Chapter 191. Anesthesia for Cerclage

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