervix
for funneling and shortening in response to transfundal
pressure has been found to be useful in the evaluation of
incompetent cervix.
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14. Other findings observed on ultrasound examination
include the following:
• Cervical length < 25mm. However finding of the short cervical length on TVS is
not a confirmed diagnostic test for incompetent cervix. It could also be due to
early preterm labor.
• Protrusion of the membranes.
• Presence of the fetal parts in the cervix or vagina.
• Cervical dilation and effacement with the changes in form of T, Y, V, U (can be
remembered using the mnemonic “Trust Your Vaginal Ultrasound”)
• Another important finding on TVS examination of cervical incompetence is
funneling. Funneling implies herniation of fetal membranes into the upper part of
endocervical canal. However this too is not diagnostic of incompetent os.
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17. Non-Pregnant State
• The Internal OS allows the
passage of No. 8 Hegar’s Dilator or
foley’s catheter filled with 1 ml
water without resistance.
• Premenstrual
hysterocervicography will show
the typical funneling of internal
OS.
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18. PRESURGICAL PREPARATION
• Contraindications to cerclage include bleeding, contractions,
or ruptured membranes, any of which substantially raise
the likelihood of labor and failure.
• Prophylactic elective cerclage before dilation is preferable,
timing between 12 and 14 weeks’ gestation allows early
intervention.
• Still, it avoids surgery in the first trimester, which is when most
predestined spontaneous losses occur, and screening or
aneuploidy and malformation is completed.
• Cervical neoplasia screening in suitable candidates and
gonorrhea and chlamydial infection testing are done.
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19. PRESURGICAL PREPARATION
• Obvious cervical infection is treated.
• At times, the cervix instead is found to be dilated,
effaced, or both, and an emergency cerclage is
performed
• In more-advanced pregnancy, the risk of
stimulating preterm labor or of rupturing
membranes with the surgery is greater.
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20. • Regional analgesia is suitable and preferred then placed in
standard lithotomy position.
• The vagina and perineum are cleaned For surgery and the
bladder is drained.
• Some operators do not use potentially irritating antiseptic
solution in amnionic membranes are exposed and instead
use warm saline
• For suturing, options include a no. 1 or 2 nylon or
polypropylene monofilament suture or 5-mm Mersilene
tape.
• During placement, the suture is placed as cephalad along
the cervical length as possible, is anchored into the dense
cervical stroma, yet avoids the bladder. Two tandem
cerclage suture rings are not more effective than one
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21. • Emergency cerclage placement with a thinned dilated cervix is more
difficult, and tissue tearing and membrane puncture are risks.
• Gentle replacement of the prolapsed amnionic sac back into the
uterus can aid suturing. Options include steep terendelenburg or
flling the bladder with 600 mL of saline through a Foley catheter in
the bladder. However, these steps may carry the cervix cephalad
and away from the operating field.
• Instead, membranes can be pushed inward by a wide, moist sponge
stick.
• A Foley catheter can instead be inserted through the cervix, and
infation of the 30-mL balloon can detect the amnionic sac inward.
• The balloon is gradually defated as the cerclage suture is tightened
around the catheter tubing, which is then removed. With any of
these, simultaneous gentle outward traction created by ring forceps
placed on the cervical edges may be helpful.
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22. STEPS OF SHIRODKAR’S OPERATION
Step I: The patient is
put under light general
anesthesia and placed
in lithotomy position
with good exposure of
the cervix by a
posterior vaginal
speculum. The lips of
the cervix are pulled
down by sponge
holding forceps or Allis
tissue forceps.
Step II: A transverse
incision is made
anteriorly below the
base of the bladder on
the vaginal wall and
the bladder is pushed
up to expose the level
of the internal os. A
vertical incision is
made posteriorly on
the cervicovaginal
junction.
Step III: The
nonabsorbable suture
material—Mersilene
(Dacron) or Ethibond
tape is passed
submucousl with the
help of an aneurysm
needle or cervical
needle so as to bring
the suture ends
through the posterior
incision.
Step IV: The ends of
the tapes are tied up
posteriorly by a reef
knot. The bulging
membranes, if
present, must be
gently reduced
beforehand into the
uterine cavity. The
anterior and posterior
incisions are repaired
by interrupted stitches
using chromic catgut.
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23. 1/9/2024

24. Shirodkar technique:
• A high transvaginal purse string
suture placed following bladder
mobilization to allow insertion
above cardinal ligaments.

26. McDONALD’S OPERATION
• The nonabsorbable suture (Mersilene) material is placed as a
purse-string suture as high as possible (level of internal os) at
the junction of the rugose vaginal epithelium and the smooth
vaginal part of the cervix below the level of the bladder.
• The suture starts at the anterior wall of the cervix. Taking
successive deep bites (4–5 sites), it is carried around the lateral
and posterior walls back to the anterior wall again where the
two ends of the suture are tied.

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29. • During procedure, risk of tissue tearing and membrane rupture is
more.
• To prevent this, steep Trendelenburg’s or filling the bladder with
600ml of normal saline through an Foley's catheter.
• For uncomplicated pregnancy without labor , cerclage is usually cut
and removed at 37 weeks of gestation.

30. • Wurm’s procedure:
• Also known as Hefner’s cerclage, it is done by application of U or
mattress sutures and is of benefit when minimal amount of length
of cervical canal is left.

31. • Lash procedure
• This surgical procedure is usually performed in nonpregnant woman.
It is usually performed for an anatomical defect in cervix resulting
from cervical trauma.
• In this surgery, the cervical mucosa is opened anteriorly, bladder
reflected and the cervical defect repaired with interrupted
transverse sutures before closing the vaginal mucosa.

32. Contraindications for cerclage
• Uterine contractions/bleeding.
• Clinical evidence of Chorioamnionitis.
• Premature rupture of membranes.
• Cervical dilatation of more than 4 cm
• Polyhydramnios
• Fetal anomaly incompatible with life.
● Women with Mullerian anomalies.
● Previous cervical surgery.
● Multiple dilatation and evacuation.
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33. Risks of cerclage
• Premature rupture of the membranes
• Chorioamnionitis
• Preterm labor
• Cervical laceration or amputation resulting in the formation of scar
tissue over the cervix
• Bladder injury
• Maternal hemorrhage
• Cervical dystocia
• Uterine rupture, vesicovaginal fistula
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34. Removal of cerclage
• Transvaginal cerclage should be removed before labor, usually 36
and 37 weeks of gestation.
• In women in establishing preterm labor, cerclage should be removed
to minimize cervical trauma.
• A Shirodkar suture usually require anesthesia to remove.
• All women with transabdominal cerclage, require delivery by
caesarean section.

35. REMOVAL FOLLOWING PPROM (24-34) WEEKS
• Without evidence of infection or preterm labour, delayed removal of
the cerclage for 48 hours can be considered, for a course of
prophylactic steroids and/or in utero transfer.
• Delayed suture removal until labour is a/w an increased risk of
maternal/fetal sepsis and is not recommended.
• Should be removed immediately following PPROM before 23 weeks
and after 34 weeks.

36. Alternative to cervical cerclage
• may be bed rest alone to avoid pressure on the cervix.
• Injection of 17a-hydroxyprogesterone caproate 500
mg IM weekly is given as cervical incompetence is
considered as a continuum of preterm birth syndrome.
• Use of vaginal pessary, when cervix is found short on
ultrasound, is found helpful.

37. Advice on discharge
• (a) Usual antenatal advice.
• (b) To avoid intercourse.
• (c) To avoid rough journey.
• (d) To report if there is vaginal bleeding or abdominal
pain.
• (e) Periodic ultrasonographic monitoring of the fetus
and the cervix.

38. References

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