Cervical

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Cervical Incompetence

Dr.Ashraf K. fouda
Domiatte General Hospital
2
DEFINITION

• Condition in which the cervix fails to retain the
  conceptus during pregnancy.
• There are arguments about the occurrence and
  incidence of incompetent cervix

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Prevalence

• Affects around
• 1 of pregnant patients

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Cervical incompetence

• Cervical incompetence has long been recognized as
  a potential cause of preterm delivery recurrent
  mid trimister abortionns.

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Cervical incompetence

• It is believed that cervical incompetence is the
  cause of 20 - 25 of all second trimester losses

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AETIOLOGY

• Idiopathic (most cases).
• Congenital disorders (congenital mullerian duct
  abnormalities eg. Septate uterus, Bicornuate
  uterus).
• DES exposure in utero.
• Connective tissue disorder (Ehlers- Danlos
  syndrome).
• Surgical trauma
• Conization,( resulting in substantial loss of
  connective tissue) or
• Traumatic damage to the structural integrity of
  the cervix (repeated forced cervical dilatation
  associated with DC).

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AETIOLOGY

• The cervical competence is an active, not
  passive, phenomenon, and it is a specific entity
  involving not just an abnormality or defect of
  cervical collagen, but is also due to either
• Absence of the usual cervical musculature in
  cases of congenital cervical incompetence, or
• Injury or damage to the cervical musculature
  caused by previous trauma.

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Symptoms

• Women with incompetent cervix typically present
  with "silent" cervical dilatation (i.e., with
  minimal uterine contractions) between 16 and 28
  weeks of gestation.

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Symptoms

• Patient present with significant cervical
  dilatation (2 cm or more) and minimal symptoms.
• When the cervix reaches 4 cm or more, active
  uterine contractions or rupture of membranes may
  occur.

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Pathogenesis

• The function of the cervix during pregnancy
  depends on the regulations of connective tissue
  metabolism.
• Collagen is the principal component in the
  cervical matrix, others are (proteoaminoglycans,
  elastin and glycoproteins, like fibronectin).

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Pathogenesis

• The biochemical events implicated in the cervical
  ripening are
• Decrease in total collagen content,
• Increase in collagen solubility and
• Increase in collagenolytic activity.

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Diagnosis

• It is a clinical diagnosis marked by gradual,
  painless dilatation and effacement of the cervix
  with membranes visible through the cervix.
• This history establishes the diagnosis,
  eventually, women with this cervical status may
  develop membrane rupture labor.
• Short labors with the delivery of an immature
  fetus or loss of the pregnancy at progressively
  earlier gestational ages in successive
  pregnancies is characteristic of reduced
  competence.

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Diagnostic Criteria

• Historical factors
• History of painless cervical dilatation with
  preterm delivery
• History of forceful cervical dilatation and
  evacuation
• History of obstetric trauma cervical
  lacerations, prolonged second stage followed by
  cesarean
• Prior cervical surgery cone, loop
• DES exposure in utero
• Cervical sonography
• Short cervical length
• Cervical funneling

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IMPROVMENTS IN DIAGNOSIS

• The diagnosis is at present largely subjective
  and retrospective.
• If possible, an objective (i.e. measurable)
  diagnosis, made before pregnancy or in the early
  stages (first or early second trimester) would
  provide
• An accurate incidence of cervical incompetence,
• Allow treatment to be targeted appropriately and
• Also provide the basis for definitive trials of
  treatment.

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Diagnosis

• Dilators or balloons to determine cervical
  resistance and/or hysterosalpingograms to measure
  the width of the cervical canal between
  pregnancies are neither sensitive nor specific.
• Digital examination of the cervix is highly
  subjective.
• Sonography has provided a reproducible method of
  evaluating the cervix.

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Ultrasonography

• Initial use of ultrasound to observe the cervix
  was transabdominal but the necessity for a full
  bladder to visualize the cervix elongates the
  cervix to such a degree as to make objective,
  reproducible measurements difficult.
• The development of transvaginal scanning (TVS)
  allowed for accurate cervical measurements with
  an empty bladder and no distortion .

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Transvaginal ultrasound

• 'funneling' or 'breaking' of the internal
  cervical os
• ( at rest or particularly in response to
  transabdominal pressure on the uterine fundus )
• is the ultrasonographic appearance of cervical
  incompetence .

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Cervical measurements
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Transvaginal ultrasound

• Provide a significant advance in the diagnosis of
  cervical incompetence
• In contrast to the hysteroscopic evaluation of
  the cervix, it is
• non-invasive, repeatable over time and can be
  performed during pregnancy.

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Sonographic findings

• Funneling of the cervix with the changes in forms
  T, Y, V, U (correlation between the length of the
  cervix and the changes in the cervical internal
  os). (Trust Your Vaginal Ultrasound)
• Cervix length lt 25 mm
• Protrusion of the membranes.
• Presence of fetal parts in the cervix or vagina

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2 images of the same cervix, 20 seconds apart,
without and with applying pressure

•  

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Am J Obstet Gynecol 1997177660-5.

• Sonographic serial evaluation
• ( every two weeks) of the cervix for funneling
  and shortening in response to transfundal
  pressure has been found to be useful in the
  evaluation of incompetent cervix.

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TREATMENTS

• Surgical repair of the cervix using a vaginal or
  abdominal approach.
• Other alternatives that have been considered have
  included
• Bed rest, for which no trial has been conducted
  and for which little evidence of effectiveness
  exists, and
• The use of vaginal pessaries to elevate and close
  the cervix.

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TREATMENTS

• The initial descriptions of cervical cerclage for
  cervical incompetence came with Shirodkar and
  McDonald in the 1950s, when both developed
  techniques for physical support for what was
  presumed to be a structurally weak cervix.

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Surgical approaches to cervical incompetence
is, at present, the mainstay of treatment
28
Am J Obstet Gynecol 1982 Mar 1142(5)506-12
,Obstet Gynecol 1989 Feb73(2),Am J Obstet
Gynecol 1993 Nov169(5)1125-9  PMID 8238171,J
Reprod Med 1994 Nov39(11)880-2 PMID

• Cerclage is not indicated solely based on risk
  factors or prior cerclage placed for doubtful
  indications.

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Prophylactic Cerclage

• Prophylactic cerclage sutures (Shirodkar,
  McDonald )may be placed at 12 to 16 weeks'
  gestation.
• Do not use tocolytics at the time of prophylactic
  cerclage, but give perioperative antibiotics.
• Intercourse, prolonged standing (gt90 minutes),
  and heavy lifting are omitted following cerclage.
  
• Follow these patients with periodic vaginal
  sonography to assess stitch location and
  funneling.

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Prophylactic Cerclage

• No additional restrictions are recommended as
  long as the stitches remain within the middle or
  upper third of the cervix without the development
  of a funnel, and the length of the cervix is
  greater than 25 mm.
• For patients who have not been successful with a
  vaginal suture despite aggressive care and
  sonographic surveillance, a transabdominal
  cerclage may be appropriate.

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Emergency Cerclage

• Care of the patient with newly detected reduced
  cervical competence in the second trimester is
  both difficult and controversial.
• When the diagnosis is made before cervical
  dilatation has occurred and when there is still
  10 to 15 mm or more of cervical length, admit the
  patient for 24 hours of treatment with
  perioperative indomethacin and broad-spectrum
  antibiotics before placing the cerclage sutures,
  and observe the patient for 48 to 96 hours
  postoperatively.

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Emergency Cerclage

• However, if the cervix has dilated to allow
  visualization of the membranes, the patient may
  remain hospitalized for several days after
  cerclage placement.
• The prognosis for these patients is better than
  generally expected, with many women delivering a
  "viable" (usually defined as gt1,000 g) infant,
  but aggressive therapy may be required to achieve
  these results.
• The prognosis is influenced by the gestational
  age at the time when the suture is placed.

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Emergency Cerclage

• In the case of advanced dilatation with bulging
  membranes, several techniques may be helpful
• Pre cerclage amniocentesis to remove sufficient
  fluid to reduce the bulging membranes can be
  helpful.
• Overfilling the bladder with 1,000 ml of saline
  may help by elevating the membranes out of the
  operative field, but may also obstruct the
  surgeon's view.
• Place a Foley catheter balloon inside the cervix,
  and overfill it with at least 50 ml of saline to
  gently push the membranes out of the lower
  segment.
• The cerclage suture can then be placed and tied
  as the balloon fluid is evacuated.

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Emergency Cerclage

• Cerclage is rarely performed after 24 to 25 weeks
  of pregnancy.
• The great risk of inducing PROM or preterm labor
  and the ability to prolong gestation with bed
  rest and suppressive medications argue against
  surgical intervention in such cases.
• The cerclage is removed at 37 weeks' gestation or
  at the onset of labor.

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Indication for cerclage

• History compatible with incompetent cervix AND
• Sonogram demonstrating funneling OR
• Clinical evidence of extensive obstetric trauma
  to cervix

ACOG Criteria Number 17 October 1996, ACOG
Criteria Number 18 October 1996
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Contraindications

• 1.Uterine contractions.
• 2.Uterine bleeding
• 3.Chorioamnionitis
• 4.Premature rupture of membranes
• 5.Fetal anomaly incompatible with life

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Cerclage procedures

• There are five different techniques for
  performing the cerclage
• McDonald procedure
• Shirodkar operation
• Wurm procedure (Hefner cerclage)
• Transabdominal cerclage
• Lash procedure
• The two most common are the McDonald and
  Shirodkar.

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McDonald procedure

• The McDonald procedure is done with a 5 mm band
  of permanent suture is placed high on the cervix.
• This is indicated when there is significant
  effacement of the lower portion of the cervix.
• It is generally removed at 37 weeks, unless there
  is a reason to remove it earlier, like infection,
  preterm labor, premature rupture of the
  membranes, etc.
• It is also shown that this has very little impact
  of the chance for vaginal delivery.

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McDonald operation

• The McDonald technique requires no bladder
  dissection, and the cervix is closed using four
  or five bites with the needle to create a purse
  string around the cervix.

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McDonald operation
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Shirodkar operation

• The Shirodkar is also a frequently used
  technique.
• However, this was previously a permanent purse
  string suture that would remain intact for life.
• There are physicians performing modified
  techniques, where the delivery does not
  necessarily have to be by cesarean, nor the
  suture left intact.

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Shirodkar operation

• Place the suture as near the internal os as,
  opening the anterior fornix and dissecting away
  the adjacent bladder, before placing the suture
  submucosally, tied anteriorly and the knot buried
  by suturing the anterior fornix mucosal opening.
• The original intention with the Shirodkar method
  was to leave the suture in place and aim for
  delivery by caesarean section.

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Shirodkar operation
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Shirodkar and McDonald

• Both initially started suturing with catgut, but
  Shirodkar turned to fascia lata and McDonald
  turned to ( 0 )silk as they realized the
  importance of a permanent cervical support.
• One significant difference since then has been
  the present day use of Mersilene tape as the
  suture material.

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Shirodkar and McDonald

• Both the McDonald and Shirodkar cervical sutures
  are equally effective as a vaginal approach to
  cervical cerclage.
• McDonald suture is generally easier to perform
  with no major difference in success.

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Wurm procedure

• The Hefner cerclage, also known as the Wurm
  procedure, is used for later diagnosis of the
  incompetent cervix.
• It is usually done with a U or mattress suture,
  and is of benefit when there is minimal amounts
  of cervix left.

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Trans abdominal cerclage

• One further development in the 1960s was the
  description of the transabdominal cerclage by
  Benson and Durfee in 1965 a technique now
  largely used after the failure of vaginal
  cerclage procedures or in the presence of
  congenital anomalies, particularly those produced
  by diethylstilboestrol exposure.

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Trans abdominal cerclage

• The original intention with the transabdominal
  approach was that the suture was inserted between
  pregnancies or in early pregnancy, and left in
  situ for the rest of the woman's reproductive
  life, delivery being undertaken by caesarean
  section for each pregnancy.

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Trans abdominal cerclage

• In this method, a midline or Pfannenstiel
  abdominal incision allows access to the
  vesicouterine fold of peritoneum, which is
  divided and the bladder reflected caudally.
• The uterine vessels are then identified and a
  Mersilene tape suture is passed through the broad
  ligament below the uterine vessels in the
  potential 'free space' between the uterine
  vessels and the ureter, with the suture tied
  anteriorly or posteriorly (anterior being
  reported as surgically easier) and the bladder
  replaced.

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Trans abdominal cerclage
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Lash procedure

• The last procedure, the Lash, is performed in the
  non-pregnant state.
• It is typically done after cervical trauma that
  has caused an anatomical defect.

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Lash procedure

• Lash described techniques aimed at the repair of
  a specific anterior cervical structural defect.
• The cervical mucosa was opened anteriorly, the
  bladder reflected and the cervical defect
  repaired with interrupted transverse sutures
  before closing the vaginal mucosa.

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Preoperative evaluation

• Ultrasound for anomaly and viability
• MS-AFP( Alpha Fetopritein) if appropriate
• Wet mount.( For vaginal infections).
• G Beta Streptococci, Gonococci, and Chlamydia
  cultures.
• Treat appropriately for infection.

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ORDERS

• Admit for cerclage
• NPO after midnight
• Bed rest.
• Trendelenberg if cervix is effaced or dilated.
• Surgical consent
• A 100-mg dose of indomethacin may be given per
  rectum during the operative period, followed by a
  50-mg oral dose every 6 hours

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ORDERS

• McDonald cerclage
• Postop. ,Transfer to postpartum for observation
• Regular diet
• Bed rest 12-24 hours
• May discharge if no uterine contractions, vaginal
  bleeding, or rupture of membranes during
  observation.

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Risks of Cerclage

• Premature rupture of membranes (1-9)
• Chorioamnionitis (Infection of the amniotic sac,
  1-7) (This risk increases as the pregnancy
  progresses and is at 30 for a cervix that is
  dilated more than 3 cms.)
• Preterm Labor
• Cervical laceration or amputation (This can be at
  the procedure or at the delivery, from scar
  tissue that forms on the cervix.)
• Bladder Injury (rare)
• Maternal hemorrhage
• Cervical dystocia
• Uterine rupture

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Risks of Cerclage

• For elective cerclage at the beginning of the
  second trimester, the risk of infection is small,
  estimated at less than 1 percent.
• Later in the pregnancy, displacement of the
  suture also can occur (3 to 12 percent).
• A second cerclage has a much lower success rate.

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Risks of Cerclage

• Late complications of cerclage include PROM or
  preterm labor and chorioamnionitis.
• When fluid leakage occurs in a patient with a
  cerclage, removal of the suture, to reduce the
  risk of infection is controversial.

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Risks of Cerclage

• Finally, even though cerclage placement is
  considered a benign procedure, a maternal death
  secondary to sepsis in a patient with retained
  cerclage has been reported.
• The liberal use of this surgical procedure should
  be carefully balanced against potential harm, in
  particular for patients in whom the indications
  for cerclage are not clear.

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Efficacy of Cerclage

• Cerclage seems to be a very effective treatment
  for incompetent cervix.
• The success rates can be very high (80-90),
  particularly when done earlier in a pregnancy.

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RCOG Guidelines

• Cervical incompetence is often over-diagnosed as
  a cause of mid-trimester miscarriage.
• Cervical cerclage should only be considered when
  the history of miscarriage is preceded by
  spontaneous rupture of membranes or painless
  cervical dilatation.
• The MAC/RCOG trial of the use of cervical
  cerclage reported a small decrease in preterm
  birth, but no significant improvement in fetal
  survival.
• (Grade B recommendation)

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RCOG Guidelines

• Transabdominal cerclage performed preconceptually
  has been advocated as a treatment for second
  trimester miscarriage and the prevention of early
  preterm labour.
• The reported improvement in pregnancy outcome is
  difficult to assess in the absence of a control
  group.

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Thank you