A cervical cerclage is a procedure where a stitch is placed around the cervix, the neck of the womb, to keep it closed during pregnancy. This intervention helps maintain the cervix’s integrity to prolong a pregnancy. The Shirodkar cerclage is a specific and more complex type of this procedure, involving a different surgical technique than other common methods.
When a Shirodkar Cerclage is Recommended
A Shirodkar cerclage is primarily recommended for individuals with cervical insufficiency. This condition involves the cervix shortening and opening painlessly before the pregnancy reaches full term, which can lead to second-trimester pregnancy loss or premature birth. The decision to place a cerclage is based on a person’s medical history and current pregnancy circumstances.
One indication is a “history-indicated” or prophylactic cerclage. This is offered to individuals who have experienced one or more second-trimester pregnancy losses related to painless cervical dilation. In these cases, the cerclage is placed proactively between 12 and 14 weeks of gestation, before any cervical changes are detected.
Another scenario is an “ultrasound-indicated” cerclage. This is for individuals with a prior spontaneous preterm birth before 34 weeks, where an ultrasound reveals a cervical length of less than 25 millimeters before 24 weeks of gestation. A “rescue” cerclage may also be considered if the cervix is found to be dilated on a physical exam, though this carries more risk. Contraindications for any cerclage include active preterm labor, vaginal bleeding, or an intrauterine infection.
The Shirodkar Cerclage Procedure
The Shirodkar cerclage is a surgical procedure performed in a hospital under regional anesthesia, such as a spinal or epidural block. This allows the patient to remain awake without feeling pain from the waist down. The procedure is more invasive than the more common McDonald cerclage because it requires the surgeon to make incisions into the vaginal tissue to access a higher portion of the cervix.
The patient is placed in the lithotomy position, and the surgeon makes a small, transverse incision in the vaginal wall at the front of the cervix. This is done to gently move the bladder away and expose the cervix at the level of the internal os. A similar incision may be made on the posterior side of the cervix. This dissection allows the surgeon to place the suture much higher up around the cervix, closer to the uterus.
A non-absorbable tape, such as 5-mm Mersilene tape, is passed around the cervix through the space created by the incisions. The surgeon tightens the tape to close the cervix and secures it with a knot. A defining feature of the Shirodkar technique is that the knot is often buried by suturing the vaginal mucosa back over it, which makes the stitch more durable but also more complex to remove.
Life After the Cerclage Placement
Following the Shirodkar procedure, a period of hospital monitoring is typical, lasting from a few hours to overnight. A urinary catheter may be placed temporarily since regional anesthesia can make urination difficult. It is common to experience minor abdominal cramping, light bleeding, or spotting for a few days post-procedure, which should gradually subside. An increase in vaginal discharge throughout the rest of the pregnancy can also be expected.
Once discharged, a period of rest at home for a few days is recommended, with an avoidance of strenuous physical activity. Pelvic rest, which includes abstaining from sexual intercourse, is often advised for at least a week and sometimes for longer durations as determined by the physician. Most people can resume their normal, non-strenuous activities within one to two weeks.
Regular follow-up appointments are scheduled to monitor the stitch and the health of the pregnancy. It is important to contact a healthcare provider immediately if the following symptoms occur, as these could signal a potential issue:
- Contractions
- Lower abdominal or back pain that comes and goes
- Vaginal bleeding
- Fever
- Leaking fluid
Potential Risks and Complications
While a Shirodkar cerclage is intended to prevent pregnancy loss, the procedure itself carries potential risks. During the operation, there is a small chance of complications like bleeding or injury to the bladder or cervix. In rare instances, the amniotic sac can rupture during or shortly after the surgery.
After the procedure, one of the primary concerns is infection, such as chorioamnionitis (infection of the amniotic sac and fluid). Signs of infection like fever, chills, or foul-smelling discharge require immediate medical attention. The stitch itself can sometimes irritate the cervix, which may trigger uterine contractions or preterm labor.
In some cases, the suture material can migrate from its original placement. While the goal is to prolong the pregnancy, the procedure does not eliminate the possibility of preterm birth and may not be successful in preventing it.
The Cerclage Removal Process
The removal of a Shirodkar cerclage is a planned event, scheduled to take place around 36 to 37 weeks of gestation. This timing allows for a full-term delivery while avoiding complications that could arise if labor were to begin with the stitch in place. If a cesarean delivery is planned, the stitch may be left in and removed during that procedure.
Because the Shirodkar stitch is placed high on the cervix and the knot is often buried, its removal frequently requires a return to the operating room. Spinal anesthesia is commonly used to ensure comfort during the removal process, which is quicker and simpler than the placement surgery. Most patients can go home the same day after the anesthesia wears off.
If spontaneous labor begins or the water breaks before the scheduled removal date, the cerclage must be removed promptly to prevent the cervix from tearing during contractions. After the stitch is taken out, labor might not start immediately. The time from removal to delivery varies; some individuals go into labor within hours or days, while for others it may be weeks.