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• Condition in which the cervix fails to retain the conceptus during pregnancy. • There are arguments about the occurrence and incidence of incompetent cervix

Affects around 1% of pregnant patients

Cervical incompetence has long been recognized as a potential cause of preterm delivery & recurrent mid trimister abortionns. .

25 % of all second trimester losses .It is believed that cervical incompetence is the cause of 20 .

Surgical trauma :  Conization. Congenital disorders (congenital mullerian duct abnormalities eg.Danlos syndrome). Bicornuate uterus). DES exposure in utero. 2. 3. Connective tissue disorder (Ehlers. . Septate uterus.1.( resulting in substantial loss of connective tissue) or  Traumatic damage to the structural integrity of the cervix : (repeated forced cervical dilatation associated with D&C). 4. Idiopathic (most cases). 5.

The cervical competence is an active. but is also due to either: 1. not passive. and it is a specific entity involving not just an abnormality or defect of cervical collagen. Injury or damage to the cervical musculature caused by previous trauma. . or 2. Absence of the usual cervical musculature in cases of congenital cervical incompetence. phenomenon.

Women with incompetent cervix typically present with "silent" cervical dilatation (i. .. with minimal uterine contractions) between 16 and 28 weeks of gestation.e.

.• Patient present with significant cervical dilatation (2 cm or more) and minimal symptoms. • When the cervix reaches 4 cm or more. active uterine contractions or rupture of membranes may occur.

. others are: (proteoaminoglycans. elastin and glycoproteins. • Collagen is the principal component in the cervical matrix.• The function of the cervix during pregnancy depends on the regulations of connective tissue metabolism. like fibronectin).

The biochemical events implicated in the cervical ripening are: 1. . Increase in collagenolytic activity. 2. Increase in collagen solubility and 3. Decrease in total collagen content.

eventually. women with this cervical status may develop membrane rupture & labor. • Short labors with the delivery of an immature fetus or loss of the pregnancy at progressively earlier gestational ages in successive pregnancies is characteristic of reduced competence.• It is a clinical diagnosis marked by gradual. painless dilatation and effacement of the cervix with membranes visible through the cervix. . • This history establishes the diagnosis.

prolonged second stage followed by cesarean 4.History of obstetric trauma: cervical lacerations.History of forceful cervical dilatation and evacuation 3.– Historical factors 1.Cervical funneling .Short cervical length 7.History of painless cervical dilatation with preterm delivery 2.Prior cervical surgery: cone. loop 5.DES exposure in utero – Cervical sonography 6.

Allow treatment to be targeted appropriately and 3. • If possible. Also provide the basis for definitive trials of treatment. measurable) diagnosis. An accurate incidence of cervical incompetence. made before pregnancy or in the early stages (first or early second trimester) would provide : 1. 2. an objective (i. .e.• The diagnosis is at present largely subjective and retrospective.

• Digital examination of the cervix is highly subjective. . • Sonography has provided a reproducible method of evaluating the cervix.• Dilators or balloons to determine cervical resistance and/or hysterosalpingograms to measure the width of the cervical canal between pregnancies are neither sensitive nor specific.

• Initial use of ultrasound to observe the cervix was transabdominal but the necessity for a full bladder to visualize the cervix elongates the cervix to such a degree as to make objective. reproducible measurements difficult. • The development of transvaginal scanning (TVS) allowed for accurate cervical measurements with an empty bladder and no distortion . .

.'funneling' or 'breaking' of the internal cervical os ( at rest or particularly in response to transabdominal pressure on the uterine fundus ) is the ultrasonographic appearance of cervical incompetence .

Cervical measurements .

it is : non-invasive.• Provide a significant advance in the diagnosis of cervical incompetence • In contrast to the hysteroscopic evaluation of the cervix. . repeatable over time and can be performed during pregnancy.

Protrusion of the membranes. U (correlation between the length of the cervix and the changes in the cervical internal os). Presence of fetal parts in the cervix or vagina . Cervix length < 25 mm 3. 4.1. Funneling of the cervix with the changes in forms T. Y. V. (Trust Your Vaginal Ultrasound) 2.

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20 seconds apart.2 images of the same cervix. without and with applying pressure: .

177:660-5. Am J Obstet Gynecol 1997.Sonographic serial evaluation ( every two weeks) of the cervix for funneling and shortening in response to transfundal pressure has been found to be useful in the evaluation of incompetent cervix. .

• Surgical repair of the cervix using a vaginal or abdominal approach. for which no trial has been conducted and for which little evidence of effectiveness exists. Bed rest. and 2. • Other alternatives that have been considered have included : 1. . The use of vaginal pessaries to elevate and close the cervix.

.The initial descriptions of cervical cerclage for cervical incompetence came with Shirodkar and McDonald in the 1950s. when both developed techniques for physical support for what was presumed to be a structurally weak cervix.

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169(5):11259 PMID: 8238171.J Reprod Med 1994 Nov.73(2).Am J Obstet Gynecol 1993 Nov.Cerclage is not indicated solely based on risk factors or prior cerclage placed for doubtful indications. Am J Obstet Gynecol 1982 Mar 1.Obstet Gynecol 1989 Feb.39(11):880-2 PMID: .142(5):506-12 .

Cerclage Prophylactic Emergency .

McDonald )may be placed at 12 to 16 weeks' gestation. .• Prophylactic cerclage sutures (Shirodkar. • Do not use tocolytics at the time of prophylactic cerclage. • Follow these patients with periodic vaginal sonography to assess stitch location and funneling. • Intercourse. prolonged standing (>90 minutes). and heavy lifting are omitted following cerclage. but give perioperative antibiotics.

• For patients who have not been successful with a vaginal suture despite aggressive care and sonographic surveillance. a transabdominal cerclage may be appropriate.• No additional restrictions are recommended as long as the stitches remain within the middle or upper third of the cervix without the development of a funnel. and the length of the cervix is greater than 25 mm. .

• When the diagnosis is made before cervical dilatation has occurred and when there is still 10 to 15 mm or more of cervical length. admit the patient for 24 hours of treatment with perioperative indomethacin and broad-spectrum antibiotics before placing the cerclage sutures. and observe the patient for 48 to 96 hours postoperatively.• Care of the patient with newly detected reduced cervical competence in the second trimester is both difficult and controversial. .

with many women delivering a "viable" (usually defined as >1. if the cervix has dilated to allow visualization of the membranes. • The prognosis for these patients is better than generally expected. .• However. • The prognosis is influenced by the gestational age at the time when the suture is placed. the patient may remain hospitalized for several days after cerclage placement. but aggressive therapy may be required to achieve these results.000 g) infant.

In the case of advanced dilatation with bulging membranes. but may also obstruct the surgeon's view. 2. The cerclage suture can then be placed and tied as the balloon fluid is evacuated. Pre cerclage amniocentesis to remove sufficient fluid to reduce the bulging membranes can be helpful. several techniques may be helpful: 1. Overfilling the bladder with 1. 3.000 ml of saline may help by elevating the membranes out of the operative field. Place a Foley catheter balloon inside the cervix. and overfill it with at least 50 ml of saline to gently push the membranes out of the lower segment. .

. • The cerclage is removed at 37 weeks' gestation or at the onset of labor. • The great risk of inducing PROM or preterm labor and the ability to prolong gestation with bed rest and suppressive medications argue against surgical intervention in such cases.• Cerclage is rarely performed after 24 to 25 weeks of pregnancy.

Clinical evidence of extensive obstetric trauma to cervix ACOG Criteria Number 17 October 1996. History compatible with incompetent cervix AND 2. ACOG Criteria Number 18 October 1996 .1. Sonogram demonstrating funneling OR 3.

2.1.Uterine contractions.Premature rupture of membranes 5.Uterine bleeding 3.Chorioamnionitis 4.Fetal anomaly incompatible with life .

Transabdominal cerclage 5. Wurm procedure (Hefner cerclage) 4.There are five different techniques for performing the cerclage: 1. . Shirodkar operation 3. Lash procedure The two most common are the McDonald and Shirodkar. McDonald procedure 2.

unless there is a reason to remove it earlier. premature rupture of the membranes. etc.• The McDonald procedure is done with a 5 mm band of permanent suture is placed high on the cervix. like infection. . • It is also shown that this has very little impact of the chance for vaginal delivery. • It is generally removed at 37 weeks. preterm labor. • This is indicated when there is significant effacement of the lower portion of the cervix.

and the cervix is closed using four or five bites with the needle to create a purse string around the cervix. .• The McDonald technique requires no bladder dissection.

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this was previously a permanent purse string suture that would remain intact for life. . where the delivery does not necessarily have to be by cesarean. • However. nor the suture left intact. • There are physicians performing modified techniques.• The Shirodkar is also a frequently used technique.

tied anteriorly and the knot buried by suturing the anterior fornix mucosal opening. • The original intention with the Shirodkar method was to leave the suture in place and aim for delivery by caesarean section. opening the anterior fornix and dissecting away the adjacent bladder. .• Place the suture as near the internal os as. before placing the suture submucosally.

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• One significant difference since then has been the present day use of Mersilene tape as the suture material. but Shirodkar turned to fascia lata and McDonald turned to ( 0 )silk as they realized the importance of a permanent cervical support. .• Both initially started suturing with catgut.

• McDonald suture is generally easier to perform with no major difference in success. .• Both the McDonald and Shirodkar cervical sutures are equally effective as a vaginal approach to cervical cerclage.

and is of benefit when there is minimal amounts of cervix left. is used for later diagnosis of the incompetent cervix. • It is usually done with a U or mattress suture.• The Hefner cerclage. also known as the Wurm procedure. .

particularly those produced by diethylstilboestrol exposure.One further development in the 1960s was the description of the transabdominal cerclage by Benson and Durfee in 1965 a technique now largely used after the failure of vaginal cerclage procedures or in the presence of congenital anomalies. .

The original intention with the transabdominal approach was that the suture was inserted between pregnancies or in early pregnancy, and left in situ for the rest of the woman's reproductive life, delivery being undertaken by caesarean section for each pregnancy.

• In this method, a midline or Pfannenstiel abdominal incision allows access to the vesicouterine fold of peritoneum, which is divided and the bladder reflected caudally. • The uterine vessels are then identified and a Mersilene tape suture is passed through the broad ligament below the uterine vessels in the potential 'free space' between the uterine vessels and the ureter, with the suture tied anteriorly or posteriorly (anterior being reported as surgically easier) and the bladder replaced.

• It is typically done after cervical trauma that has caused an anatomical defect.• The last procedure. the Lash. . is performed in the non-pregnant state.

• Lash described techniques aimed at the repair of a specific anterior cervical structural defect. . the bladder reflected and the cervical defect repaired with interrupted transverse sutures before closing the vaginal mucosa. The cervical mucosa was opened anteriorly.

. and Chlamydia cultures. 4.1. Wet mount.( For vaginal infections). Treat appropriately for infection. G Beta Streptococci. Gonococci. MS-AFP( Alpha Fetopritein) if appropriate 3. Ultrasound for anomaly and viability 2.

Trendelenberg if cervix is effaced or dilated.• • • • • • Admit for cerclage NPO after midnight Bed rest. Surgical consent A 100-mg dose of indomethacin may be given per rectum during the operative period. followed by a 50-mg oral dose every 6 hours .

.Transfer to postpartum for observation • Regular diet • Bed rest 12-24 hours • May discharge if no uterine contractions.• McDonald cerclage • Postop. or rupture of membranes during observation. . vaginal bleeding.

Chorioamnionitis (Infection of the amniotic sac. Premature rupture of membranes (1-9%) 2. Cervical dystocia 8.) 5.1. Preterm Labor 4. Uterine rupture . 1-7%) (This risk increases as the pregnancy progresses and is at 30% for a cervix that is dilated more than 3 cms. Cervical laceration or amputation (This can be at the procedure or at the delivery.) 3. Maternal hemorrhage 7. Bladder Injury (rare) 6. from scar tissue that forms on the cervix.

• Later in the pregnancy. estimated at less than 1 percent. • A second cerclage has a much lower success rate. the risk of infection is small. displacement of the suture also can occur (3 to 12 percent).• For elective cerclage at the beginning of the second trimester. .

• When fluid leakage occurs in a patient with a cerclage. removal of the suture. .• Late complications of cerclage include PROM or preterm labor and chorioamnionitis. to reduce the risk of infection is controversial.

• The liberal use of this surgical procedure should be carefully balanced against potential harm. even though cerclage placement is considered a benign procedure.• Finally. in particular for patients in whom the indications for cerclage are not clear. . a maternal death secondary to sepsis in a patient with retained cerclage has been reported.

• The success rates can be very high (80-90%).• Cerclage seems to be a very effective treatment for incompetent cervix. . particularly when done earlier in a pregnancy.

• Cervical cerclage should only be considered when the history of miscarriage is preceded by spontaneous rupture of membranes or painless cervical dilatation.• Cervical incompetence is often over-diagnosed as a cause of mid-trimester miscarriage. • The MAC/RCOG trial of the use of cervical cerclage reported a small decrease in preterm birth. but no significant improvement in fetal survival. (Grade B recommendation) .

• The reported improvement in pregnancy outcome is difficult to assess in the absence of a control group.• Transabdominal cerclage performed preconceptually has been advocated as a treatment for second trimester miscarriage and the prevention of early preterm labour. .