1. UTERUS

2. INCOMPETENT CERVIX

3. CERVIX

4. INTRODUCTION
Cervical incompetence accounts for 15% of all habitual abortions. Typically, cervical incompetence causes abortion after the 14th week of gestation.

5. The usual sequence of events:
Painless dilatation of the cervix and herniation of amniotic sac through the dilated cervix.
Rupture of the membranes with leakage of liquor.
Quick abortion with little pain or bleeding.
DEFINITION:
It is characterized by painless dilatation of the cervix in the second trimester or early in the third trimester of pregnancy, with prolapse of membranes through the cervix and ballooning of the membranes into the vagina, followed by rupture of the membranes and subsequent expulsion of a fetus that is 50 immature that it is likely to succumb.

6. CAUSES:
Congenital : Rare
Anatomic:
Developmental abnormalities.
Cervicouterine anomalies : subseptate uterus.
Acquired : Common
Cervical trauma
MTP (first and second trimester)
Excessive dilatation during curettage.
Instrumental delivery (previous) 
Damage to the cervix

7. Other Causes:
Cervical cauterization (to remove growths or stop bleeding)
Cone biopsy (to remove a cone-shaped section of tissue)
Multiple Gestation

8. DIAGNOSIS
Diagnosis is based on the following criteria:
History
Internal examination
During pregnancy
INVESTIGATION:
A thorough Medical, Surgical, Obstetric history followed clinical examination.

9. INTERCONCEPTIONAL PERIOD:
Passage No. 6-8 Hegar dilator.
Premenstrual hystero-cervicography.
During pregnancy : Uterosonographic findings
Chronic material illness
Infection
Unexplained
Histology of the placenta or karyotyping of the conceptus, if available.

10. Other Diagnostic Tests:
Blood – glucose (fasting and post prandial)
VDRL
Thyroid function test
ABO and Rh grouping (husband and wife)
Toxoplasma antibodies IgG and IgM.
Hysterosalpingography
Endocervcial swab.

11. TREATMENT:
Interconceptional period.
To alleviate anxiety.
Hysteroscopic resection.
Chromosomal anomalies.
Endocrine dysfunction.
Genital tract infections.

12. DURING PREGNANCY:
Reassurance
Ultrasound
Rest
Chromosome anomaly
Leukocyte immunisation
Inherited thrombophilias
Medical complications in pregnancy.
Unexplained.

13. CIRCLAGE OPERATION:
The operations are named after Shirodkar (1955) and McDonald (1957).

14. Principle:
A non-absorbable encircling suture is placed around the cervix at the level of internal os. It operates by interfering with the uterine polarity, preventing the internal os and the adjacent lower segment from being “taken up”.

15. Time of Operation:
In a proven case, the operation should be done around 14 weeks of pregnancy or at least two weeks earlier than the lowest period of previous wastage, as early as the 10th week.

16. Steps of Shirodkars Operation:
Step I: The patient is put under light general anaesthesia and placed in lithotomy position with good exposure of the cervix by a posterior vaginal speculum. The lips of the cervix are pulled down by sponge holding forceps or Allis tissue forceps.
Step II: A transverse incision.
Step III: The non absorbable suture material.
Step IV: The ends of the suture are tied up posteriorly.

17. McDonalds Operation:
The non absorbable suture (Merseline) material is placed as a purse string suture as high as possible at the junction of the rugose vaginal epithelium and the smooth vaginal part of the cervix below the level of the bladder.
The suture starts at the anterior wall of the cervix. Taking successive deep bites (4-5 bites) it is carried around the lateral and posterior walls back to the anterior wall again where the two ends of the suture are tied.

18. Post Operative:
The patient should be in bed for at least 2-3 days.
Isoxsupline (tocolytics) 10mg tablet is given thrice daily to avoid uterine irritability.

19. ADVICE ON DISCHARGE:
Usual antenatal advice.
To avoid intercourse.
To avoid rough journey.
To report if there is vaginal bleeding or abdominal pain.
Periodic ultrasonographic monitoring of the fetus and the cervix.
REMOVAL OF STITCH:
The stitch should be removed at 38th week or earlier if labour pain starts or features of abortion appear.
If the stitch – is not cut in time, uterine rupture or cervical tear may occur.

20. RISKS OF CERVICAL CIRCLAGE:
Infection
Damage to the cervix during surgery
Excessive blood loss
Preterm premature rupture of membranes
Preterm labour
Permanent narrowing or closure of the cervix (cervical stenosis).
Tearing of the cervix or uterus if labour progresses with the stitches still in place.

21. Contraindications:
Intrauterine infection.
Ruptured membrane
History of vaginal bleeding
Severe uterine irritability
Cervical dilatation > 4 cm.

22. COMPLICATIONS:
Slipping or cutting through the suture.
Chorioamnionitis.
Rupture of the membranes.
Abortion / preterm labour.

23. THANK YOU