Cervical cerclage

Learning objectives

Cervical cerclage is performed as an attempt to prolong pregnancy in women who are at high risk of preterm delivery due to cervical insufficiency
Suturing of the cervix to prevent rupture of fetal membranes

Prior cervical procedures or trauma:
- Loop electrode excisional procedure
- Cone biopsy
- Prior cervical lacerations
- Repetitive cervical dilation and/or pregnancy terminations
Maternal connective tissue diseases or abnormalities
Congenital Mullerian anomalies
Maternal exposure in utero to diethylstilbestrol

History-indicated: One or more second-trimester pregnancy losses related to painless cervical dilation and in the absence of labor or abruptio placentae, or prior cerclage placed due to cervical insufficiency in the second trimester
Ultrasound-indicated: History of spontaneous loss or preterm birth at less than 34 weeks if the cervical length in a current singleton pregnancy is less than 25 mm before 24 weeks of gestation
Rescue cerclage: Singleton pregnancy at less than 24 weeks with advanced cervical dilation in the absence of contractions, intraamniotic infection, or placental abruption
Not recommended in pregnancies of multiple gestations

Transvaginal
- McDonald method: Simple purse-string suture at the cervicovaginal junction
- Shirodkar method: Suturing anterior-posterior and posterior-anterior after an incision of the mucosa of the anterior cervix, with the aid of an Allis clamp
Transabdominal
Remove sutures between weeks 36-38 in women anticipating vaginal delivery:
- McDonald cerclage requires no anesthesia
- Shirodkar requires anesthesia (spinal, epidural)
- Highly epithelialized sutures may require Cesarean section