Cervical Cerclage (Cervical Stitch) in India and UAE | Complete Patient Guide

• IDEAL CANDIDATES — HISTORY-INDICATED (PROPHYLACTIC) CERCLAGE:

• Women with a history of ≥1 second-trimester pregnancy losses or preterm births (< 34 weeks) attributed to painless cervical dilation in the absence of contractions or placental abruption

• Women with a prior cervical cerclage that successfully prolonged a pregnancy

• Women with a history of significant cervical surgery (cone biopsy, LEEP/LLETZ) resulting in measurable cervical shortening

• Congenital Müllerian anomalies associated with cervical structural weakness

• Diagnosis of connective tissue disorders (e.g., Ehlers-Danlos syndrome, Marfan syndrome) with documented cervical incompetence

• ULTRASOUND-INDICATED (THERAPEUTIC/SECONDARY) CERCLAGE:

• Asymptomatic pregnant women (typically 16–24 weeks) with transvaginal cervical length < 25 mm on serial ultrasound surveillance

• Short cervix with funneling of the internal os (> 25% of cervical length) without active uterine contractions

• Particularly indicated if short cervix coexists with prior spontaneous preterm birth history (combined risk > 70% of recurrent preterm birth at < 35 weeks)

• RESCUE (EMERGENCY/PHYSICAL EXAMINATION-INDICATED) CERCLAGE:

• Patients at 16–26 weeks with an acutely dilated cervix (typically 1–4 cm) with or without bulging membranes visible at or beyond the external os

• Decision must exclude active chorioamnionitis, active labor, placental abruption, and fetal anomalies incompatible with life

• REQUIRED DIAGNOSTIC WORKUP PRIOR TO PROCEDURE:

• Transvaginal ultrasound (TVUS) for precise cervical length measurement (ideally ≥ 2 serial measurements ≥ 1 week apart for ultrasound-indicated cases)

• High-vaginal swab and cervical cultures (Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas, group B Streptococcus, bacterial vaginosis assessment)

• Cervicovaginal fetal fibronectin (fFN) — positive result increases rescue cerclage risk assessment

• Detailed fetal anomaly ultrasound (to exclude major structural abnormalities or aneuploidy before committing to cerclage)

• Amniocentesis and amniotic fluid interleukin-6 (IL-6), glucose, white-cell count, and culture in rescue cerclage cases to exclude subclinical intra-amniotic infection

• Full blood count, CRP, procalcitonin (infection markers)

• Karyotyping or chromosomal microarray if fetal anomalies suspected

• Maternal thrombophilia screen (antiphospholipid antibodies, factor V Leiden) in patients with recurrent pregnancy loss

• Uterine cavity assessment: saline-infusion sonohysterography (SIS) or MRI pelvis to evaluate for co-existing uterine anomalies

• CONTRAINDICATIONS (ABSOLUTE):

• Active intra-amniotic infection (chorioamnionitis) — confirmed by amniotic fluid analysis

• Active preterm labor with regular painful uterine contractions

• Placenta previa or active antepartum haemorrhage

• Fetal demise or lethal fetal anomaly

• Preterm premature rupture of membranes (PPROM)

• Gestational age > 26+6 weeks (generally; individual specialist assessment required for rescue cases)

• RELATIVE CONTRAINDICATIONS:

• Uncontrolled maternal medical conditions (e.g., poorly controlled diabetes, severe pre-eclampsia)

• Active genital herpes outbreak

• Significant uterine irritability without confirmed labor

TECHNIQUE 1 — McDONALD CERCLAGE (VAGINAL, PURSE-STRING):

The McDonald technique is the most commonly performed vaginal cerclage worldwide and the first-line choice for most candidates. Under spinal or general anesthesia (procedure duration 15–30 minutes), the surgeon places a braided polyester suture (Mersilene 5 mm tape or equivalent non-absorbable material) in a purse-string fashion circumferentially around the cervix at the cervicovaginal junction, as high as anatomically achievable vaginally. The knot is tied anteriorly for easy identification and removal. No bladder dissection is required. The suture is routinely removed at 36–37 weeks of gestation or earlier if labor establishes. The McDonald technique is associated with minimal operative time, low intraoperative blood loss, and rapid recovery, making it the preferred approach for both prophylactic and ultrasound-indicated cerclage placement.

TECHNIQUE 2 — SHIRODKAR CERCLAGE (VAGINAL, SUBMUCOSAL HIGH PLACEMENT):

The Shirodkar technique involves reflecting the vaginal mucosa anteriorly and posteriorly to allow submucosal placement of the non-absorbable suture (typically Mersilene tape) at the anatomical level of the internal cervical os — significantly higher than the McDonald suture position. This approach requires greater surgical expertise, bladder mobilization, and repair of the vaginal epithelium. While theoretically achieving a more physiologically correct placement, meta-analyses have not demonstrated consistently superior perinatal outcomes compared to the McDonald technique in head-to-head randomized studies. The Shirodkar suture may be left permanently in situ (requiring elective caesarean delivery) or removed at 37 weeks to permit vaginal delivery.

TECHNIQUE 3 — TRANSABDOMINAL CERCLAGE (TAC): OPEN vs. LAPAROSCOPIC:

Transabdominal cerclage is reserved for patients in whom vaginal cerclage has previously failed (suture cut through cervical tissue) or for women with an extremely short, amputated, or surgically absent cervix that precludes vaginal suture placement. A 5 mm Mersilene mesh tape is placed at the cervico-isthmic junction through either a Pfannenstiel laparotomy incision or, increasingly, via laparoscopic (minimally invasive) access using 3–4 ports and high-definition magnification.

Laparoscopic TAC offers shorter hospital stay (1–2 days vs. 3–5 days for open), reduced blood loss (< 50 mL vs. 100–200 mL), faster return to daily activities (1 week vs. 2–3 weeks), and equivalent procedural success rates to open TAC. Several high-volume centers in India and the UAE now perform laparoscopic TAC as a day-surgery procedure. TAC is a permanent placement; all subsequent deliveries must be by elective caesarean section. It may be placed between pregnancies (interval TAC) or during the first trimester (12–14 weeks) under direct vision.

TECHNIQUE 4 — RESCUE (EMERGENCY) CERCLAGE WITH MEMBRANE REDUCTION:

In cases of an acutely dilated cervix with bulging membranes at 16–26 weeks, rescue cerclage is performed after membrane reduction using Trendelenburg positioning, bladder filling (retrograde instillation of 500–750 mL saline to reduce membrane prolapse), and occasionally a No. 30 Foley balloon. Amniocentesis to exclude intra-amniotic infection (IAI) should ideally precede rescue cerclage; if IAI is excluded, cerclage can extend pregnancy by a median of 5–9 weeks and improve perinatal survival. Procedurally, rescue cerclage most commonly uses the McDonald technique, modified Shirodkar, or an emergency TAC in specialist centers.

ADJUNCT PHARMACOLOGICAL & MONITORING PROTOCOLS:

• Progesterone supplementation (vaginal micronized progesterone 200–400 mg nightly or 17-alpha-hydroxyprogesterone caproate 250 mg IM weekly) is routinely combined with cerclage for synergistic risk reduction in women with prior preterm birth and short cervix.

• Tocolytics (indomethacin 25–50 mg orally/rectally perioperatively for 48 hours; or nifedipine) are used to suppress post-procedural uterine irritability.

• Prophylactic antibiotics (typically cefazolin IV intraoperatively, followed by a short course of oral amoxicillin-clavulanate or erythromycin) are administered per institutional protocol.

• Cervical length surveillance by TVUS every 2–4 weeks post-cerclage is standard of care for monitoring suture integrity and residual cervical length.

• Cervicovaginal fetal fibronectin testing at 22–28 weeks can risk-stratify for premature rupture of membranes despite cerclage.

• Antenatal corticosteroids (betamethasone 12 mg IM × 2 doses, 24 hours apart) are administered if preterm delivery appears imminent between 24–34 weeks, even in the presence of a cerclage.

PHASE 1 — PRE-PROCEDURE EVALUATION (Days –14 to –3 before cerclage):

International patients arriving in India or the UAE for cerclage undergo a structured pre-admission workup coordinated by GAF Healthcare. This includes a telemedicine consultation with the MFM sub-specialist prior to travel, followed by in-country transvaginal ultrasound for precise cervical length measurement, high-vaginal swab cultures, complete blood count, CRP, blood group and screen, and a detailed morphology ultrasound at 18–20 weeks (if not already performed). For rescue cerclage candidates, emergency admission is coordinated directly on arrival. Anaesthesia review is completed, and the surgical technique (McDonald, Shirodkar, or laparoscopic TAC) is confirmed based on clinical findings and surgical history.

PHASE 2 — ADMISSION DAY (Day 0):

The patient is admitted on the morning of the procedure (or the evening prior for planned general anaesthesia). A final bedside TVUS confirms cervical status. Informed consent covers the specific technique, anesthetic approach, procedural risks (rupture of membranes, chorioamnionitis, preterm labor, suture displacement), and alternative management options. Fasting per standard anaesthetic guidelines (6 hours for solids, 2 hours for clear fluids) is observed. IV access is established, prophylactic antibiotics are administered, and tocolytic premedication (typically indomethacin) is given.

PHASE 3 — THE PROCEDURE (Duration: 15–45 minutes depending on technique):

McDonald or Shirodkar cerclage: performed in the operating theatre under spinal anaesthesia (preferred) or general anaesthesia. The patient is positioned in the dorsal lithotomy position. The surgeon identifies the cervicovaginal junction, positions the Mersilene tape under direct visualization with a headlight or operating scope, and completes the purse-string suture. Intraoperative TVUS may confirm suture position and post-placement cervical length. Laparoscopic TAC: the patient is placed in steep Trendelenburg. Three or four laparoscopic ports are inserted. The uterovesical peritoneum is mobilized, the uterine vessels are identified and retracted, and the 5 mm Mersilene tape is passed medial to the uterine vessels at the cervico-isthmic junction using a curved needle carrier. The tape is secured with a non-slip knot anteriorly or posteriorly. CO₂ pneumoperitoneum is deflated and ports are closed.

PHASE 4 — IMMEDIATE POST-OPERATIVE MONITORING (Days 1–2):

The patient remains in the recovery unit for 2–4 hours post-procedure with continuous fetal heart rate monitoring (cardiotocograph, CTG) to confirm fetal wellbeing. Vital signs, uterine activity monitoring, and vaginal bleeding assessment are performed hourly. Tocolytic therapy (indomethacin or nifedipine) is continued for 24–48 hours. A post-procedure TVUS is performed on day 1 to confirm suture position and measure residual cervical length above the cerclage. If stable, the patient is discharged with written instructions regarding pelvic rest (absolute avoidance of sexual intercourse), activity restriction, and warning signs (fever > 37.8°C, regular contractions, increased vaginal discharge, rupture of membranes).

PHASE 5 — IN-COUNTRY OBSERVATION PERIOD (Weeks 1–4 post-procedure):

Patients remain in India or the UAE for a minimum of 2 weeks (typically 3–4 weeks for rescue cerclage or laparoscopic TAC cases) to allow:

• Confirmation of absence of post-procedural chorioamnionitis or premature rupture of membranes

• Follow-up TVUS at 10–14 days to confirm suture integrity and residual cervical length

• Fetal wellbeing assessment (biophysical profile if indicated)

• Wound check for laparoscopic port sites (TAC cases)

Fit-to-fly clearance is issued by the MFM specialist after the follow-up scan confirms no cervical change, no membrane prolapse, and fetal heart rate is normal. Patients are supplied with a detailed clinical summary, operative notes, post-procedure imaging, and a management plan for their home obstetrician.

PHASE 6 — LONG-TERM FOLLOW-UP (Home country, weeks 4 onward through delivery):

Cervical length surveillance every 2–4 weeks via TVUS in the home country. Continuation of vaginal progesterone or 17-OHPC injections as prescribed. Planning for elective caesarean delivery at 37–38 weeks (TAC) or suture removal at 36–37 weeks with anticipated vaginal delivery (McDonald/Shirodkar). Administration of antenatal corticosteroids if early delivery is anticipated. Emergency management plan for PPROM or threatened preterm labor is provided to the patient in written form for presentation to local emergency obstetric services.