The inability of the uterine cervix to retain a pregnancy in the absence contractions, labor or both in the second trimester.

1. 6/10/2016
Dr Ahmad Taha
Fetal Medicine Unit
Orient Hospital
Damascus – Syria

2. The inability of the uterine cervix to retain a
pregnancy in the absence contractions, labor or
both in the second trimester.
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6. Cervical length can be measured by:
Transabdominally
or
Transperineally
but
Transvaginal assessment is the most accurate
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7. Standard cervical measurements use the (white
stripe) of the internal cervical os as an anatomic
land mark for proper caliper placement
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8. Varies between
45±7 mm
(Anderson et al)
And
35±8 mm
(Lams et al)
SO
The short cervix varies between
15 mm (Hassan et al) and 26 mm (Lams et al)
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9. The very most important for assessment is
Progressive shortening
with or without
1. Funneling
2. V shaped lower uterine segment
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10. Women at risk of developing a weak cervix
include:
1. Women with a history of D&C (Dilation and
Curettage) for abortion, miss carriage etc…
2. Women who have had surgery on the cervix
3. Women with a damage to cervix from
previous births
4. Daughters of women who took DES
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11. There are no established
criteria for diagnosing
cervical incompetence
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12. History
Physical Examination
Diagnostic tools (N8 Hegar, HSG, etc……)
Ultrasound scan
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13. Miscarriage
• 2nd trimester miscarriage
• Subsequent miscarriages are usually earlier
• Preceded by spontaneous rupture of membranes
• Bulging membranes through the cervix prior to onset of
labour
• Painless and progressive cervical dilatation
• Fetus alive during miscarriage
History of cervical surgery (cone biopsy, LLETZ)
No satisfactory objective test
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15. Used when the diagnosis is uncertain but
suspected during pregnancy
Cervical length < 2.5 cm
± Funneling of the internal os
Is suggestive of cervical incompetence
Repeated TVS is a essential in the border cases
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21. • Women with a history of second-trimester miscarriage and
suspected cervical weakness who have not undergone a
history-indicated cerclage may be offered serial cervical
sonographic surveillance.
• In women with a singleton pregnancy and a history of one
second-trimester miscarriage attributable to cervical factors,
an ultrasound-indicated cerclage should be offered.
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22. Elective cerclage Urgent cerclage
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23. Three or more other wise unexplained
second trimester pregnancy loses
Three or more preterm deliveries
Women who had hysteroscopy
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24. Performed between 13-16 weeks of gestation
after ultra sound evaluation of fetal viability to
avoid the risk of spontaneous loss of fetus.
Suture remove at 37 weeks of gestation.
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25. Performed for women who have serial ultra
sonographic changes consistent with short
cervix or evidence of funneling
Timing of cerclage is usually not placed
beyond 26-28 weeks of gestation
Emergency cerclage may be considered in
women if clinical chorioamnionitis or signs of
labor are not present
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26. Active preterm labour
Clinical evidence of chorioamnionitis
Continuing vaginal bleeding
PPROM
Evidence of fetal compromise
Lethal fetal defect
Fetal death
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27. Most common complications associated with vaginal
cerclage are:
1. Suture displacement
2. Rupture of membranes at the time of cerclage
placement
3. Chorioamnionitis
4. Hemorrhage
5. Damages to surrounding organs (bladder,
urethra…)
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28. 1. Increased risk of caesarean section
2. Chorioamnionitis
3. Preterm delivery
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29. Shirodkar operation
McDonald procedure
Wurm procedure (hefner cerclage)
Transabdominal cerclage
Lash procedure
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30. Usually requires anesthesia for removal there for
carries an additional anesthetic (risk).
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34. • A transvaginal cervical cerclage should be
removed before labour, usually between 36+1
and 37+0 weeks of gestation
• unless delivery is by elective caesarean section,
in which case suture removal could be delayed
until this time
• In women presenting in established preterm
labour, the cerclage should be removed to
minimize potential trauma to the cervix.
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41. • Cervical insufficiency: a presumed physical weakness of cervical
tissue that causes or contributes to the early delivery of an
otherwise healthy pregnancy, usually in the second trimester.
• Using historic factors alone, cervical insufficiency is defined as
painless cervical dilatation leading to recurrent second trimester
pregnancy losses/births.
• Cervical insufficiency may be congenital or acquired. Women at risk
include those with a history of cervical trauma (eg, dilation and
curettage, dilation and evacuation), collagen disorders, or congenital
anomalies of the uterus/cervix.
• The diagnosis of cervical insufficiency is either based on historic
factors or on a combination of historic factors and transvaginal
ultrasound (TVU) measurement of cervical length.
6/10/2016

42. • Cervical length <25 mm and/or advanced cervical changes on
physical examination before 24 weeks of gestation in women
with either:
• One or more prior pregnancy losses/births at 14 to 36
weeks, and/or
• Other significant risk factors for cervical insufficiency.
• For women with two or more consecutive prior second
trimester pregnancy losses or three or more early preterm
births who have risk factors for cervical insufficiency and in
whom other causes of preterm birth have been excluded 
we recommend history-indicated cerclage.
6/10/2016

43. • For women with suspected cervical insufficiency  sonographic
surveillance should be started early in pregnancy (eg, 14 to 16
weeks).
• We suggest cerclage for women who develop a short cervix (<25
mm) before 24 weeks.
• Vaginal progesterone administration or placement of a pessary are
alternative approaches.
• We recommend progesterone supplementation for women with
singleton gestations and a history of spontaneous preterm birth.
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44. Clinical Team
S. Samawi
N. Kafri
S. Modi
M. Mousa
IVF Lab
o M.H.Droubi
o R. Doghoz
o A. Konali
Fetal Med.
A. Taha
M. Khalaf
M. Hazemah
Andrology Lab
W. Hamad
N. Assaf
M. Othman
N. Mazzawi
S. Sheko
Bio-Ginitic Lab
J.Sharif
A. Khatib
M. Kinj
Administration
F. Hamad
R. Qamar
M. Haj hasan
N. Olabi
E. Fayad
W. Saker
Med Engineering
Y. Khabori
S. Khayat
Anesthesia
R. Tarko
Y. Lakkis
M. Khadra
H. Sulaiman
Acknowledgement
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