1. Cervical Incompetence

2. Incidence and Prevalence
Definition
Inability of the uterine cx to retain a pregnancy in the absence of contractions or labor
Incidence and Prevalence
The lack of objective findings and clear dx criteria makes the incidence of CI difficult to ascertain

3. Risk Factors Congenital Acquired Congenitally short Cx Trauma
Mullerian duct abnormalities
Cx laceration following SVD
Prolonged 2nd stage of labor
Deficiencies in Cx collagen
& elastin
Surgical Procedures involving
the Cx (D&C, Cone bx)
Uterine over distention
(multiple gestation, Polyhydramnios)

4. Clinical Manifestations
► The classic presentation of CI is:
Cx dilatation and effacement in the 2nd trimester with fetal membranes visible at or beyond the external os in the absence of contractions. Which maybe asymptomatic or associated with:
Vaginal fullness or pressure
Spotting or bleeding
An ↥ volume of watery, mucousy or brown VD
Vague discomfort in the lower abdomen or back
(sonographic manifestations of CI often occur prior to clinically detectable Cx changes)

5. Diagnosis Non-Pregnant women Pregnant women
• There are no tests which can be performed to predict CI in a future pregnancy.
• Those that have been proposed are inaccurate, inconvenient, or unproven in scientific studies
• This may be based upon historical, clinical or sonographic criteria
(non has been validated in well designed studies)

6. Pregnant women Historical features of CI
Hx of two or more 2nd trimester pregnancy losses
Hx of losing each pregnancy at an earlier gestational age
Hx of painless Cx diltation of up to 4-6 cm
Absence of clinical findings consistent with placental abruption
Hx of Cx trauma caused by
Cone bx
Intrapartum Cx lacerations
Excessive, forced Cx dilatation during TOP
Harger JH. An evidance based analysis. Obstet Gynecol 2002;100: (level II-2)
Diagnosis

7. Pregnant women
Clinical criteria
A digital examination should always be performed to evaluate the Cx in cases of CI, followed by TVS if the clinical examination is not diagnostic
Clinical findings include → significant premature Cx effacement and/or dilatation (> 2cm) specially with prolapse of fetal membranes into or completely through the endocervical canal (hourglassing)
Diagnosis

8. Pregnant women Sonographic features
• US of the Cx is more accurate and reproducible than D/E
• The most consistent image of the Cx is obtained by TVS performed at ≥ 16 wks
• Noninvasive stress techniques as :
transfundal pressure, coughing and standing have been used to elicit US Cx changes
• Serial US assessment of Cx length in women between wks has been correlated with PTD
Iams, JD, Goldenberg, RL, Meis, PJ, et al. N Engl J Med 1996; 334:567(level II-2)
Diagnosis

9. Treatment approaches Non-surgical modalities Surgical (cerclage)
Modified activity
Bed rest
Pelvic rest
IM hydroxyprgesteron
Vaginal pessaries
Have not achieved wide spread acceptance and have not yet been proved to be effective
The rational for surgery is that cerclage compensate for inherent Cx weakness & the only indication is the prevention of CI during pregnancy
Cx cerclage is the standard treatment for CI, despite little data from randomized trials proving efficacy
Newcomer J. Ostet Gynecol Surv 2000; 55: (level III)
MRC/RCOG Working Party on Cervical Cerclage. Br J Obstet Gynaecol 1993; 100:516 (level I).
Lazar, P, Gueguen, S, Dreyfus, J, et al. Br J Obstet Gynaecol 1984; 91:731. (level I)

10. Contraindications to Cerclage
Maternal factors:
Premature labor
Premature rupture of membranes
Abruption of placenta
Intraamniotic, cervical, or vaginal infection
Medical condition that precludes administration of anesthesia or continuation of pregnancy
Fetal factors:
Fetal demise
Fetal anomaly incompatible with extrauterine life
Nonreassuring fetal status
GA > 24 to 28 wks
Treatment approaches
Surgical

11. Cervical Cerclage Procedure Objective Transvaginal Transabdominal
To reinforce the Cx at the level of the internal os;
a 2ry effect is to lengthen the Cx
Transvaginal
Transabdominal
Treatment approaches
Surgical

12. Treatment approaches
Surgical

13. Cervical Cerclage Transvaginal
McDonald: a purse-string suture placed around the Cx as cephalad as possible & without dissection of the bladder or rectum.
Treatment approaches
Surgical

14. Cervical Cerclage Transvaginal
Shirodkar: is performed using a 5 mm Mersilene tape placed around the Cx at the level of the internal os after surgically reflecting the UB anteriorly & the rectum posteriorly.
Treatment approaches
Surgical

15. Cerclage removal
The cerclage is removed electively at 37 to 38 weeks or immediately with the onset of premature labor to avoid cervical laceration and/or uterine rupture
Whether to remove the cerclage in the setting of PPROM is controversial
A Shirodkar cerclage does not have to be removed if cesarean delivery is anticipated and future pregnancies are planned
Treatment approaches
Surgical

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