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Cervical insufficiency affects about 1% of all pregnancy. It is defined as painless cervical dilation in the second trimester. Cervical insufficiency can be preceded by cervical shortening (less than 2.5 cm). It is associated with an increased risk of preterm labor and birth.

The risks of cervical insufficiency include:

  • Idiopathic

  • Surgical trauma from loop electrosurgical excision procedures and cervical conization

  • Repeated forced cervical dilation associated with dilation and curettage

  • Obstetric lacerations

  • Prior history of cervical insufficiency

  • Congenital disorders: Mullerian duct abnormalities, Ehlers-Danlos syndrome, congenital deficiencies in collagen and elastin


Types of Cerclages1

Transvaginal Cervical Cerclage

The McDonald and Shirodkar techniques are most often used. Both use nonabsorbable sutures and requite removal before the commencement of labor to avoid cervical trauma. In the McDonald procedure, a simple suture is placed in a “purse string” like manner circumferentially around the cervix; the Shirodkar procedure involves the dissection of the cervical mucosa in order to place the suture as close as possible to the internal OS of cervix. There is insufficient data to support the superiority of one surgical technique over another type.

Transabdominal Cervical Cerclage

It is accomplished through open laparotomy or laparoscopy. It can be performed during the late first trimester or the early second trimester or even in non-pregnant status. The stitch is placed at the internal OS and can be left in place between pregnancies. Cesarean delivery is the required mode of delivery subsequently. Transabdominal cervical cerclage is more invasive and is reserved for those who have failed vaginal cerclage.2


In the patient with prior cervical insufficiency, or those with a history of preterm birth and a short cervix, cerclage is associated with significant reduction in preterm birth and the consequences of prematurity. Thus, the procedure itself can be urgent in nature; however, cerclage is contraindicated in the setting of painful contractions, bleeding, or uterine infection. Overall, cerclage is a very safe procedure with low risk of complications.

Although cerclage is an ambulatory procedure, the choice of anesthesia and dosing of spinal medication are most diversified. Here we will discuss the anesthetic considerations in general:

  • Lithotomy position that may affect the spread of spinal block.

  • Surgical duration varies, but it is usually less than 60 minutes.

  • Intraoperative fetal monitoring is not used routinely as the procedure is always performed prior to fetal viability.

  • Left uterine displacement if gestation age is greater than 18 weeks.

  • Aggressively prevent and treat hypotension associated with regional anesthesia (Chapter 50, “Hypotension After Spinal Anesthesia”).

  • Regional anesthesia is preferred to minimize the fetal exposure to anesthetics and maternal risks related to general anesthesia.

  • Sacral coverage is mandatory; so hyperbaric ...

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