1. Cervical Incompetence
Dr.Sameera Madan

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. most common developmental factor
Risk Factors
A. Congenital
1. Congenitally short Cx
most common developmental factor
Contributing to CI, as the function of the Cx is related to its
length & this was illustrated in a prospective study where
the RR of PTL was higher in women with Cx length below
the 5th percentile (22 mm) compared with those at 75th percentile (40 mm)
Iams, JD, Goldenberg, RL, Meis, PJ, et al. N Engl J Med 1996; 334:567(level II-2)

5. 2. Mullerian duct abnormalities
Risk Factors
A. Congenital
2. Mullerian duct abnormalities
The risk of CI is highest among women with bicornuate &
unicornuate uteri

6. 1. Trauma Risk Factors B. Acquired Cx laceration following SVD
Prolonged 2nd stage of labor
Surgical Procedures involving the Cx (D&C, Cone bx)
(although data confirming this association are limited)
Iams, JD, Goldenberg, RL, Meis, PJ, et al. N Engl J Med 1996; 334:567.(level II-2)

7. 2. Uterine over distention (multiple gestation, Polyhydramnios)
Risk Factors
B. Acquired
2. Uterine over distention
(multiple gestation, Polyhydramnios)
Uterine over distention may cause subsequent preterm birth due to Cx shortening from mechanical factors or biochemical changes
The only randomized trial evaluating use of elective prophylactic cerlcage in twin pregnancies did not find a benefit
Dor, J, Shalev, J, Mashiach, S, et al. Gynecol Obstet Invest 1982; 13:55 . (level I)
The value of this procedure in higher order multiple pregnancies is controversial
Elimian, A, Figueroa, R, Nigam, S, et al. J Matern Fetal Med 1999; 8:119.

8. 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)

9. 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)

10. 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

11. 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

12. 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

13. 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)

14. 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

15. 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

16. Cervical Cerclage Transabdominal Indications and contraindications
Transabdominal cerclage has not been shown to be more effective than TV , and it is a more morbid procedure that requires a laparotomy and subsequent C/S delivery. As such, it should be reserved for women with CI who have either failed previous TV cerclages or in whom a TV cerclage is technically impossible to perform due to extreme shortening, scarring, or laceration of the cx.
Treatment approaches
Surgical

17. Treatment approaches
Surgical

18. 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

19. 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

20. Preoperative preparation
Cervical Cerclage
Preoperative preparation
  General issues
An US examination should be performed proximate to the procedure to determine if there are gross fetal structural anomalies.
Cultures for gonorrhea and chlamydia should also be taken if the patient is at risk.
Antibiotic treatment should be initiated, as appropriate, if cultures are positive and treatment should be completed prior to elective cerclage placement.
ACOG practice bulletin number 47, October 2003:
Obstet Gynecol 2003; 102:875.
Treatment approaches
Surgical

21. Preoperative preparation
Cervical Cerclage
Preoperative preparation
  General issues
Testing for GBS is not required .
Confirmation of fetal viability, is mandatory immediately before and after the procedure.
The routine use of periop antibiotics for prophylactic or emergency cerclage remains controversial, and is not generally recommended due to insufficient evidence of benefit. There is also no proven benefit to postop antibiotic administration.
ACOG practice bulletin number 47, October 2003:
Obstet Gynecol 2003; 102:875.
Treatment approaches
Surgical

22. Cervical Cerclage / post op care:
Prophylactic cerclage is typically an ambulatory surgery procedure. The patient may be discharged after recovery &
when she is able to ambulate & void.
Acetaminophen alone provides adequate analgesia for most women.
They should be told to expect some spotting, cramps, and dysuria which will abate within a few days.
Patients are maintained on reduced activity and pelvic rest (eg, no coitus, tampons, or douching) for one week and then liberalize activity based upon the individual's clinical circumstances.
There is no evidence that coitus adversely affects perinatal outcome in patients with a cervical cerclage.
Treatment approaches
Surgical

23. Postoperative Care
All women are followed as outpatients on a regular basis with frequent visits for cervical checks.
US assessment of the Cx (at least four weeks post op) may also be useful for predicting those patients at highest risk for preterm delivery after the procedure, although the utility of post-cerclage cervical length measurement is controversial
O'Brien, JM, Hill, AL, Barton, JR. Ultrasound Obstet Gynecol 2002; 20:252.
Alternatively, hospitalization and/or antenatal corticosteroids may be considered if the Cx is dilating & effacing & preterm delivery appears likely.
Rust, OA, Atlas, RO, Meyn, J, et al. Does cerclage location influence perinatal outcome?. Am J Obstet Gynecol 2003; 189:1688.
Treatment approaches
Surgical

24. 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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