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Cervical incompetence

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how to diagnose and fix the evidence practice gap in cervical incompetence

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Cervical incompetence

  1. 1. Dr.Mohammed Abdalla Domiat general hospital cervical incompetence
  2. 2. The cervix is said competent when it retains pregnancy till term. if not it is considered incompetent .
  3. 3. Mostly incompetence is idiopathic but it may be secondary to anatomical, traumatic, or congenital connective tissue disorder.
  4. 4. Although the efficacy of cerclage for cervical incompetence has never been fully confirmed in randomized clinical trials, the role of cerclage has been expanded to include women with “risk factors” for spontaneous preterm birth or nonreassuring sonographic cervical findings in the mid trimester.
  5. 5. So before you send your patient to the theater for cerclage your diagnosis necessities solid criteria.
  6. 6. But unfortunately there is no consensus about the cervical cut off length as most literatures failed to state a discriminatory cervical length, which varied widely between 15-25mm. in singleton pregnancy
  7. 7. Cervical cut off length in singleton pregnancy is much more than in multiple pregnancy.
  8. 8. Risk with CL <25 mm in twin pregnancies is similar to the risk with CL <15 mm in singleton pregnancies (52%(
  9. 9. 4% 35%
  10. 10. This wide variation in discriminatory cervical length will result in the categorization of 5% to 10% of pregnant women as having a short cervix.
  11. 11. As any controversial issue we have here white and black faces but always within the grey zone, which lies in between, we fall in doubt.
  12. 12. White face here is the women with irrelevant obstetric and gynecological history, as they need no screening.
  13. 13. But those who have three or more midtrimester losses or preterm births represent the black face of the problem and the decision is a prophylactic cerclage performed at 13 to 16 weeks of gestation .
  14. 14. The grey zone represented here by those women of low or moderate risk, and they need an ultrasound screening by transvaginal ultrasonography.
  15. 15. Ultrasound screening if we are going to screen this group of patients with mild to moderate risk : when to start? what is the ultrasonic criteria of incompetent cervix? and when to intervent?
  16. 16. when to start TVS should not begin before 16 weeks as the upper portion of the cervix is not easily distinguished
  17. 17. ultrasonic criteria of incompetent cervix Make sure to use proper technique. Knowing what to measure . Know what's normal, and what's abnormal . Linking cervical assessment to gestational age .
  18. 18. proper technique patients are asked to empty their bladder . the vaginal probe, which is advanced in the anterior fornix until a midline sagittal view of the cervix and lower uterine segment and the internal os, external os, cervical canal, and endocervical mucosa, are identified the probe is slowly withdrawn as excessive pressure with the probe may elongate the cervix. The cervical length is measured by freezing the screen three separate times with no more than 2 to 3 mm variations. Funneling can only be recognized by being certain that the walls of the funnel are formed by endocervical mucosa. If the cervical canal is sometimes curved, therefore, cervical length should be determined by tracing the length of the cervix or by adding the sum of two straight sections. Apply transfundal pressure for 15 seconds, and record any changes in cervical length or funneling. “cervical stress test” .
  19. 19. “cervical stress test”
  20. 20. what's normal In low-risk women, CL during pregnancy has a mean of 35 to 40 mm from 14 to 30 weeks. the lower 10th percentile being 25 mm and the upper 10th (90th percentile) 50 mm.
  21. 21. 3812521998Heath et al 421751997Tongsong et al 41411996Cook et al 3529151996Iams et al 371061995Iams et al 421541994Zorzoli et al 371771993Murakawa et al 42771991Andersen et al 48241990Kushnir et al 411251990Andersen et al 48801988Podobnik et al 521501988Ayers et al Cervical Length (mm)NYearReference CERVICAL LENGTH (MEAN OR MEDIAN) IN LOW-RISK POPULATIONS IN MIDTRIMESTER
  22. 22. The discriminatory length of cervical shortening varies widely between 25mm to 15mm what's abnormal?
  23. 23. 97 4799 8≤1514–24Hassan et al 99 5299 58≤1523Heath et al 99 39100 6≤2518–22Taipale et al 97 2697 23<2024Iams et al % NPV% PPV % Specificity % SensitivityCutoff(wks)Reference value of cervical sonography in the screening of preterm birth
  24. 24. Low %PPV means that many undue cerclages were done.
  25. 25. high %NPV means that the test is reassuring when negative.
  26. 26. So we cannot rely on cervical length alone as a predictor of incompetence
  27. 27. the progressive shortening detected by serial sonar, funneling (width and length), v-shaped lower uterine segment and dynamic cervical changes with fundal or suprapubic pressure. What are the most important?
  28. 28. 1 2 3 4
  29. 29. bulging of the membranes in the vagina. The fetal lower limb protruded into the vagina.
  30. 30. But how to avoid undue cerclage and how not to miss a case?
  31. 31. RISK ASSESMENT >=3 unexplained second-trimester losses or preterm deliveries. Elective Cerclage at 14-16 wk. No risk factor routine ultrasound screening of the cervix is not recommended <3 unexplained second-trimester losses or preterm deliveries. routine ultrasound screening of the cervix is done at 16-20 wk. serial ultrasonographic changes consistent with a short cervix or evidence of funneling. Urgent cerclage if noted before fetal viability after fetal and maternal evaluation
  32. 32. Can a Cervical Cerclage be Used to Prevent Preterm Delivery in Patients with a Short Cervix or Funneling?
  33. 33. 263116Obstetrician uncertainty 12921993MRC/RC OG 6.75.5<28Moderate risk of cervical incompetence 5061984Lazar et 343218High risk of cervical incompetence 1941984Rush et al. % Controls % Cerclage Weeks at CerclageIndicationNReference Year Delivery <37 Weeks RANDOMIZED STUDIES OF ELECTIVE CERVICAL CERCLAGE
  34. 34. results of randomized clinical trials suggest that cerclage either had a modest effect on reducing the rate of preterm delivery or no effect whatsoever. RANDOMIZED STUDIES OF ELECTIVE CERVICAL CERCLAGE
  35. 35. Key points The high negative predictive value for preterm birth associated with a long cervix and with the absence of funneling has important clinical implications in symptomatic patients.
  36. 36. Using TVU to assess CL is an effective way to predict PTB and "incompetent cervix," now better named cervical insufficiency. It's safe and patients accept the examination well. Key points
  37. 37. Screening frequency should depend on severity of obstetric history, with serial TVU of the cervix having a better predictive accuracy than one, especially in high-risk populations. Key points
  38. 38. the shorter the cervix, the higher the risk of PTB, and the earlier in gestational age at which the shortening occurs, the higher the risk. Key points
  39. 39. screening high-risk women with TVU of the cervix and placement of a cerclage for the short or funneled cervix should not be considered standard care until proven by properly conducted, large randomized trials Key points
  40. 40. Thank you
  41. 41. Relative Risk (95% Cl)NPVPPV Specifici ty Sensitivi ty 6.4 (2.8–14.7)86% (31/36) 89% (16/18) 94% (31/33) 76% (16/21) Cervical index ≥ 0.52 3.9 (1.8–8.5)83% (29/35) 67% (16/24) 78% (29/37) 73% (16/22) Cervical length ≤ 18 mm 2.0 (1.4–6.0)78% (25/32) 64% (14/22) 76% (25/33) 67% (14/21) Funnel width ≥ 6 mm 5.0 (2.3–10.7)83% (30/36) 83% (15/18) 91% (30/33) 71% (15/21) Funnel length ≥ 9 mm 2.5 (1.1–5.9)80% (20/25) 50% (17/34) 54% (20/37) 77% (17/22) Funneling present Gomez R, et al., Am J Obstet Gynecol. 1994;171:956–964.
  42. 42. Urgent, or therapeutic, cerclage for women who have serial ultrasonographic changes consistent with progressive shortening or evidence of cervical funneling.
  43. 43. ACOG Practice Bulletin No. 48November 2003 serial TVS should not begin before 16 weeks as the upper portion of the cervix is not easily distinguished Urgent, or therapeutic, cerclage
  44. 44. The anatomic cervical changes of dilation of the internal os, prolapse of the fetal membranes into the endocervical canal, shortening of the distal cervical segment, and exacerbation with transfundal pressure have been suggested as a final common pathway for multiple pathophysiologic processes. Urgent, or therapeutic, cerclage
  45. 45. Transabdominal cerclage an alternative approach to the incompetent cervix
  46. 46. Indications of transabdominal cerclage •If cervix is absent or severely shortened, •if congenital or traumatic defects •if the transvaginal approach is not feasible or has failed.
  47. 47. ORIt is most often placed at 10 to 14 weeks gestation Timing of placement Preconception transabdominal cerclage placement
  48. 48. has many practical benefits: easier . smaller incision. Safer to fetus. Can be done laparoscopically. Preconception transabdominal cerclage placement
  49. 49. The overall live birth rate for prophylactic transabdominal cerclage approaches 90%, in whom transvaginal cerclage has been unsuccessful. When cerclage is performed on an emergent basis-rather than prophylactically-the success rate drops to less than 60% due to the increased risk of rupturing the membranes during the procedure or trapping the membranes below the level of the cerclage.
  50. 50. cerclage placement Adverse effects
  51. 51. *Suture displacement, *rupture of membranes, *and chorioamnionitis are the most common complications associated with vaginal cerclage placement,
  52. 52. *Transabdominal cerclage can be complicated by: rupture of membranes . chorioamnionitis. intraoperative hemorrhage. known risks associated with laparotomy.
  53. 53. Life-threatening complications of uterine rupture and maternal septicemia are extremely rare but have been reported with all types of cerclage.
  54. 54. Key points When a cervical length (CL) below 25 mm is found in low-risk women with an overall incidence of PTB of 4%, the positive predictive value (PPV) of CL is 18%. When the same 25 mm cut-off is used in high-risk patients with a history of PTB at less than 32 weeks with an overall incidence of PTB of 26%, PPV jumps to 55%. The most common gestational age at which a short cervix or funneling develops is 18 to 22 weeks. So if a screening program is to only include one CL assessment, perform it during this interval. While many women would be expected to have a PTB based solely on their histories, a CL at or above 35 mm between about 18 and 24 weeks was correlated with preterm delivery risk of only 4% in both high-risk singleton and twin gestations.
  55. 55. Key points
  56. 56. Key points
  57. 57. % NPV% PPV % Specificity % Sensitivity % PTDCutoff(wks)NReference 721001002734≤20 mm 18– 37 32Murakawa et al. 1006571100≥35 mm 100554410040<30 mm 24– 35 60Iams et al. 8367787337≤18 mm 20– 35 59Gomez et al. 7671796843≤20 mm 24– 36 108Rizzo et al. 8950737526≤26 mm 24– 34 76Rozenberg et al. PTD, preterm delivery; PPV, positive predictive value; NPV, negative predictive value. the shorter the cervix at presentation, the higher the risk for preterm delivery.
  58. 58. PTB% Cerclage gp PTB% Expect.gp NoCL cut offstudy 5% Shirodkar 52%43<15mmHeath et al 13% Shirodkar 50%2400<15mmNicolaides et al 27% McDonald 23%168<25mmBerghella et al Can a Cervical Cerclage be Used to Prevent Preterm Delivery
  59. 59. In whom is an urgent cerclage indicated?
  • AbdullahEssawy1

    Feb. 25, 2020

how to diagnose and fix the evidence practice gap in cervical incompetence

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