Cervical Incompetence and Cerclage - 8 - Shirodkar vs McDonald Cerclage
Monday, September 15, 2008
Kenneth F. Trofatter, Jr., MD, PhD
When I trained, we were almost exclusively taught to perform a Shirodkar cerclage (Antiseptic 1955;52:299). This procedure is done by dissecting the vaginal mucosa and bladder off the cervix anteriorally, and if necessary, opening the cul-de-sac (dissecting the vaginal mucosa off the cervix) posteriorally and then placing the suture as high as possible around the cervix tunneling through the cervical stroma. The cerclage is usually begun at the 12:00 o’clock position and then placed circumferentially with as few exit points as possible until the starting point is reached and the suture is tied. The vaginal mucosa is then reapproximated to cover the cerclage.
The procedure was first described by Shirodkar using absorbable catgut suture, but this was soon replaced with Mersilene tape – the ‘permanent’ material still most often used for this procedure today. The advantage of the Shirodkar cerclage is that one can place the suture almost as high (if not as high) as the internal cervical os. However, the disadvantages are that it is a more challenging procedure (especially with obese, primigravida patients or those with advanced cervical changes), often requiring more time in the operating room, with greater risk for hemorrhage, and perhaps infection, using a material that is sometimes more difficult to pass through the cervical tissue, and certainly more difficult to remove. Indeed, many patients with successful pregnancies and ‘good’ Shirodkars simply have a cesarean section performed for delivery and leave the original suture in place for a subsequent pregnancy. It is not a very practical procedure for ‘emergent’ or ‘rescue’ procedures when the membranes are deep in the cervical canal or ballooning past the external cervical os.
From my perspective, I mention the Shirodkar almost for historical purposes since most of the cerclages I have performed over the past 20-odd years have been McDonald cerclages. This procedure was described by McDonald (J Obstet Gynaecol Br Empire 1957;64:356) a few years after Shirodkar. It does not involve dissection of the vaginal mucosa off the cervix and is simply a ‘purse string’ suture placed around the cervix in 4 to 6 ‘bites’. Again, when I was first taught this procedure, I used Mersilene tape, but soon learned that the disadvantages, for the reasons noted above, made this suture material especially impractical when a ‘rescue’ procedure was necessary – something I was being called upon to perform more often in my consulting role in Maternal-Fetal Medicine. Indeed, despite taking great care, I remember iatrogenically rupturing membranes several times during ‘rescue’ procedures simply as the result of the difficulty of tightening the mersilene tape around the cervix after the cerclage had been placed. As the result of these experiences, I switched to #5 Ethibond and have used this successfully for more than 20 years as will be described in our next post.
The primary advantages of the McDonald procedure are that it can be performed quite rapidly, with minimal risk for blood loss or infection, and can be more easily removed to permit a vaginal delivery. The disadvantages are that it usually cannot be placed as high on the cervix as a Shirodkar, and many clinicians shy away from adequate placement for fear of damaging the bladder or rectum. Indeed, in my experience, the greatest reasons for failure of McDonald cerclages are threefold: they are not placed highly enough, deeply enough, or tied tightly enough to prevent cervical change and downward displacement of the membranes….
Labels: cerclage, cervical incompetence, cervical insufficiency; premature labor
29 Comments:
At Wed Sep 17, 08:10:00 AM 2008,
sknitter said…
Thank you so much for the information you've provided on cervical incompetence. You are very effective at putting these difficult issues into perspective for patients.
I had a second trimester loss earlier this year and my OB and peri suspect that cervical incompetence played a significant role. I am pregnant again -- 8 weeks -- and my OB is willing to perform (in fact, very strongly recommends) a preventive cerclage. So, we are planning to do that (probably McDonald) around 14 weeks. I'm currently weighing my testing options and was offered the possibility of having CVS so that I could have test results before the cerclage is placed. I think I'd prefer to assess my individual risk through screening (e.g., nuchal translucency andn blood test ~16 weeks) and make a decision about whether or not to have an amnio based on those test results.
But, I have a question that I can't seem to find an answer to. Does the cerclage increase the risk of miscarriage due to amnio? In particular, I was wondering whether any bleeding due to the amnio is trapped in the uterus? I'm worried about this because it is my understanding that blood irritates the uterus and cause problems.
At Fri Sep 19, 05:59:00 AM 2008,
andreab said…
Thanks for this blog - I'm finding it very useful to read a down-to-earth explanation of cervical incompetence and cervical stitch. I have read a lot of research and am very confused. The research seems to be ambivalent about the efficacy of cervical stitches, saying that they make no difference to pregnancy loss, premature birth, or neonatal mortality, and there is a higher risk of infection. If this is so, why are they still recommended and used?
At Fri Sep 19, 06:48:00 PM 2008,
Alicia said…
Hello Dr Trofatter,
I have a question for you. I guess I'll start with a history. I'm 24 yrs old, husband 26. Pregnant with our first baby girl. 2 and 1/2 years ago, we were pregnant but due to school & a new business we decided to have an abortion. The abortion was done but I had to undergo TWO D&Cs as there was retained product from the first one as indicated on ultrasound. Fast forward to now. At roughly 19 weeks I had my full anatomy ultrasound which showed everything being perfect. Baby was great, I was great. About 4 days after the ultrasound I began having TERRIBLE (about 8 on a scale of 1-10) cramping which I went to the emergency room 3 times. Finally in the assessment room of the maternity ward they told me everything was fine. I was no dilated and PROBABLY had a UTI (which I didn't). Anyway, my dr suggested I redo the ultrasound. I did the second ultrasound at 21 wks 4 days. The tech told me my cervix had drastically shortened in the 3 weeks since I was there and was funnelling a little. I saw my dr the next day who assessed me and said my cervix was not open from the outside and that I had a cervical length of about 20mm or a little more. He booked me for an emergent cerclage the following day (21 weeks, 6 days) which was done under General anesthesia and it was the McDonald cerclage. Now I am 22 weeks & 2 days. I'm feeling no pain from the procedure and my bleeding stopped from before the first 24 hours were over and none to very light cramping on occasion. I'm not familiar with what to expect now that the sutures are in place and I want to know what the likelihood of my baby surviving is. Can you please enlighten me as I find that your blog is so informative and has told me a lot. Please give me some form of hope that I can at least make it to 28 weeks...I don't ask for more than that. I eagerly await your response. Thanks so much. Alicia
At Tue Sep 23, 06:46:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To sknitter: The combined first trimester screening should give you the information you need so that you can decide if an invasive diagnostic study of some sort should be done before or after the cerclage. We use a very thin needle for amniocentesis and there usually is very little bleeding. In my experience, a cerclage by itself does not increase the complication rates of amniocentesis, although I am not sure if anyone has ever tested that experimentally. Good luck with the rest of the pregnancy and let us know how things turn out. Dr T
At Tue Sep 23, 06:50:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To andreab: To be absoluetly blunt, the literature is mixed because not all practitioners are as skilled at placing a cerclage as others. Ask the many women in whom I have placed a 'rescue cerclage' with the cervix dilated and membranes visible at 19-22 weeks (on the verge of losing their babies) who went on to carry successful pregnancies if they think cerclages don't work! That's why we still do them. They DO work, but they must be properly placed. Dr T
At Sun Oct 05, 05:06:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Alicia: Well, if you are still pregnant, you are now almost 25 weeks and if you haven't had any new complications, and the cerclage is in good position and has restored some cervical length, I think you are in very good position for getting to more than 28 weeks. Has your doctor looked again to see what result he/she got with the cerclage? Best wishes and please let us know how things turn out. Dr T
At Tue Nov 04, 07:32:00 PM 2008,
Anonymous said…
Dr. T,
Thanks so much for all of your posts on this subject and useful info. I am a 38 year old at 13 weeks two days - pregnant with fraternal twins. I had a LEEP procedure done 8 years ago. My perinatologist has talked about weekly transvaginal ultrasounds to assess the need for cerclage. My ob is in favor of a preventative cerclage rather than a rescue. What's your thoughts on this based on the fact that I am carrying twins and the history of 1 LEEP procedure? Also, baby A is positioned low down in my uterus.
At Thu Nov 06, 05:02:00 PM 2008,
Anonymous said…
Thanks so much Dr. T for all of your useful info. I am 13+ weeks pregnant with twins. I am 38 years old and 118lbs. I had a LEEP procedure over 8 years ago and was wondering if cerclage would be of benefit to me. My doctors are considering a preventive measure instead of a rescue. I have read about the mixed results with cerclage and am nervous. I suffered with OHSS through the beginning of the pregnancy and severe morning sickness since - losing almost 15 lbs. Any thoughts??? I sure would be greatful!!
At Wed Nov 12, 07:38:00 PM 2008,
doris said…
Hi Dr. Trofatter,
I am 30 wks pregnant and had a shirokdar cerclage put in place during my 20th wk. My doctor is recommending I keep the cerlclage in place for a future pregnancy and delivery via C-section. I am wondering what impact leaving the cerlage has on being able to get pregnant in the future since my cervix has been closed. I am also wondering what the disadvantages are to leaving the cerclage in, other than not being able to deliver vaginally.
At Thu Nov 27, 05:47:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Doris: A Shirodkar can be difficult to remove since it is buried underneath the vaginal mucosa. It could impair fertility, but most are not tied so tightly that they will completely occlude the cervical canal. I have had women ho have developed pain with intercourse, bleeding, and infections, but most of the time these things do not happen. My suggestion would be to leave it in unless you developed difficulty conceiving or any of the other conditions I have mentioned. Best wishes. Dr T
At Mon Jan 12, 03:32:00 AM 2009,
timika said…
Dear Dr. T, My name is Timika and at 20wks gestation I had cerclage done due to my cervical length being 1cm and the membranes coming down. After the procedure I was put on bedrest and told to come in every 2wks for a checkup. At 25wks 2days I went in for a chekup and was told that my cervical length was about 2.3cm I had some funneling but my cervix had opened up. I am now 27wks and wanted to know what are the possibilities of me making it to full term and do you think by my cervix eing open will my baby be ok?
At Mon Mar 16, 01:22:00 PM 2009,
Anonymous said…
Hi My daughter-in-law who is now 19 weeks into her fourth pregnancy - all by IVF and three resulting in miscarriages all before 14 weeks. She has just had the procedure, not sure which one, performed by her very competent surgeon who has performed all four of her IVF procedures. She had this three days ago and is still experiencing blood loss although this only occurs when she is sick - poor girl has had a migraine also which I think caused the sickness. Is this blood loss normal? She has also been advised complete bed rest for the forseeable future. Her obs history is diabolical but the baby is moving around and kicking, has a strong heartbeat, is growing and to all intents and purposes is absolutely healthy, it is only her who feels like death warmed over! Any advice please. Oh so worried mum - in - law.
At Sun May 31, 07:26:00 PM 2009,
Cherry said…
Hi Dr. T.
I had a McDonald cerclage placed at 14 wks. in my previous pregnancy. I was diagnosed with IC, due to premature labor, caused by a tear in my cervix. I ruptured membranes at 23 wks. I am pregnant again, 13 wks. and shortened cervix-2.3cm. My Dr., a highly reputable OB and surgeon recommends cerclage again. She calls it a double stitch, above the tear. I guess this is the Shirodkar method, you explained before. I am apprehensive about this treatment, and would greatly appreciate your opinion based on your wealth of knowledge and experience.
At Tue Jun 16, 08:26:00 PM 2009,
Lynnie said…
Dear Dr. Trofatter,
I just turned 40 years old last week and I had my 4th miscarriage 4 days before my birthday. I had 3 MacDonald cerclages. My Perinatologist suggested that I have a Shrodkar cerclage next time. I'm worried about there even being a next time. I'm having a very hard time getting over this loss. My Husband is concerned about my having a Shrodkar cerclage. (Does this go in before getting pregnant? If not, at what stage does this procedure occur?) He doesn't want anything to happen to me. We do want a baby. What do you suggest?
I have an incompetant cervix, but I don't see how any type of a cerclage is going to help me. My membranes were strong as I ate well and had L. Acidophilus from yogurt everyday. I also took prenatal vitamins and a separate Omega 3 fatty acid pill everyday. We would consider trying again, but want to be more prepared. We have a 10 year old daughter and have been trying for 8 years for a second child. I need more information to determine if we want to even try again.
Thanks for your help!
Lynnie
At Thu Jun 18, 05:02:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Cherry May 31: It really is impossible to say without actually examining you myself from below and by ultrasound. A better procedure might actually be an abdominal cerclage if there is inadequate tissue with which to work vaginally. Best of luck to you and let us know how things turn out.
Dr T
At Thu Jun 18, 05:03:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Lynnie June 16: Before I answer your questions, how far did you get in the pregnancies you lost and what were the circumstances surrounding the losses.
Dr T
At Fri Jun 26, 08:27:00 AM 2009,
Karen said…
Dr Trofatter -
First, thank you for providing such in-depth information. I am currently pregnant with my second child. My first was born at 28wk after I ruptured at 27w. Although we weren't able to determine the cause of my prom with certainty, we decided to go with a preventative cerclage during this pregnancy. I have a single McDonald placed at 14.5 weeks. The placement went well, however at the time my cervical length was already at 2.4cm. I had a second length done at 19.5w, which showed my CL at 3cm with some funneling. At 21w I was funneled to the stitch with 2cm of closed cervix below. I went on strict bedrest at this point and in another 2 weeks I was down to 1.6cm, but the sitch was holding. It has been stable now for 4 weeks. I am currently 27w4d (past the time of my previous prom). If I continue to remain stable, they plan to lift some of my restrictions starting around 32 weeks.
We are more and more confident that I'll get to term or very close to it. So now, being on bedrest with not much else to do, I'm researching things that we might do differently in a subsequent pregnancy to prevent the need for 3 months of bedrest. We have a lot of support, but it has been especially hard on me, my husband and toddler.
I've met a number of women who insist TAC's are the way to go. I'm a little wary of that approach as it is a major permanent surgery and we are only planning on having one more child. I wondered if I just had a TVC placed earlier and higher - possibly a double McDonald or Shirodkar - if that would lessen the need for bedrest. Just wondering what you would recommend for a patient in my situation.
At Mon Jun 29, 08:13:00 PM 2009,
Anoomai@aol.com said…
Hi I am pregnant for the second time. The first time I was pregnant I had an emergent cerclage at 23.5 weeks with very short cervix 1.8 and had the stitch taken out at 36 weeks. I ended up a week late and delivered a health boy at 41 weeks. Now that I am pregnant again, I am not sure weather to follow through with having an earl cerclage at 13 weeks. Did I really need the first one? Do I really need one again? Thanks for the smart and thorough info. Thanks, Fanny
At Thu Jul 02, 07:11:00 AM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Karen: In a subsequent pregnancy ou might benefit from a simple McDonald cerclage placed a little higher and tighter or a Shirodkar by someone with good experience with that procedure. I doubt you would actually need an abdominal cerclage based on what you have told me. I have reserved those for patients with little or no cervix with which to work in the vagina or patients who have a congenital uterine abnormality and marked deformation at the internal cervical os. Best wishes and thanks for writing.
Dr T
At Thu Jul 16, 01:43:00 PM 2009,
Stef. said…
Dr. Trofatter,
I just lost my twins at 19 weeks to an incomptent cernix. My dr. wants to do a shirokdar cerclage before we do ivf again. I wasn't sure we could do ivf again if i had this done. Could you let me know? Thank you much
At Wed Aug 12, 01:42:00 PM 2009,
Anonymous said…
Dear Dr. T.,
I want so much to have a child and have suffered 3 second trimester miscarriages. I was diagnosed with Cervical Incompetence and this last pregnancy I received the McDonald Cerclage. Do you suggest if I become pregnant again and use the same method, or should I just have the Shirodkar placed.
At Fri Sep 04, 01:41:00 PM 2009,
lara said…
Dr T. Thank you for all the information you've provided! Next week I will have a Shirodkar cerclage placed at almost 15 wks. Five years ago I had a "generous" successful cone biopsy to remove abnormal glandular cells. Consequently, during my first (and only other) pregnancy 2 years ago, my dr recommended cerclage at 14 wks, but we decided to wait and monitor my cervix. By 21 weeks it was getting quite short and a Shirodkar cerclage was put in place. It was removed at 37 wks and I went into labout at 38.5 wks. My labour was very fast (2 hrs 45 min) and now, as I am about to have another Shirodkar placed, I am worried about what could happen if I should go into labour with the suture in place, given that my previous labour was so fast.
At Wed Sep 30, 02:14:00 PM 2009,
Anonymous said…
Hello Dr Trofatter,
I am looking for some information/advice/reassurance regarding cervical incompetence and miscarriage and/or pre-term labor. Okay, let's start with a little bit of history first. I am 30 years old and have never been pregnant before. In May of 2009, I was diagnosed with CIN and told that I would need to have a cone biopsy to a.) remove the pre-cancerous/cancerous cells and b.) have the removed portion of my cervix sent for additional testing. Approximately 3 months ago I had the surgery, which went very well, but I have not had the 4 month follow-up pap smear, as it has only been 3 months, so the results of the cone biopsy are still unknown. Now, here comes the tricky part, I have just confirmed that I am 8 weeks pregnant. I had my first prenatal visit earlier this week and I am indeed pregnant, and very excited about it I might add, but I am extremely concerned about being able to carry the baby to term. Before going to the doctor, I felt confident and happy, as I knew that there were some risks involved in having a child after having a cone biopsy, but I was under the impression that many women who have had the cone biopsy done, go on to get pregnant with only minor complications. I am aware that I may need to have Cerclage performed, but I am extremely worried that my babies health as well as my own may be in jeopardy. At my appointment, my doctor informed me that when she performed the cone biopsy, she removed half of my cervix; leaving me with a "short-cervix." I will be seeing a maternal fetal specialist in the coming weeks to determine whether or not I will need to have a ceclage performed, but in the meantime: What do you think my chances are of having a miscarriage? And if I do not miscarry, what are my chances of carrying my baby to term, or at least until 34 weeks?
At Wed Sep 30, 05:00:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Stef Jul 16: Yes, in most cases IVF can be done with a cerclage in place. The difficulty arises if the pregnancy is nonviable and is too large to be easily removed without taking out the cerclage. That's why many of us will wait until 13 weeks to place a cerclage. Best wishes.
Dr T
At Wed Sep 30, 05:07:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Aug 12: In most cases a well-placed McDonald cerclage is as effective as a Shirodkar and MUCH easier to put in! Best wishes...
Dr T
At Wed Sep 30, 05:09:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
Lara: if you go into labor, you cannot deliver through the stitch but usually there is adequate time to remove it before you tear through your cervix. Best wishes.
Dr T
At Wed Sep 30, 05:14:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Sep 30: Most women who have had a cervical conization do NOT have early deliveries. The key to cervical integrity is not necessarily the length of the cervix but the configuration of the cervix at the internal cervical os. As the MFM doctor will tell you, the length of the cervix and status of the internal cervical os can be followed by transvaginal ultrasound and if there are changes, a cerclage can often be placed before those changes dramatically increase your risk for extremely preterm delivery. Congratulations on your pregnancy, best wishes to you and thanks for writing!
Dr T
At Mon Oct 05, 09:38:00 PM 2009,
scmom32 said…
Hi, Thank you so much. I am a 28 year old from columbia sc.
Hi I wanted to get your insight. I had a emergency mcdonalad placed at 16 weeks and 4 days. My cervical length was 5mm and 2.3x 2.5 cm funneling. I lost the pregnacy at 19 weeks and 5 days I started cramping and bleeding and was admitted because i began to funneling and 2 of the 4 stiches they put in was coming through the stich and the bag was being exposed so after being in the hospital for 2 days i camed down with a fever got and infection called chorioaminoittis. So i had to be induced. My post partum appointment I mention a abdominal cerclage he said that they dont do them unless u have had more then one loss with a vaginal cerclage. They would perform a Shirodkar next. I am feeling like that want work because my cervix was changeing so early in the pregnancy. I started to bleed off and on since 13 weeks and my ic is due to a leep that i had done. I am a type 2 diabetic that is controlled and i do have pcos so i need fertility assitance to get pregnant. I just dont think i can handle another loss knowing that i didn't do all i could to prevent it. Thanks
At Thu Oct 08, 04:22:00 PM 2009,
Kenneth F. Trofatter, Jr., MD, PhD said…
To scmom32: The type of cerclage you need depends on many factors such as the overall length of the cervix to begin with, the configuration of the cervix at the internal os, and the amount of the cervix that extends into the vaginal vault. If you had bleeding in your previous pregnancy, that might have eventually led to an ascending infection (chorioamnionitis) that caused you to lose the pregnancy as well rather than cervical insufficiency, although you do have several risk factors for it as you point out. When there is enough cervix in the vagina, it is the rare patient I have had who did not do as well with a McDonald as with a Shirodkar and if there is very little cervix to work with vaginally, then I have tended to move directly to an abdominal cerclage. Best wishes and sorry I can't be more help at this time.
Dr T
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