cervical incompetence

Dr.Mohammed Abdalla Domiat general hospital

Cervical incompetence is defined as the inability to

support pregnancy till term
because of a functional or structural defect of the cervix

Mostly the incompetence is idiopathic 90%….but it may be secondary to anatomical, traumatic, or congenital connective tissue disorder.

Although the efficacy of cerclage for cervical incompetence

has never been fully confirmed
in randomized clinical trials ,the role of cerclage has been expanded to include women with “risk factors” for spontaneous preterm birth or nonreassuring sonographic cervical findings in the mid trimester.

So, before you send your patient to the theater for cerclage your diagnosis necessities solid criteria otherwise many will be unduly done.

But unfortunately there is no consensus about the cervical cut off length

< 25mm Or < 15mm

the cervical cut off length in singleton pregnancy Cannot be applied in multiple pregnancy?

As the risk with CL <25 mm in multiple pregnancies is 6-8

times

the risk with the same length in singleton pregnancies .

35%

4%

problem
Inconsensus about cutoff cervical length will result in the categorization of 5% to 10% of pregnant women as having a short cervix.

As any controversial issue we have here white and black faces but always within the grey zone, which lies in between, we fall in doubt.

White face here is the women with irrelevant obstetric and gynecological history, as they need no screening.

1

The black face of the problem is represented by those who have three or more midtrimester losses or preterm births , the decision is a prophylactic cerclage performed at 13 to 16 weeks of gestation .

2

The grey zone is represented here by those women of low or moderate risk, and they need serial ultrasound screening by transvaginal ultrasonography.

3

Ultrasound screening
if we are going to screen this group of patients with mild to moderate risk :

when to start? what is the ultrasonic criteria of incompetent cervix? and when to intervent?

when to start
TVS should not begin before 16 weeks
as the upper portion of the cervix is not easily distinguished

ultrasonic criteria of incompetent cervix
Make sure to use proper technique. Knowing what to measure . Know what's normal, and what's abnormal . Linking cervical assessment to gestational age .

proper technique
patients are asked to empty their bladder . You should identify at the same sagittal view the internal os, external os, cervical canal, and endocervical mucosa. the probe is slowly withdrawn to avoid false elongation of the cervix. The cervical length is measured by freezing the screen three separate times with no more than 2 to 3 mm variations.

proper technique
To recognize funneling the walls of the funnel are formed by endocervical mucosa. If the cervical canal is sometimes curved, therefore, cervical length should be determined by tracing the length of the cervix or by adding the sum of two straight sections. Apply transfundal pressure for 15 seconds, and record any changes in cervical length or funneling. “cervical stress test” .

cm 2

1. 5

1.2

“cervical stress test”

the walls of the funnel are formed by endocervical mucosa.

what's normal
In low-risk women, CL during pregnancy has a mean of 35 to 40 mm from 14 to 30 weeks. the lower 10th percentile being 25 mm and the upper 10th (90th percentile) 50 mm.

CERVICAL LENGTH (MEAN OR MEDIAN) IN LOW-RISK POPULATIONS IN MIDTRIMESTER

Reference Ayers et al Podobnik et al Andersen et al Kushnir et al Andersen et al Murakawa et al Zorzoli et al Iams et al Iams et al Cook et al Tongsong et al Heath et al

Year 1988 1988 1990 1990 1991 1993 1994 1995 1996 1996 1997 1998

N 150 80 125 24 77 177 154 106 2915 41 175 1252

Cervical Length (mm)

52
48 41 48 42 37 42 37

35
41 42 38

?what's abnormal
The discriminatory length of cervical shortening varies widely between 25mm to 15mm

value of cervical sonography in the screening of preterm birth
Reference (wks) Cutoff % Sensitivity % Specificity % PPV % NPV

Iams et al Taipale et al Heath et al Hassan et al

24

<20

23 6 58 8

97

26

97

18–22

≤25

100

39
52 47

99

23

≤15

99

99

14–24

≤15

99

97

Low %PPV means that many undue cerclages were done.

high %NPV means that the test is reassuring when negative.

So we cannot rely on cervical length alone as a predictor of incompetence

What are the most important?
funneling (width and length), v-shaped lower uterine segment and dynamic cervical changes with fundal or suprapubic pressure.

the progressive shortening detected by serial sonar,

1

2

3

4

bulging of the membranes in the vagina. The fetal lower limb protruded into the vagina.

But how to avoid undue cerclage and how not to miss a case?

RISK ASSESMENT
>=3 unexplained second-trimester losses or preterm deliveries.

No risk factor

<3 unexplained second-trimester losses or preterm deliveries.

Elective Cerclage at 14-16 wk.

routine ultrasound screening of the cervix is not recommended

routine ultrasound screening of the cervix is done at 16-20 wk.

Urgent cerclage if noted before fetal viability after fetal and maternal evaluation

serial ultrasonographic changes consistent with a short cervix or evidence of funneling.

Can a cervical cerclage be used to prevent preterm delivery in patients with a short cervix or funneling?

RANDOMIZED STUDIES OF ELECTIVE CERVICAL CERCLAGE
Delivery <37 Weeks
Referenc e
Year

N 194

Indication High risk of cervical incompetence Moderate risk of cervical incompetence

Weeks at Cerclage

% Cerclage

% Controls

Rush et al.

1984

18

32 5.5

34 6.7

Lazar et

1984

506

<28

MRC/RC OG

1993

1292

Obstetrician uncertainty

16

31

26

RANDOMIZED STUDIES OF ELECTIVE CERVICAL CERCLAGE

results of randomized clinical trials suggest that cerclage either had a modest effect on reducing the rate of preterm delivery or no effect whatsoever.

Key points
The high negative predictive value for preterm birth associated with a long cervix and with the absence of funneling has important clinical implications in symptomatic patients.

Key points
Using TVU to assess CL is an effective way to predict PTB and "incompetent cervix," now better named cervical insufficiency. It's safe and patients accept the examination well.

Key points
Screening frequency should depend on severity of obstetric history, with serial TVU of the cervix having a better predictive accuracy than one, especially in high-risk populations.

Key points
the shorter the cervix, the higher the risk of PTB, and the earlier in gestational age at which the shortening occurs, the higher the risk.

Key points
screening high-risk women with TVU of the cervix and placement of a cerclage for the short or funneled cervix should not be considered standard care until proven by properly conducted, large randomized trials

Thank you