A Shirodkar cerclage is a surgical intervention designed to reinforce the cervix, the lower part of the uterus, during pregnancy. This procedure addresses cervical insufficiency, a condition where the cervix painlessly shortens and opens too early, often leading to late miscarriage or preterm birth. By placing a strong stitch high up on the cervix, the cerclage acts as a mechanical barrier to keep the cervical canal closed under the pressure of the growing pregnancy. The goal is to prolong gestation, allowing the pregnancy to reach full term or past the point where the baby faces the highest risk of complications from premature delivery.
The Purpose and Placement of the Cerclage
The Shirodkar procedure is recommended for individuals with a history of second-trimester loss or premature birth linked to cervical insufficiency, or for those whose cervix is significantly short during early pregnancy monitoring. This technique is generally performed electively between 12 and 14 weeks of gestation, after the first trimester risk of spontaneous miscarriage has passed and fetal viability is confirmed. This timing provides maximum benefit before the cervix begins to dilate under the weight of the pregnancy.
The placement is a detailed surgical process, usually conducted in a hospital setting under regional anesthesia, such as a spinal block. The surgeon accesses the cervix through the vagina, making a precise transverse incision in the vaginal mucosa near the internal opening. A step involves carefully dissecting and retracting the bladder and rectum away from the cervix to expose the higher portion of the cervical tissue.
This dissection allows the surgeon to place the suture material, often a synthetic tape like Mersilene, as high as possible near the internal os, the narrowest point of the cervical canal. Placing the cerclage at this high point provides greater mechanical support. Once the suture is tightened and secured, the incisions in the vaginal mucosa are closed, burying the knot and suture material beneath the mucosal layer. This covering reduces the suture’s exposure to the vaginal environment, potentially lowering the risk of ascending infection.
Key Distinction from Other Procedures
The Shirodkar technique and the McDonald cerclage are the two most common types, differentiated by their surgical approach and placement. The fundamental distinction is that Shirodkar involves incisions in the cervical mucosa to place the stitch submucosally, or beneath the surface layer. This makes it a more complex procedure than the McDonald method, which uses a simpler purse-string suture placed lower on the cervix without mucosal dissection.
The Shirodkar cerclage is viewed as a more robust stitch due to its placement closer to the internal os, the higher, more fibrous part of the cervix. The synthetic tape provides a strong barrier to premature dilation. It may be chosen if a patient has significant structural defects or if a previous McDonald cerclage failed to prevent preterm birth.
The McDonald cerclage knot is typically left exposed, making it easier to remove later in the pregnancy. Because the Shirodkar stitch is buried and covered by vaginal tissue, its removal is more involved, sometimes requiring a return to the operating room. The choice between the two techniques often depends on the patient’s anatomy, the indication for the cerclage, and the surgeon’s preference.
Post-Procedure Care and Monitoring
Following placement, patients typically experience a short hospital recovery period, usually one to two days. Mild symptoms immediately after the procedure are common, including light vaginal spotting or bleeding and minor abdominal cramping, managed with prescribed pain relievers. A thin, white vaginal discharge may also be noticed and can persist throughout the pregnancy.
Long-term care involves specific restrictions to minimize stress on the cerclage. Patients are advised to observe pelvic rest, including abstaining from sexual intercourse. Strenuous activities, heavy lifting, and intense exercise are restricted for the remainder of the pregnancy. Most individuals can resume light, normal daily activities within one to two weeks after the surgery.
Close monitoring is instituted for the duration of the pregnancy to evaluate the cerclage and the baby’s health. This involves regular follow-up appointments, often weekly or biweekly, which may include transvaginal ultrasound assessments. Ultrasounds measure cervical length and observe the cerclage’s position, helping to identify signs of shortening or failure. Immediate medical attention is required if warning signs develop, such as heavy bleeding, painful uterine contractions, or any gush or steady leak of fluid indicating premature rupture of membranes or infection.
Timing of Removal and Delivery
The Shirodkar cerclage is typically removed electively between 36 and 37 weeks, when the risks of prematurity are significantly lower. Removing the stitch at this time prevents potential complications like cervical laceration or uterine rupture if labor were to begin with the cerclage in place. The removal procedure is simpler and quicker than the placement, often performed as an outpatient procedure without deep or general anesthesia.
Because the knot is often buried beneath the cervical mucosa, removal may involve a minor procedure to locate and cut the suture. Once the cerclage is removed, the body is free to begin labor naturally. For most patients, labor does not start immediately; the mean time from elective removal to delivery is approximately 13 days, with only a small percentage delivering within 24 hours.
In rare cases, if a patient is scheduled for a planned Cesarean section, the surgeon may recommend leaving the cerclage in place until delivery. This differs from a transabdominal cerclage, which is placed through an abdominal incision and often left in permanently, requiring a Cesarean delivery. The standard Shirodkar cerclage, as a transvaginal procedure, is almost always removed to allow for a trial of labor and potential vaginal birth.