Evaluation of a new technique of prophylactic cervical cerclage simplified from the Shirodkar cerclage: A pilot study

Perinatal Outcomes Associated With the Modified Shirodkar Cervical Cerclage Technique

OBJECTIVE

The objective of this study was to describe demographic and clinical characteristics and surgical and neonatal results related to the modified Shirodkar cervical cerclage technique.

MATERIALS AND METHODS

This was an observational descriptive and retrospective study. Data was called from anonymized medical records of women who were pregnant and diagnosed with cervical incompetence and who had also undergone cervical cerclage procedures using the modified Shirodkar technique. The variables recorded included demographics such as the maternal age of patients, clinical features like obstetric history, physical examination, and ultrasound findings, and surgical and neonatal outcomes. The qualitative variables were processed using frequencies and percentages, and the quantitative variables were obtained through median, interquartile range, mean, and standard deviation.

RESULTS

Our study included 39 anonymized medical records. The main indication for cervical cerclage placement was prophylactic (56%). The median gestational age at cerclage placement was 16 weeks, with a median gestational age at birth of 38 weeks; only 13% had complications related to prematurity, and 5% were admitted to the neonatal intensive care unit.

CONCLUSION

The modified Shirodkar technique is associated with favorable surgical, maternal, and neonatal outcomes.

Comparison of two emergency cervical cerclage techniques in twin pregnancies: A retrospective cohort study matched with cervical dilation

OBJECTIVES

This retrospective cohort study aimed to assess the efficacy of emergency cervical cerclage (ECC) performed with the combined McDonald-Shirodkar technique in twin pregnancies between 18 and 26 weeks of pregnancy with painless cervical dilation 1 to 6 cm.

METHODS

A retrospective cohort study matched with the degree of cervical dilation was conducted. The study group (case group) included women with twin pregnancies undergoing combined McDonald-Shirodkar approach with cervical dilation ≥1 cm between 18 to 26 weeks of gestation at four institutions, from December 2015 to December 2022. To minimize confounding factors, we elucidated the causality structure using a directed acyclic graph and performed 1:1 case-control matching. A control group underwent the McDonald approach. The primary outcome was gestational age (GA) at delivery. The secondary outcomes were pregnancy latency; the rates of spontaneous preterm birth at <28, <30, <32, and <34 weeks; and neonatal outcomes. Additional subanalysis was performed by dividing the patients into two subgroups of women with cervical dilation ≥3 cm and <3 cm.

RESULTS

A total of 84 twin pregnancies were managed with either the combined McDonald-Shirodkar approach (case group: n = 42) or the McDonald approach (control group: n = 42). Demographic characteristics were not significantly different in the two groups (P > 0.05). After adjusting for confounders that were represented by a directed acyclic graph, median GA at delivery was significantly higher (30.5 vs 27 weeks; Bate: 3.40 [95% confidence interval (CI), 2.13-4.67], P < 0.001) and median pregnancy latency was significantly longer (56 vs 28 days; Bate: 24.04 [95% CI, 13.31-34.78], P < 0.001) in the case group compared with the control group. Rates of spontaneous preterm birth at <28, <30, <32, and <34 weeks were significantly lower in the case group than in the control group. For neonatal outcomes, there was higher birth weight (1543.75 vs 980 g; Bate: 420.08 [95% CI, 192.18-647.98], P < 0.001) and significantly lower overall perinatal mortality (7.1% vs 31%; adjusted odds ratio, 0.16 [95% CI, 0.04-0.70], P = 0.014) in the case group compared with the control group. When cervical dilation was ≥3 cm, the combined McDonald-Shirodkar procedure can significantly reduce perinatal mortality (8.3% vs 46.7%; adjusted odds ratio, 0.09 [95% CI, 0.01-0.77], P = 0.028), significantly decrease the risk of delivery at <28 and <30 weeks, and prolong GA at delivery and pregnancy latency compared with the McDonald procedure.

CONCLUSIONS

ECC performed with the combined McDonald-Shirodkar procedure in women with twin pregnancies who have cervical dilation 1 to 6 cm in midtrimester pregnancy may reduce the rate of spontaneous preterm birth and improve perinatal and neonatal outcomes compared with the McDonald procedure, especially for twin pregnancies in women with cervical dilation of 3 to 6 cm and prolapsed membranes.

McDonald versus Shirodkar cerclage technique in the prevention of preterm birth: A systematic review and meta-analysis

BACKGROUND

Cervical cerclage has been used for decades to reduce preterm birth. The Shirodkar and McDonald cerclage are the most commonly used techniques with no current consensus on the preferred technique.

OBJECTIVE

To compare the efficacy of the Shirodkar and McDonald cerclage techniques in preventing preterm birth.

SEARCH STRATEGY

Studies were sourced from six electronic databases and reference lists.

SELECTION CRITERIA

Studies including women with a singleton pregnancy, requiring a cervical cerclage, using either the Shirodkar or McDonald technique that ran comparative analyses between the two techniques.

DATA COLLECTION AND ANALYSIS

The primary outcome was preterm birth before 37 weeks, with analyses at 28, 32, 34 and 35 weeks. Secondary data were also collected on neonatal, maternal and obstetric outcomes.

MAIN RESULTS

Seventeen papers were included: 16 were retrospective cohort studies and one was a randomised controlled trial. The Shirodkar technique was significantly less likely to result in preterm birth before 37 weeks than the McDonald technique (relative risk [RR] 0.91, 95% CI 0.85-0.98). This finding was supported by a statistically significant reduction in rates of preterm birth before 35, 34 and 32 weeks, PPROM, difference in cervical length, cerclage to delivery interval, and an increase in birthweight in the Shirodkar group. No difference was seen in preterm birth rates <28 weeks, neonatal mortality, chorioamnionitis, cervical laceration or caesarean section rates. The RR for preterm birth prior to 37 weeks was no longer significant when sensitivity analyses were performed removing studies with a serious risk of bias. However, similar analyses removing studies that utilised adjunctive progesterone strengthened the primary outcome (RR 0.83, 95% CI 0.74-0.93).

CONCLUSION

Shirodkar cerclage reduces the rate of preterm birth prior to 35, 34 and 32 weeks' gestation when compared with McDonald cerclage; however, the overall quality of the studies in this review is low. Further, large, well-designed randomised controlled trials are required to address this important question to optimise care for women who may benefit from cervical cerclage.

McDonald versus Shirodkar cervical cerclage for prevention of preterm birth: a systematic review and meta-analysis of pregnancy outcomes

OBJECTIVE

To compare pregnancy outcomes of patients undergoing either McDonald or Shirodkar cervical cerclage.

METHODS

PubMed, Web of Science, Scopus, and Google scholar were systematically searched up to June 2020. Inter-study heterogeneity was assessed using Cochrane's Q test and the I² statistic. Data were pooled using the fixed- or random-effects model and expressed as relative risk (RR) or weighted mean difference (WMD) as appropriately.

RESULTS

A total of eight observational studies, reporting data on 724 pregnancies, were included in this meta-analysis. As compared to the Shirodkar cerclage, the pooled findings showed that the gestational age at delivery (WMD = -1.95, 95% CI: -2.89 to -1.01, p < .001; I² = 57.5%) and birth weight (WMD = -355.69, 95% CI: -413.76 to -297.62, p < .001; I² = 28.8%) were significantly lower in McDonald cerclage. The risk of preterm premature rupture of the membranes (PPROM) (RR = 1.76; 95% CI: 1.14 - 2.71; I² = 0.0%) and neonatal intensive care unit (NICU) admission (RR = 1.61; 95% CI: 1.09 - 2.39; I² = 62.1%) were also higher for McDonald group. However, no significant difference was observed between both groups in terms of cesarean delivery and perinatal/neonatal death.

CONCLUSION

McDonald cerclage is associated with a shorter duration of pregnancy, lower mean birth weight and increased risk of PPROM and NICU admission compared to the Shirodkar procedure.

Shirodkar cerclage: Obstetrical and neonatal outcomes in a single-center cohort of 55 cases

BACKGROUND

Cervical insufficiency is thought to be responsible for 10% of preterm deliveries. Shirodkar cerclage is among the available techniques ranging from McDonald's to definitive procedures, however the indications for the prevention of preterm births and mid-trimester miscarriages are still poorly delineated.

OBJECTIVE

To describe the characteristics, obstetrical and neonatal outcomes of pregnancies with Shirodkar cerclage procedures.

METHOD

We performed a descriptive retrospective single-center study, including all patients who had a Shirodkar cerclage between January 1, 2008 and December 31, 2020. The main outcomes measured were delivery at or beyond 24 and 32 weeks of gestations (WG).

RESULTS

55 Shirodkar cerclages were performed over the period studied. 7.3% of patients had a uterine malformation, 9% had a history of cervical conization. 74.5% had history of one or more mid-trimester miscarriages. 63.6% had a history of a failed emergency or prophylactic cerclage. The median gestational age (GA) at cerclage placement was 14 WG. There were 4 deliveries before 24 WG, 8 before 32 WG and 16 before 37 WG. Overall neonatal survival was 48/53 (90.6%). The median GA at delivery was 38 weeks (IQR 35-39), with 70.3% of vaginal deliveries.

CONCLUSION

Shirodkar cerclage was successful in more than 90% of patients, despite their obstetric history. Shirodkar cerclage may be indicated in the event of prior cerclage failure using the McDonald technique or in order to allow for correct stitch placement in very short cervixes. Its advantage over definitive cerclage is to allow for vaginal delivery.

The Short Cervix: A Critical Analysis of Diagnosis and Treatment

A short cervix in the second trimester is a significant risk factor for spontaneous preterm birth, preterm prelabor rupture of membranes, and subsequent adverse perinatal outcome. The pathophysiology is complex and multifactorial with inflammatory and/or infectious processes often involved. Biomarkers have been developed in an effort to predict preterm birth with varying degrees of success. The treatment options of cerclage, progesterone, pessary, and combination therapy are reviewed. Evidence-based protocols are summarized for singleton and multiple gestation.