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

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) .

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.
5. 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.

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 . 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. It is important to avoid high doses of anesthetic agents to prevent excessive motor block or hypotension, which can lead to uteroplacental insufficiency . 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 .

Procedure variants

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