Cerclage placement

Cerclage placement

Anesthesia type
Airway
Lines and access
Monitors
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
Article quality
Editor rating	In development
User likes	0

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. 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.

Surgical procedure

The procedure involves multiple key steps:

1. 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.
2. 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.
3. 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.
4. 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

Procedure variants

	Variant 1	Variant 2
Unique considerations
Indications
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications