Difference between revisions of "Cerclage placement"
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=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | === Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | ||
Spinal anesthesia is a common choice for cervical cerclage placement, providing adequate analgesia and muscle relaxation without compromising the patient's level of awareness. When administering spinal anesthesia for this procedure, it is vital to keep in mind the altered physiology of the gravid patient.The anesthesiologist must account for the increased blood volume, decreased functional residual capacity, and changes in drug pharmacokinetics during pregnancy <ref>Cousins, M. J., & Bridenbaugh, P. O. (2012). ''Cousins and Bridenbaugh’s Neural Blockade in Clinical Anesthesia and Pain Medicine'' (4th ed.). Lippincott Williams & Wilkins.</ref>. | Spinal anesthesia is a common choice for cervical cerclage placement, providing adequate analgesia and muscle relaxation without compromising the patient's level of awareness. When administering spinal anesthesia for this procedure, it is vital to keep in mind the altered physiology of the gravid patient.The anesthesiologist must account for the increased blood volume, decreased functional residual capacity, and changes in drug pharmacokinetics during pregnancy <ref>Cousins, M. J., & Bridenbaugh, P. O. (2012). ''Cousins and Bridenbaugh’s Neural Blockade in Clinical Anesthesia and Pain Medicine'' (4th ed.). Lippincott Williams & Wilkins.</ref>. | ||
The anesthetic agent, typically a low dose of bupivacaine combined with fentanyl, is administered into the subarachnoid space, which provides a sensory block to the lower abdomen, pelvis, and lower extremities sufficient for the procedure. Chloroprocaine (either isobaric or hypobaric) is also a viable option although its use is less common compared to more widely used agents like bupivacaine or lidocaine. It is a fast-acting, short-duration anesthetic that can provide rapid onset and quick recovery, making it suitable for brief surgical procedures <ref>Kleif, J., & Jørgensen, H. (2003). ''Hypobaric chlorprocaine: A review of its clinical use and pharmacological properties''. Acta Anaesthesiologica Scandinavica, 47(3), 258-263.</ref>. It is estimated that motor blockade for chloroprocaine is typically 60 minutes with sensory blockade estimated to be about 90 minutes for an approximate starting dose of 50 mg (3% Chloroprocaine) which is roughly 1.67 mL [''citation needed'']. | |||
It is important to avoid high doses of anesthetic agents to prevent excessive motor block or hypotension, which can lead to uteroplacental insufficiency <ref name=":0">Harbaugh, M. C., Abrahams, M. P., & McLellan, M. (2016). ''Anesthesia for obstetric surgery''. In M. S. Clark (Ed.), ''Chestnut's Obstetric Anesthesia: Principles and Practice'' (6th ed.). Elsevier.</ref>. It is important to monitor the patient closely for signs of hypotension, bradycardia, and respiratory depression, as these may occur due to the block's effects on the autonomic nervous system. Vasopressors, such as phenylephrine, may be necessary to maintain maternal blood pressure and fetal perfusion <ref name=":0" />. | |||
== Intraoperative management == | == Intraoperative management == | ||
Revision as of 16:17, 8 January 2025
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Cervical cerclage placement is a procedure where the cervix is sewn closed with stitches to prevent premature labor.
Overview
Indications
A cervical cerclage is a procedure used to prevent preterm birth in women at risk of cervical insufficiency, ultimately to prevent potential miscarriage.
The primary indications for cerclage placement include a history of spontaneous preterm birth, a previous cerclage procedure, and diagnosed cervical insufficiency, often characterized by a cervical length of less than 25mm in the second trimester as measured via transvaginal ultrasound [1]. Women with a history of multiple second-trimester losses or preterm deliveries related to cervical dilation may also benefit from cerclage. Additional indications include the presence of painless cervical shortening in the absence of contractions or membrane rupture, and in certain cases, cerclage may be considered for those with abnormal cervical findings discovered on ultrasound screening in asymptomatic women at high risk [2].
Surgical procedure
Cervical cerclage is most commonly performed between 12 and 14 weeks of gestation but can be done later in cases of emergency cerclage (e.g., when cervical changes occur after 20 weeks) [3][4].
The procedure involves multiple key steps:
- Preparation and Positioning: The patient is positioned in a lithotomy position, similar to that for a pelvic examination. After ensuring sterile technique, a speculum is inserted into the vagina to expose the cervix.
- Cervical Examination: The cervix is evaluated for abnormalities, such as shortening, dilation, or funneling. If no signs of infection or active labor are present, the decision to proceed with the cerclage is confirmed.
- Placement of the Cerclage: A purse-string suture (usually made of a non-absorbable material) is placed around the cervix. The suture is typically inserted at the level of the internal os, ensuring it is snug but being careful to avoid damage to the cervical tissue. The suture is then tied, effectively "closing" the cervix to prevent early dilation.
- Confirmation and Closure: The cervix is re-examined to ensure the suture is correctly placed. After confirming that the suture is secure, the speculum is removed, and the patient is monitored for complications, like bleeding.
- Post-Procedure Care: The patient is usually monitored for a short period following the procedure, and they are advised to avoid heavy physical activity for several weeks post-cerclage.
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Airway | Evaluate for Mallampati score, upper Bite Lip test, checking for lose or chipped dentition and overall keeping in mind that the airway tends to be edematous and friable in gravid patients. |
| Neurologic | Complete a standard neurological exam, asking detailed questions about chronicity of lower back pain, any history of sciatica, spine surgery, and/or extremity weakness, numbness or tingling. |
| Cardiovascular | Obtain a brief history of the patients cardiovascular tolerance before and during pregnancy and auscultate to rule out murmurs. |
| Pulmonary | Obtain a detailed history on pulmonary diseases such as asthma, recent URI, or cough. No other special considerations beyond being aware of the standard pulmonary changes that occur in pregnancy. |
| Gastrointestinal | Confirm if the patient is on medication for GERD and verify NPO status. |
| Hematologic | Obtain a brief history on any history coagulopathy since neuraxial is a consideration for this procedure. |
| Other |
Labs and studies
Cervical cerclage placement is typically performed in a sterile surgical setting, often under regional anesthesia (such as a spinal or epidural block), though general anesthesia may be used in certain cases. Important studies required prior to cerclage placement include a BMP, CBC, PT, PTT/INR. Other necessary information would be to confirm if the patient has been given any medication for DVT prophylaxis and if so, what the dose was and how long ago it was given.
Patient preparation and premedication
Regional and neuraxial techniques
Spinal anesthesia is a common choice for cervical cerclage placement, providing adequate analgesia and muscle relaxation without compromising the patient's level of awareness. When administering spinal anesthesia for this procedure, it is vital to keep in mind the altered physiology of the gravid patient.The anesthesiologist must account for the increased blood volume, decreased functional residual capacity, and changes in drug pharmacokinetics during pregnancy [5].
The anesthetic agent, typically a low dose of bupivacaine combined with fentanyl, is administered into the subarachnoid space, which provides a sensory block to the lower abdomen, pelvis, and lower extremities sufficient for the procedure. Chloroprocaine (either isobaric or hypobaric) is also a viable option although its use is less common compared to more widely used agents like bupivacaine or lidocaine. It is a fast-acting, short-duration anesthetic that can provide rapid onset and quick recovery, making it suitable for brief surgical procedures [6]. It is estimated that motor blockade for chloroprocaine is typically 60 minutes with sensory blockade estimated to be about 90 minutes for an approximate starting dose of 50 mg (3% Chloroprocaine) which is roughly 1.67 mL [citation needed].
It is important to avoid high doses of anesthetic agents to prevent excessive motor block or hypotension, which can lead to uteroplacental insufficiency [7]. It is important to monitor the patient closely for signs of hypotension, bradycardia, and respiratory depression, as these may occur due to the block's effects on the autonomic nervous system. Vasopressors, such as phenylephrine, may be necessary to maintain maternal blood pressure and fetal perfusion [7].
Intraoperative management
Monitoring and access
Induction and airway management
Positioning
Maintenance and surgical considerations
Emergence
Postoperative management
Disposition
Pain management
Potential complications
Procedure variants
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| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
References
- ↑ Lyndon, A., Smith, R. S., & McIntire, D. D. (2021). Cervical cerclage: Indications, techniques, and outcomes. American Journal of Obstetrics and Gynecology, 224(4), 455-463.
- ↑ Klemm, P., Vayssière, C., & Marret, H. (2020). Cervical cerclage in prevention of preterm birth: A critical review of indications and efficacy. European Journal of Obstetrics & Gynecology and Reproductive Biology, 249, 31-37.
- ↑ Coomarasamy, A., Small, R., & Cacciatore, S. (2017). Cervical cerclage for preventing preterm birth in women with a short cervix. Cochrane Database of Systematic Reviews, 2017(7)
- ↑ Klemm, P., Vayssière, C., & Marret, H. (2020). Cervical cerclage in prevention of preterm birth: A critical review of indications and efficacy. European Journal of Obstetrics & Gynecology and Reproductive Biology, 249, 31-37.
- ↑ Cousins, M. J., & Bridenbaugh, P. O. (2012). Cousins and Bridenbaugh’s Neural Blockade in Clinical Anesthesia and Pain Medicine (4th ed.). Lippincott Williams & Wilkins.
- ↑ Kleif, J., & Jørgensen, H. (2003). Hypobaric chlorprocaine: A review of its clinical use and pharmacological properties. Acta Anaesthesiologica Scandinavica, 47(3), 258-263.
- ↑ 7.0 7.1 Harbaugh, M. C., Abrahams, M. P., & McLellan, M. (2016). Anesthesia for obstetric surgery. In M. S. Clark (Ed.), Chestnut's Obstetric Anesthesia: Principles and Practice (6th ed.). Elsevier.