Shirodkar cerclage in a multifactorial approach to the patient with advanced cervical changes.

Patients with a markedly effaced or dilated cervix and protruding membranes between 21 and 26 weeks' gestation were managed by Shirodkar cervical cerclage, perioperative tocolysis, broad-spectrum antibiotic therapy, and, in selected cases, inhibition of prostaglandin synthesis with indomethacin. The average duration of pregnancy after cerclage in nine patients was 11.8 weeks (range, 1 to 18 weeks). The mean birth weight was 2456 gm (range, 810 to 4341 gm). Eight of the nine pregnancies resulted in live infants (fetal survival rate, 89%); six patients (66%) were delivered at or near term. Preterm delivery occurred at 28 and 35 weeks' gestation in two patients and premature rupture of the membranes occurred in another at 25 weeks, 5 days after cerclage. There was no maternal postoperative or postpartum morbidity. A multifactorial approach to the patient with advanced cervical changes and protruding membranes in the second trimester resulted in a high rate of fetal survival and prolongation of pregnancy until term in the majority of patients. The Shirodkar cerclage holds a distensible cervix closed while the adjunctive medical therapy restores homeostasis.