What is the role of anesthesia in cervical cerclage (cervical encirclement) during pregnancy?

From the Guidelines

Cervical cerclage during pregnancy should be performed under regional anesthesia, specifically spinal or epidural, as the preferred approach in most cases, due to its advantages in reducing morbidity, mortality, and improving quality of life. The use of neuraxial procedures during pregnancy and delivery has been reported to be safe, even in patients with COVID-19 infection, with no increased risk of neurological complications or hemodynamic instability 1. A typical spinal anesthetic would include 10-12.5mg of hyperbaric bupivacaine with 10-25mcg of fentanyl, aiming for a T10 sensory level. For epidural anesthesia, 15-20ml of 2% lidocaine with epinephrine 1:200,000 or 0.5% bupivacaine can be used.

Key Considerations

• Regional anesthesia offers advantages including avoidance of airway manipulation, reduced risk of aspiration, decreased fetal exposure to anesthetic drugs, and better postoperative pain control.
• General anesthesia may be necessary in cases of patient preference, contraindications to neuraxial techniques, or emergency situations.
• When using general anesthesia, rapid sequence induction with propofol 1.5-2.5 mg/kg and succinylcholine 1-1.5 mg/kg is recommended, followed by maintenance with volatile agents at 0.5-0.8 MAC to minimize uterine relaxation.
• Intraoperative monitoring should include standard ASA monitors, and left uterine displacement should be maintained to prevent aortocaval compression.

Anesthetic Technique

• The choice of anesthetic technique should be individualized based on patient factors, gestational age, surgical urgency, and provider expertise.
• Caution should be exercised when attempting to reduce the duration of the spinal anaesthetic by using short-acting spinal anaesthetics or reducing the dose of the spinal anaesthetic agent, as conversion to general anaesthesia is the least desirable outcome 1.
• Routine asepsis techniques being practised for non-COVID patients should still be followed, and an epidural positioning device could be used to reduce the contact of the assistant with a suspected or confirmed COVID-19 patient 1.

From the Research

Anesthesia in Cervical Cerclage

• The role of anesthesia in cervical cerclage is to provide effective pain management and ensure the safety of both the mother and the fetus during the procedure 2, 3, 4, 5, 6.
• Studies have compared the use of regional and general anesthesia for cervical cerclage, with regional anesthesia being used in 17.5% of cases and general anesthesia being used in 82.5% of cases 2.
• The choice of anesthesia technique depends on various factors, including the patient's medical history, the surgeon's preference, and the availability of resources 2, 3, 4, 5, 6.

Types of Anesthesia Used

• General anesthesia is commonly used for cervical cerclage, with facemask being the most commonly used technique, followed by intravenous deep sedation, laryngeal mask airway (LMA), and tracheal intubation 2.
• Regional anesthesia, including spinal and epidural anesthesia, is also used for cervical cerclage, with studies comparing the effectiveness of different local anesthetics, such as bupivacaine and chloroprocaine 3, 4, 5, 6.
• Chloroprocaine has been shown to have a shorter duration of action and faster recovery times compared to bupivacaine, making it a suitable option for outpatient procedures like cervical cerclage 4, 5, 6.

Outcomes and Complications

• Studies have reported no significant differences in demographic characteristics between women receiving general and regional anesthesia for cervical cerclage 2.
• The duration of surgery, recovery time, and postoperative pain scores have been compared between different anesthesia techniques, with chloroprocaine showing faster recovery times and similar pain scores compared to bupivacaine 4, 5, 6.
• Complications, such as transient neurologic symptoms (TNS), back pain, and headache, have been reported in some studies, but the incidence is generally low 3, 4, 5, 6.