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Cervical incompetence is a common cause of miscarriage. Placing a suture around the cervical os of the uterus mechanically prevents premature opening of the cervix and subsequent premature delivery of the baby.

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  • Pudendal (S2–4) and genitofemoral (L1–2) nerves supply the surgical area
  • Surgical approach is transvaginal
  • Lithotomy position
  • Duration variable but usually less than an hour in experienced hands
  • Intraoperative fetal monitoring not routinely used

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Management:

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  • “High saddle block” is the most commonly used approach (the block has to reach T12):
    • One to 1.2 mL hyperbaric 0.75% bupivacaine
    • One to 1.2 mL hyperbaric 5% lidocaine (rarely used because of risk of TNS)
    • Patient should remain sitting for 3–5 minutes to establish saddle block
  • General anesthesia is an option
  • Epidural anesthesia is a poor choice as sacral sparing is common
  • Adequate perioperative hydration is important to prevent increase in uterine activity
  • Treat hypotension associated with spinal anesthesia aggressively:
    • Retching may result in bearing down and rupture of the amniotic membrane; this is hypotension-induced, no indication for PONV prophylaxis
  • Use of intrathecal short-acting neuraxial opioids (e.g., fentanyl 25 μg) is controversial:
    • Improves intraoperative analgesia
    • Extends duration of block
    • May contribute to postoperative urinary retention
  • Use of long-acting neuraxial opioids is not recommended

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Comments:

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  • Postoperative pain is variable:
    • If the pain does not respond to common analgesics, admission may be necessary
  • Urinary retention is a significant complication (patients need to void before discharge)
  • Uterine contractions may follow and may require admission for hydration and bed rest

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Management:

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  • The patient presents at term and the cerclage is removed
  • Patient presents/returns to the labor and delivery unit when in active labor

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Comments:

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  • This is often done without anesthesia in the office setting
  • If anesthesia is indicated, a low saddle block (0.8–1 mL hyperbaric 0.75% bupivacaine or 0.8–1 mL hyperbaric 5% lidocaine) is adequate

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  • The patient presents with contractions or with ruptured membranes and is allowed to labor
  • The cerclage is often removed without an anesthetic
  • In this setting, if the patient is a candidate for labor analgesia, a modified combined spinal epidural is the recommended approach:
    • A low saddle dose (see above) is administered as the spinal component
    • An epidural catheter is threaded and is used to provide analgesia for labor

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  • Selected patients may undergo an abdominal approach for closing the cervix
  • The surgical approach is usually a Pfannenstiel incision
  • Duration is dependent on level of experience of surgeon (about 60–90 minutes)
  • Abdominal cerclage is permanent. Delivery is by Cesarean section
  • Spinal, epidural, combined spinal epidural, and GA have all been used successfully
  • Usual precautions for anesthesia during second trimester (see Chapter 186)
  • Dosing is similar to anesthesia for Cesarean section (see Chapter 189)
  • May need hospital admission postoperatively for pain management, hydration, and observation for uterine contractions

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