Max Brinsmead MB BS PhD

May 2015
Classic Cervical Incompetence:
 Is present when painless mid-trimester loss of
apparently normal fetuses occurs recurrently
 AND
 The cervix accepts a 9 mm dilator without
resistance in the non-pregnant interval
 It can be successfully treated by prophylactic
cervical cerclage
○ >95% term deliveries when patient acts as her own control
 But there is probably a continuum of disorder
with...
○ Pre term delivery
○ Findings of a short cervix

 And that’s where it all gets confused

A little bit of history...
 1955 Shirodkar – an operation for recurrent
miscarriage that restores the internal cervical
sphincter
○ Performed at 14w
○ Bladder dissection & Mersilene tape
○ Removed at 37w
 1957 McDonald – a purse-string suture with
nylon or any similar monofilament suture
 An epidemic of “stitches for pregnancy loss”
began
○ Not less than 1:100 patients
 1980 The era of Evidence-based medicine
begins and questions were asked
More recent history...
 Colposcopic evaluation of CIN and its limited
treatment aims to avoid the risks of cervical
incompetence associated with cone biopsy
 Vaginal ultrasound and measures of cervical
length
○ A relationship between short cervix and risk of pre term
delivery emerges
○ Excellent visualisation of the internal os
 Risks of cervical suture emerge
○ Infection with fetal & maternal sequelae
○ Cervical stenosis
○ Further cervical injury
Questions
 How is cervical incompetence diagnosed?
 Does a cervical suture do more good than
harm?
 What is the best form of suture?
○ Shirodkar or McDonald
○ Vaginal or abdominal
 When should it be inserted?
 Is there a place for cervical cerclage with
advanced cervical dilatation?
 Or should it be used prophylactically in
high risk patients
But let ‘s digress & discuss aetiology...
 Congenital
Associated with uterine abnormality
 Example bicornuate uterus
With connective tissue disorder
 Example Ehler’s Danlos
Idiopathic
 Acquired
Inappropriate cervical dilation
 For primary dysmenorrhoea
 For termination of pregnancy
Cervical surgery
 Cone biopsy
 Cervical amputation
Surgical treatment of CIN
 Limited treatments such as diathermy, Laser,
LETZ & cryotherapy were designed to leave
the upper cervix intact
 Increased risk of pre term delivery after these
procedures ascribed to concomitant factors
esp. smoking
 Current data suggests that all treatments for
CIN increase the risk of pre term delivery
 But whether this is due to “Cx incompetence”
is unknown
 And it is one reason why protocols for the
management of HPV/CIN have been revised
Cochrane reviews of cervical cerclage
 Meta analysis in 1989 by Grant of Cx
cerclage for liberal indications concluded
that...
They prevent ONE pre term delivery for every 20
inserted
 The current review by Drakeley et al was
posted in 2003 and updated 2010
○ Reviewed RCT’s of cerclage vs no treatment
○ Compared methods of cerclage
○ Evaluated prophylactic and emergency cerclage
 Particularly with respect to the optimal management of
a short cervix diagnosed by ultrasound
Outcomes included possible adverse effects
2010 Cochrane Review
 6 trials, 2175 women
 No overall reduction in pregnancy loss or
pre term delivery rate
 Adverse effects include:
Mild pyrexia more common
More tocolysis used
More hospitalisations
Serious morbidity is uncommon
 2 trials of prophylactic cerclage for
ultrasound-diagnosed short cervix
No reduction in the rate of delivery before 28 and
34 weeks
MRC/RCOG study of 1993
 Single largest trial, 1292 women
 Multicentre and international
 80% were McDonald purse-string sutures
 74% used Mersilene tape
 13.8% of treated patients delivered before 32w
 18.5% of untreated controls (RR 0.75, CI 0.58
- 0.98)
 But this means >80% patients did not deliver
pre term
 And one trial of strict bed rest had only 15% of
patients delivering <32w
The most recent study:
 Nicolaides et al 2001
 Recruiting 5000 women with cervix <15 mm
diagnosed on ultrasound
 This study has been stopped
 Details awaited

 Other data suggests that measures of Cx

length are a normative continuum
 And it is best used for its negative predictive
value
○ Should be >18 mm before 18 weeks
○ And >25 mm before 28 weeks
Cochrane conclusions:
 Cervical cerclage should NOT be
offered to women at low or medium risk
of mid-trimester pregnancy loss
regardless of the length of the cervix as
determined by ultrasound
 The management of patients with
pregnant patients with a short cervix
requires further study
My recommendations:
 Patients with a classic history of cervical
incompetence should have a
prophylactic cerclage after first trimester
screening for aneuploidy
 A McDonalds purse-string suture with
nylon for most
○ But a few will require an abdominal suture
 Other patients who are on the
continuum of disorders that begins with
classic cervical incompetence require
individualised management
Individualised management may include:
 Screening and treatment for bacterial
vaginosis
 Progesterone prophylaxis
 Proven by RCT to reduce the risk of pre term
delivery by 50%
 Monitoring cervical length and dynamic
evaluation of the internal cervical os
 Emergency cervical cerclage before 24
weeks
 Hospitalisation and bed rest after 26
weeks
Please leave a note on the Welcome Page to this
website