cervical incompetence

1. CERVICAL INCOMPETENCE
(CERVICAL INSUFFICIENCY)
ADIL MUHAMMED
13M004

2. • The inability of uterine cervix to retain a
pregnancy in the absence contractions, labor or
both in the second trimester.
• Cervical incompetence is characterised by
painless cervical dilation in the second or early
third trimester with ballooning of the amniotic sac
into the vagina followed by rupture of membranes
and expulsion of usually the live fetus.
• Usual timing : 16-24 weeks

4. AETIOLOGY
• CONGENITAL
- Developmental weakness of cervix
- Associated with uterine anomalies like septate
uterus.
- Following in utero exposure to diethyl stilbestrol.

5. • Acquired due to previous cervical trauma
- Forcible dilation during MTP and dilation
and curretage (D & C)
- Conization of cervix causes a risk of
subsequent pregnancy ending up in preterm
birth.
- Cauterization of cervix
- Amputation of cervix or Fothergill’s
operation.

6. • OTHERS
-one or more second-trimester miscarriages
with no known cause.
-cervical insufficiency in a prior pregnancy
-one or more spontaneous preterm deliveries
-uterine abnormality (such as a bicornuate
uterus).
- Previous surgery on the cervix.

7. DIAGNOSIS
• Diagnosis of cervical incompetence :
• A history of painless cervical dilation and
second trimester deliveries
• A history of short labors and progressively
earlier deliveries in previous pregnancies
• Advanced cervical dilation and effacement
before week 24 of pregnancy without painful
contractions, vaginal bleeding, water breaking
(ruptured membranes) or infection.

8. INVESTIAGTIONS
• PREMENSTRUAL
HYSTEROCERVICOGRAPHY :
It mainly show the typical funneling of the
internal os.
• NON PREGNANT STATE :
The internal os allows the passage of a No.8
Hegar’s cervical dilator or Folley’s catheter
filled with 1ml water without resistance.

9. • IN PREGNANCY :
- Transvaginal ultrasound is the ideal method to
follow up and detect early incompetence.
- The normal cervix length at 14 weeks is 35-40 mm
and the internal os diameter is less than 20 mm.
A cervical length less than 30 mm and a internal os
diameter more than 20mm is suggestive of cervical
incompetence.
- Funneling of the os on USG also indicates cervical
incompetence.

10. Ultrasound showing funnelling of the internal os in
cervical insufficiency

11. • LAB TESTS
If the fetal membranes are visible and an ultrasound
shows signs of inflammation but you don't have
symptoms of an infection,test a sample of amniotic
fluid (amniocentesis) to diagnose or rule out an
infection of the amniotic sac and fluid
(chorioamnionitis)
-Blood glucose(fasting and post
prandial),VDRL,Thyroid function test, ABO
- Serum LH on D2/D3 cycle
-Hyterosalpinography in the secretory phase detect –
cervical incompetence, uterine malformation.

12. MANAGEMENT
• The management is surgical by means of a cervical
cerclage.The diagnosis is difficult and cervical cerclage
is quite often performed unnecessarily.
• Cervical cerclage is usually delayed up to 12-14 weeks
so that miscarriage due to other causes can be
eliminated or it should be done atleast 2 weeks earlier
than the lowest period of earlier wastage(not earlier
than 10 weeks).
• SONOGRAPHY should be done prior to cerclage to
confirm a live fetus and to rule out anomalies.
If there is infection,it should be treated.

13. TYPES OF CERCLAGE :
- History indicated cerclage
- Ultrasound indicated cerclage
- Rescue cerclage

14. Types of operation done during pregnancy with a success rate of about
80-90%
The opertions are named after :
• Shirodkar
• McDonald
• Wurm procedure
• Transabdominal cerclage
• Lash procedure
Principal : The procedure reinforces the weak cervix by a non –
absorbable tape, placed around the cervix at the level of internal os.
Preoperative evaluation should include the following
• Fetal ultrasound assessment for viability, gestational age, and any
identifiable anomalies
• Clinical evaluation to exclude active bleeding, preterm labor, and
PPROM
• Consideration of amniocentesis to rule out a subclinical intraamniotic
infection, particularly in women with cervical dilatation at the time of
presentation

15. SHIRODKAR CERCLAGE
• It is mainly the vaginal approach to cervix.
• Involved placement of a non-absorbable suture such as fascia
lata,silk or nylon or mersilene tape around the cervix at the
internal os.
• The suture lies completely beneath vaginal and cervical mucosa.
• The junction between the anterior vaginal wall rugose with the
smooth cervical mucosa is identified.
• Transverse incision 2cm long is made at the junction and the
bladder bluntly dissected until the uterovesical peritoneum
identified.
• An atraumatic needle is passed submucossaly in the cerivx
posteroanteriorly and knotted.
• The vaginal mucosa thereafter sutured anteroposteriorly.
• The operation is techincally more involved and takes longer to
perform

17. Material of choice – Mersilene tape with two
needles

18. McDonald Procedure
• In the lithotomy position cervix is visualized using a Sim’s
speculum.
• The anterior and posterior lips held with sponge holding
forceps.
• The junction between the anterior vaginal rugose and
smooth cervical mucosa is identified – internal os
• Placement of the suture is done just below the point.
• Four bites in the substance of the cervix are taken
circumferentially purse string.
• First bite taken just before 12’0 clock and last just after 12’0
clock
• The needle removed and the knotted up to four times with
the knot left 2-3 cm long.

20. Sim’s speculum

22. Women who may have incompetent cervix and
require treatment can be divided into 4 groups:
• Women who present with H/O painless cervical
dilatation and bag of waters is visible through
external os
Managed by -
Rescue cerclage operations.

23. • Women with cervical changes visible by USG
McDonald stitch / Shirodkar cerclage
• Women with risk factors for incompetent
cervix.
Rest.No need for prophylactic cerclage.

24. • Women the incompetent cervix and failed
vaginal cerclage.
Abdominal cerclage

25. Post Operative Care
• Antibiotics
- cefoxitin,amoxicillin,ampicillin
• Tocolytics
- patients with uterine irritability
• Bed rest for 1st 24 hrs followed by
mobilization and activity

26. CONTRAINDICATIONS
• Intra uterine infection.
• Ruptured membranes.
• H/O vaginal bleeding.
• Severe uterine irritability.

27. COMPLICATIONS
EARLY COMPLICATIONS :
• Infections (Chorioamnionitis,Vulvovaginitis)
• Bleeding
• Premature labour
• Deep cervical laceration.
LATE COMPLICATIONS :
• Fistula formation
• Cervical stenosis
• Preterm deleveries