CERVICAL CERCLAGE (CERVICAL LIGATURE)

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Cervical cerclage is a surgical procedure performed during pregnancy to help prevent preterm birth or miscarriage in women with a weak or short cervix. The cervix is the lower part of the uterus that opens into the vagina, and it plays a crucial role in maintaining the pregnancy by staying closed and firm until it's time for labor and delivery.

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In a cervical cerclage, a stitch (suture) or synthetic tape is placed around the cervix to help strengthen and support it, thus reducing the risk of premature dilation or effacement (thinning). The procedure is usually performed between 14 and 24 weeks of pregnancy.

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There are different techniques used for cervical cerclage, including:

 

1. McDonald cerclage: A stitch is placed around the cervix, creating a purse-string effect to keep it closed.

2. Shirodkar cerclage: A more advanced technique where the stitch is placed higher up in the cervix, requiring a small incision to access the area.

3. In rare cases, an abdominal approach may be used.

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Cervical cerclage is not appropriate for all women with a history of preterm birth or miscarriage. It is generally only recommended for women with a diagnosed incompetent cervix or a history of cervical insufficiency. The procedure does carry some risks, such as infection, bleeding, or rupture of membranes.

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The cerclage is usually removed around 36-37 weeks of gestation to allow for natural labor and delivery, or earlier if labor starts prematurely or if complications arise.

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The goal is to prevent cervical dilatation that might result in spontaneous abortion.

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                                                             Anesthetic Implications for Cervical Cerclage

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Anesthesia type: General, neuraxial (spinal or epidural), sedation/MAC with local anesthetic

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Airway: LMA or ETT

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Preoperative:

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• If > 16-18 weeks, aspiration pneumonitis precautions and rapid sequence induction is indicated

• Drug exposure during organogenesis (15–56 d) should be minimized

• Use left uterine displacement after 20-week gestation due to aortocaval compression risk

• Maternal hyperventilation can reduce uteroplacental and umbilical blood flow

• +/- fetal heart rate monitoring

• Avoid midazolam and nitrous oxide

• The timing of cerclage during pregnancy determines the extent of physiologic changes 

• ​T10 to L1 and S2 to S4 sensory blockade is desired to provide coverage of the cervix, vagina, and perineum

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Intraoperative:

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• Ensure adequate uteroplacental perfusion and fetal oxygenation

• Maintain normal maternal blood pressure and oxyhemoglobin saturation

• Volatile anesthetics can decrease uterine smooth muscle tone and decrease intrauterine pressure

• Position: Lithotomy, left lateral pelvic tilt; Trendelenburg

• Duration: 30 min to 1 hour

• EBL 25-50 mL

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Postoperative:

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• PONV prophylaxis

• Pain management

• Avoid administration of NSAIDs during pregnancy due to the potential fetal effects

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Complications:

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• Cervical trauma

• Preterm labor

• Spontaneous abortion

• Bleeding

• Rupture of membranes

• Chorioamnionitis

• Peroneal nerve compression from lithotomy position

• Hypotension

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Sources:

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Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. 

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Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). 

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Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.

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