Cervical incompetence

1. CERVICALCERVICAL
INCOMPETENCEINCOMPETENCE
Dr Muhammad El HennawyDr Muhammad El Hennawy
Ob/gyn ConsultantOb/gyn Consultant
Rass el barr central hospital andRass el barr central hospital and
dumyat specialised hospitaldumyat specialised hospital
DumyattDumyatt –– EGYPTEGYPT
www. mmhennawy.co.nrwww. mmhennawy.co.nr

2. Cervical incompetence(CICervical incompetence(CI((
It is premature painless diltation of
endocervical canal
in pregnancy
before onset of labour

3. IncidenceIncidence
It is estimated that cervical
incompetence will complicate
anywhere from 0.1% to 2% of all
pregnancies
and is thought to be responsible for
approximately 15% of habitual
immature deliveries between 16 and
28 weeks of gestation

4. the etiologythe etiology
 In most cases, the etiologyIn most cases, the etiology isis unknownunknown
 KnownKnown causes includecauses include CongenitalCongenital
weakness as Mullerian abnormalitiesweakness as Mullerian abnormalities
(cervical hypoplasia,(cervical hypoplasia, in uteroin utero
diethylstilbestrol [DES] exposure),diethylstilbestrol [DES] exposure),
traumatictraumatic abnormalities (prior surgical orabnormalities (prior surgical or
obstetric trauma), andobstetric trauma), and connective tissueconnective tissue
abnormalities (Ehlers-Danlos syndrome).abnormalities (Ehlers-Danlos syndrome).

5. Cervical AnatomyCervical Anatomy
 Embryologically, the body and cervix of the uterus
are derived from fusion and recanalization of the
paramesonephric (Mullerian) ducts, a process that
is complete by the 5th month of pregnancy.
 Histologically, the cervix consists of fibrous
connective tissue, muscle, and blood vessels.
Muscular connective tissue constitutes
approximately 15% of the cervical stroma, but is not
uniformly distributed throughout the cervix,
constituting approximately 30%, 18%, and 7% of
the upper, mid, and lower thirds of the cervix,
respectively (2).
 Conversely, the fibrous connective tissue content
of the cervical stroma increases as one moves from
the external os to the uterine corpus, and it this
component that is believed to confer tensile
strength to the cervix. Defects in tensile strength
are thought to lead to premature cervical dilatation
and pregnancy loss.

6. Despite many advances inDespite many advances in
modern obstetrics ,theremodern obstetrics ,there
remains much controversyremains much controversy
regarding the diagnosisregarding the diagnosis
and treatment of cervicaland treatment of cervical
incompetenceincompetence

7. DiagnosisDiagnosis
There isThere is no preciseno precise method for diagnosingmethod for diagnosing
CICI
Strongest evidence for diagnosis of CI isStrongest evidence for diagnosis of CI is
lack oflack of any other causes for reccurrentany other causes for reccurrent
pregnancy loss eg : chromosomalpregnancy loss eg : chromosomal
abnormalities,infection,endocrineabnormalities,infection,endocrine
disorders,immunologic disease)disorders,immunologic disease)
WithWith history of consistent with conditionhistory of consistent with condition
. - Or + Pre-pregnancy physical findings. - Or + Pre-pregnancy physical findings
Ultrasonography isUltrasonography is usefuluseful as adjunct toas adjunct to
other diagnostic measuresother diagnostic measures

8. history of consistent with conditionhistory of consistent with condition
Painless premature cervical
diltation during pregnancy and
before onset of labour
a sudden unexpected rupture of the
membranes followed by painless
expulsion of the fetus
Resulting in repeated mid
trimester spontaneous miscarriage
or premature delivery

9. - Or + Prepregnancy physical- Or + Prepregnancy physical
findingsfindings
Ability to introduce a number 8 HegarAbility to introduce a number 8 Hegar
dilator or equivalent through thedilator or equivalent through the
internal os when patient is notinternal os when patient is not
pregnant.pregnant.
Hysterosalpingogram demonstratingHysterosalpingogram demonstrating
cervical funneling.cervical funneling.
Clinical evidence of extensive obstetricClinical evidence of extensive obstetric
or surgical trauma to cervix.or surgical trauma to cervix.

10. Ultrasonography isUltrasonography is usefuluseful
before cerclage – length of cervical canal , width of
isthmus , funneling of upper part of cervical canal with
protrusion of the membranes(when the cervical os
(opening) is greater than 2.5 cm, or the length has
shortened to less than 20 mm. Sometimes funneling is also
seen ))
After cerclage – determine exact site of cerclage,proximal
cervical canal segment length above cerclage ,distal
cervical canal segment length below cerclage,internal os
diameter ,funneling if present , and protrusion of
membranes)Negative U/S can not exclude CI
Positive U/S in routine screen in pregnant women without
history of pregnancy loss are not necessary at risk
but close follow up is required

11. tttttt
RESTREST
CERCLAGE or encerclage.CERCLAGE or encerclage.

12. The alternative to cerclageThe alternative to cerclage
 strict bed rest, sometimes in the
Trendelenburg position.
 However, when women with midtrimester
membrane prolapse are managed
expectantly, preterm prelabor rupture of
membranes occur in a great majority of
cases.
 These women rarely maintain the
pregnancy for an appreciable length of
time.

13. There's no guaranteeThere's no guarantee
that a cerclage will prevent athat a cerclage will prevent a
pregnancy loss; however, in mostpregnancy loss; however, in most
instances it will prolong theinstances it will prolong the
pregnancy, often enabling a womanpregnancy, often enabling a woman
to carry to term. You may be at riskto carry to term. You may be at risk
for incompetent cervix if you havefor incompetent cervix if you have
had a previous pregnancy loss inhad a previous pregnancy loss in
the second trimester, if you havethe second trimester, if you have
had surgery on your cervix, or ifhad surgery on your cervix, or if
you have had multiple pregnancyyou have had multiple pregnancy
terminationsterminations

14. IndicationsIndications
 Suspected cervical incompetence remains the
only acceptable indication for cervical
cerclage. Indications can be classified as
follows:
 (1) Prophylactic (elective) cervical cerclage
 (2) Asymptomatic women with sonographic
evidence of cervical shortening and/or
funneling may also benefit from cervical
cerclage (often called urgent cerclage)
 (3) Emergency (salvage) cervical cerclage
 Cerclage should be delayed until after 14
weeks so that early miscarriage caused by
other factors is possible. There is no
consensus about how late in pregnancy

15. 1-1- Prophylactic (elective) cervicalProphylactic (elective) cervical
cerclagecerclage Decision to perform cerclage must be made individually
for each patient
 There's no guarantee that a cerclage will prevent a
pregnancy loss; however, in most instances it will prolong
the pregnancy, often enabling a woman to carry to term
 Once CI has been strongly suggested by combination of
history(asymptomatic women with a history of prior
pregnancy loss and/or preterm delivery due to cervical
incompetence)clinical and U/S suggested findings
 Prophylactic cervical cerclage may be placed because the
probability of recurrence in a subsequent pregnancy is
15-30%
 It may be placed prior to pregnancy, but is more
commonly placed between 10 -16 weeks’ gestation.
 The stitch is usually removed around 37 weeks and
labour ensues fairly rapidly if the diagnosis was correct.
Abdominal cerclage requires an elective caesarean
section and the stitch is usually left in-situ for future
pregnancies.

16. In order to avoid unnecessaryIn order to avoid unnecessary
elective cerclageelective cerclage
there is a growing tendency tothere is a growing tendency to
delay it until evidence of cervicaldelay it until evidence of cervical
changes at ultrasound scanchanges at ultrasound scan
appears----appears---- urgent cervical cerclageurgent cervical cerclage ..

17. 2 - urgent cervical cerclage2 - urgent cervical cerclage
 although the data in this regard is controversial.
There are several retrospective studies
suggesting that cervical cerclage in
asymptomatic women with short cervical length
and/or funneling on endovaginal ultrasound may
improve perinatal outcome These studies
reported an overall reduction in the incidence of
preterm delivery in women identified as having a
short cervix by transvaginal sonography before
24 weeks’ gestation and subsequently treated
with cerclage to approximately 10% of controls.
However, more recent studies suggest that
cerclage does not prevent preterm delivery in
women at high-risk for preterm birth on the basis
of cervical shortening Moreover, one study
showed a higher rate of preterm PROM in
women who received a cerclage as compared
with those without cerclage Further studies are

18. 3-3- Emergency (salvage) cervicalEmergency (salvage) cervical
cerclagecerclage refers to placement of a cerclage in the setting
of significant cervical dilatation and/or
effacement prior to 28 weeks’ gestation and in
the absence of labor.
 it is a surgical procedure without proven
benefit and with well-defined operative risks.
As such, until adequate clinical trials are
available demonstrating a clear benefit,
emergency cerclage should be used judiciously
and only after extensive and comprehensive
patient counseling.
 achieved fetal survival of 80% with cerclage at
a
cervical dilatation of less than 5 cm, and 24%
when cervical dilatation was 5 cm or more

19. Emergency cervical cerclageEmergency cervical cerclage
 ContraindicationsContraindications ::
1.1.Uterine contractions.Uterine contractions.
2.2.Uterine bleedingUterine bleeding
3.3.ChorioamnionitisChorioamnionitis
4.4.Premature rupture of membranesPremature rupture of membranes
5.5.Fetal anomaly incompatible with lifeFetal anomaly incompatible with life

20. Preoperative evaluationPreoperative evaluation
 Cerclage should generally be delayed until
after 14weeks so that early abortions due to
other factors will be completed
 Obvious cervical infection should be
treated,
 cultures for gonorrhea, chlamydia, and
group B streptococci are recommanded
 Sonography to confirm a living fetus and to
exclude major fetal anomalies
 For at least a week before and after surgery
, there should be no sexual intercourse
 More advanced the pregnancy, the more
likely surgical intervention will stimulate
preterm labor or membrane rupture

21. Cerclage
Before
pregnancy
After
pregnancy
Trans-
vaginal
Trans-
AbdominalLash
CervicoisthmicHefner
McDonald Shirodkar
Burried unburried shirodkar
Modified
shirodkar

22. Choice of cervical cerclageChoice of cervical cerclage
 the decision of which technique to use can be leftthe decision of which technique to use can be left
to the discretion of the operator.Under certainto the discretion of the operator.Under certain
circumstances,circumstances,
 however, one or other technique may be preferablehowever, one or other technique may be preferable
The most commonly employed techniques areThe most commonly employed techniques are
performedperformed vaginallyvaginally Shirodkar(itself and modified)
and McDonald cerclage (cerclage ( burried and unburriedburried and unburried ))
and aand a transabdominaltransabdominal cervicoisthmiccervicoisthmic approach orapproach or
Uterosacral cardinal ligament cerclageUterosacral cardinal ligament cerclage is sometimesis sometimes
used For example, if the cervix is very short orused For example, if the cervix is very short or
lacerated, a Shirodkar cerclage may be technicallylacerated, a Shirodkar cerclage may be technically
easier to place The transabdominal route iseasier to place The transabdominal route is
beneficial in treating patients with cervices that arebeneficial in treating patients with cervices that are
either extremely short, congenitally deformed,either extremely short, congenitally deformed,
deeply lacerated, or markedly scarred because ofdeeply lacerated, or markedly scarred because of
previously failed transvaginal cerclage procedurespreviously failed transvaginal cerclage procedures
In cases where there has been extensive cervicalIn cases where there has been extensive cervical
trauma or an anatomical defect, this stitch can betrauma or an anatomical defect, this stitch can be
used. It is permanent and requires a cesareanused. It is permanent and requires a cesarean
delivery---delivery--- The Lash cerclage.The Lash cerclage.

23. The Lash cerclageThe Lash cerclage
is the only type that is placed prior tois the only type that is placed prior to
pregnancy. In cases where there haspregnancy. In cases where there has
been extensive cervical trauma or anbeen extensive cervical trauma or an
anatomical defect, this stitch can be used.anatomical defect, this stitch can be used.
It is permanent and requires a cesareanIt is permanent and requires a cesarean
delivery.delivery.

24. Shirodkar techniqueShirodkar technique
 With the Shirodkar technique, the vaginal
mucosa membrane is elevated. A band of
homologous fascia or narrow band of some
material such as Mersilene is wrapped around
the internal os and tied. The vaginal mucosa is
then restored to its original position and
sutured.
 The Shirodkar can be both permanent (requiring
a cesarean section) or it can be removed near
term. This stitch is started at a 12 o’clock
position, worked through the cervix to a 6
o’clock position, ending back in the 12 o’clock
position on the other side of the cervix. It is
also pulled tightly and tied to keep the cervix
closed. How the stitch is tied off determines
whether it will be removed or if it is permanent.

25. Modified ShirodkarModified Shirodkar’’s techniques technique
 It is done under general anaesthesia. Cervix is
exposed and held with sponge holding forceps. A
transverse incision is taken over anterior lip of
cervix at junction of portiovaginalis and vaginal
rugosity. Bladder is separated and pushed off from
area of internal os. With the help of two large
curved round body needles ligature of black silk is
passed starting from the edge through substance
of cervix and taken out posteriorly,
perpendicularly. Similar procedure is repeated on
other side. Knot is tied posteriorly in the midline
keeping it exterior. Anterior incision is sutured by
few interrupted sutures using an absorbable
material.
This procedure differs from Shirodkar’s encerclage
as the needle is not passed submucosally, but
through substance of the cervix and no incision is
taken posteriorly. The knot is kept exterior to

26. McDonald techniqueMcDonald technique
a simpler procedure, a non-absorbablea simpler procedure, a non-absorbable
suture in placed around the cervix high onsuture in placed around the cervix high on
the cervical mucosathe cervical mucosa
stitch is weaved in and out of the cervixstitch is weaved in and out of the cervix
and pulled tightly and tied to keep theand pulled tightly and tied to keep the
cervix closed.cervix closed.

27. The Hefner cerclageThe Hefner cerclage
when incompetent cervix is diagnosedwhen incompetent cervix is diagnosed
later in pregnancy. It has an added benefitlater in pregnancy. It has an added benefit
when there is little cervix to work with. Thiswhen there is little cervix to work with. This
cerclage is removed closer to term as well.cerclage is removed closer to term as well.
also know as the Wurm procedure, is usedalso know as the Wurm procedure, is used
for later diagnosis of the incompetentfor later diagnosis of the incompetent
cervix. It is usually done with a U orcervix. It is usually done with a U or
mattress suture, and is of benefit whenmattress suture, and is of benefit when
there is minimal amounts of cervix left.there is minimal amounts of cervix left.

28. Transabdominal cerclageTransabdominal cerclage
 is not frequently performedis not frequently performed
 is only indicated for those patients with previousis only indicated for those patients with previous
failed cervical cerclages, shortened or amputatedfailed cervical cerclages, shortened or amputated
cervix, and/or deep traumatized cervixcervix, and/or deep traumatized cervix
 The surgical techniqueThe surgical technique ---- caudal reflection of thecaudal reflection of the
bladder, placement of an encircling A 5mm widebladder, placement of an encircling A 5mm wide
mercilene tape medial to the uterine vessels inmercilene tape medial to the uterine vessels in
an avascular space above the junction of thean avascular space above the junction of the
cervix and the uterine isthmus without dissectioncervix and the uterine isthmus without dissection
or tunneling among broad ligament vesselsor tunneling among broad ligament vessels aboveabove
the cardinal and uterosacral ligamentsthe cardinal and uterosacral ligaments , and tying, and tying
of the knot posteriorly.of the knot posteriorly.
 This prevents erosion of the knot into the base ofThis prevents erosion of the knot into the base of
the bladder and allows for removal via posteriorthe bladder and allows for removal via posterior
colpotomy in an emergency situation.colpotomy in an emergency situation.
 Most agree that removal of the suture shouldMost agree that removal of the suture should

29. ComplicationComplication
While these procedures are life-saving, they alsoWhile these procedures are life-saving, they also
have potential risks:have potential risks:
 Premature rupture of membranes (1-9%)Premature rupture of membranes (1-9%)
 Chorioamnionitis (Infection of the amniotic sac, 1-Chorioamnionitis (Infection of the amniotic sac, 1-
7%) (This risk increases as the pregnancy7%) (This risk increases as the pregnancy
progresses and is at 30% for a cervix that is dilatedprogresses and is at 30% for a cervix that is dilated
more than 3 cms.)more than 3 cms.)
 Preterm LaborPreterm Labor
 Cervical laceration or amputation (This can be atCervical laceration or amputation (This can be at
the procedure or at the delivery, from scar tissuethe procedure or at the delivery, from scar tissue
that forms on the cervix.)that forms on the cervix.)
 Bladder Injury (rare)Bladder Injury (rare)
 Maternal hemorrhageMaternal hemorrhage
 Cervical dystociaCervical dystocia
 Uterine ruptureUterine rupture

30. Thank you