Cervical Cerclage 

 

 

Considerations

 

  • Pregnancy considerations (difficult intubation, aspiration, ↓ time to desaturation, aortocaval compression, 2 patients)

  • Risk of membrane rupture and degree of cervical dilation may dictate mode of anesthesia

  • Potential need for uterine relaxation and avoidance of coughing, straining, position changes that provoke bulging and rupture of membranes

  • Considerations for fetus:

    • Risk of preterm labor and need for fetal monitoring, avoidance of contraindicated medications (NSAIDS) after 32 weeks

 

 

Management

 

  • Depends on degree of cervical dilation with standard options of spinal, epidural or GA for transvaginal cerclage

  • Pudendal nerve block often inadequate

  • If no cervical dilation:

    • Typically spinal (or epidural) anesthesia requiring a T10 to S4 block (cervix: T10-L1 & vagina / perineum: S2-4)

  • If cervical dilation present:

    • Goals: produce adequate analgesia, prevent increase in intrauterine/intraabdominal pressure

    • Type of anesthesia depends on presence of bulging membranes and need for uterine relaxation:

      • Spinal:

        • Risk of sitting position and lumbar spine flexion leading to bulging of membranes, rupture and subsequent fetal death

        • Consider placing spinal/epidural in lateral position

        • Dose: 7.5 mg isobaric bupivacaine with fentanyl 15 mcg; alternative is 40 mg lidocaine

      • Epidural:

        • Midlumbar, 2% lidocaine with 5 mcg/mL epinephrine (10-15 mL total volume) with 100 mcg fentanyl for T8 block

      • General:

        • Indicated if bulging membranes in order to facilitate uterine relaxation with volatile anesthetics

        • Risks: coughing, bucking, vomiting leading to rupture of membranes, avoidance of GA in second trimester in terms of anesthetic exposure to fetus & risk of preterm delivery as well as risks of GA to parturient

        • CAS monitors, aspiration prophylaxis, left uterine displacement, RSI, maintain normal CO2, 0.5-1 MAC volatile plus opioid, fetal monitoring, avoidance of NSAIDS (ductus closure)

  • Removal of cervical cerclage: 

    • Removed at 37-38 weeks; earlier if rupture of membranes or if labor begins

    • McDonald cerclage suture removal requires no anesthesia

    • Shirodkar suture removal requires anesthesia due to suture epithelialization; options are spinal or epidural

    • Some highly epithelialized sutures may require cesarean section

    • If epidural catheter placed consider leaving it in as labor may ensue within a few hours

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