Skip to Main Content

++

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.

++

  • 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

++

Management:

++

  • “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

++

Comments:

++

  • 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

++

Management:

++

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

++

Comments:

++

  • 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

++

  • 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

++

  • 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

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.