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Obstetrics and Gynecology - 2009

Obstetrics and Gynecology - 2009

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Published by CCGMP
Here is a free sample chapter from the "Educational Review Manual in Obstetrics and Gynecology" published by Castle Connolly Graduate Medical Publishing (CCGMP)www.ccgmp.com.

The digital edition of this manual is now FREE for all doctors: www.ccgmp.com

Visit our Facebook page: www.facebook.com/ccgmp
Here is a free sample chapter from the "Educational Review Manual in Obstetrics and Gynecology" published by Castle Connolly Graduate Medical Publishing (CCGMP)www.ccgmp.com.

The digital edition of this manual is now FREE for all doctors: www.ccgmp.com

Visit our Facebook page: www.facebook.com/ccgmp

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Published by: CCGMP on Oct 26, 2009
Copyright:Attribution Non-commercial

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07/29/2013

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Obstetrics and Gynecology - 2009
Editor-in-Chief
Rogerio A. Lobo, M.D.
Professor of Obstetrics & Gynecology,College of Physicians and Surgeonsof Columbia University, New York, NY
 
CHAPTER9:OBSTETRICCOMPLICATIONS
217
Contents
1.CervicalInsufficiency2.PretermLabor3.Post-termPregnancy4.HypertensiveDisordersofPregnancy5.IntrauterineFetalDemise6.IntrauterineGrowthRestriction7.MultiplePregnancy8.PrematureRuptureofMembranes9.AntepartumHemorrhage10.References11.Questions
Chapter9:ObstetricComplications
 ErrolR.Norwitz,MD,PhD Men-JeanLee,MD
 
1.CervicalInsufficiency
Cervicalinsufficiency(alsoknownascervicalincom-petence)isdefinedasafunctionalweaknessofthecervixresultinginafailuretocarryapregnancytoterm.
1,2
Itcomplicates0.1%-2%ofallpregnancies,andisestimatedtoberesponsiblefor15%ofdeliver-iesbetween16and28weeksofgestation.
3-5
Theclas-sicpresentationisthatofpainlesscervicaldilatationandshorteningwithoutevidenceofuterinecontractions.
6
Etiology
Someriskfactorsforcervicalinsufficiencyaredescribed(Table1),butmostpatientshavenoriskfactors.
1,2
Theexactetiologyofcervicalinsufficiencyhasnotbeenelucidated.
6
Diagnosis
Cervicalinsufficiencyisaclinicaldiagnosischarac-terizedbyacute,painlessdilatationofthecervix,usu-allyinthemid-trimester(generallybetween16-24weeks),culminatinginfetalmembraneprolapseand/orprematureruptureofthemembranes(PROM)withresultantpretermandoftenpreviabledelivery.
Management
Cervicalcerclagehasbecomethemainstayforthemanagementofcervicalinsufficiency.Ifthepriorpretermdeliverywastheresultofpretermlabor(docu-mentedactivecontractions)andnotcervicalinsuffi-ciency,cerclageplacementisnotindicated.
2
TypesofCerclage
 Prophylactic (elective) cervical cerclage
isindicatedinwomenwithahistoryofpriorpregnancylossand/orpretermdeliverywithahistoryconsistentwithcervicalinsufficiency,becausetheprobabilityofrecurrenceof cervicalinsufficiencyinasubsequentpregnancyis15%-30%.
1,7,8
Prophylacticcervicalcerclageisplacedmostcommonlyat13-16weeksofgestation,atwhichtimethecomplicationrateislow(<1%).
2
Prophylacticcerclagefordiethylstilbestrol(DES)exposure(whenthepatientwasexposed
inutero
toDEStakenbyhermother)aloneremainscontroversial.Mostcliniciansbelievethatahistoryof 
inutero
DESexposureperse(withoutahistoryofpriorpregnancyloss)isnotanindicationforprophylacticcerclageplacement.Simi-larly,electivecerclagehasnotbeenshowntobebenefi-cialinwomenwithmultiplepregnancieswithoutapriorhistoryofcervicalinsufficiency.
9-12
Theprimaryindicationfor
emergent (salvage, res-cue) cervical cerclage
isprematureeffacementand/ordilatationofthecervixintheabsenceoflaborpriorto28weeksgestation.Itisassociatedwithalessthan50%successrate.Poorprognosticfeaturesincludecer-vicaldilatation>4cmandprolapsedmembranes.In
218
OBSTETRICSANDGYNECOLOGY—2009
Table1RiskFactorsforCervicalInsufficiency
CongenitalAcquired
MüllerianabnormalitiesCervicaltrauma(priorsurgicalor(congenitalcervicalhypoplasiaoraplasia)obstetrictrauma)
Inutero 
diethylstilbestrol(DES)exposureConnectivetissueabnormalities(Ehlers-Danlossyndrome)

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