Cervical incompetence

cervical incompetence

1. CERVICAL INCOMPETENCE (CERVICAL INSUFFICIENCY) ADIL MUHAMMED 13M004

2. The inability of uterine cervix to retain a pregnancy in the absence contractions, labor or both in the second trimester. Cervical incompetence is characterised by painless cervical dilation in the second or early third trimester with ballooning of the amniotic sac into the vagina followed by rupture of membranes and expulsion of usually the live fetus. Usual timing : 16-24 weeks

3. AETIOLOGY CONGENITAL - Developmental weakness of cervix - Associated with uterine anomalies like septate uterus. - Following in utero exposure to diethyl stilbestrol.

4. Acquired due to previous cervical trauma - Forcible dilation during MTP and dilation and curretage (D & C) - Conization of cervix causes a risk of subsequent pregnancy ending up in preterm birth. - Cauterization of cervix - Amputation of cervix or Fothergill’s operation.

5. OTHERS -one or more second-trimester miscarriages with no known cause. -cervical insufficiency in a prior pregnancy -one or more spontaneous preterm deliveries -uterine abnormality (such as a  bicornuate uterus ). - Previous surgery on the cervix.

6. DIAGNOSIS Diagnosis of cervical incompetence  : A history of painless cervical dilation and second trimester deliveries A history of short labors and progressively earlier deliveries in previous pregnancies Advanced cervical dilation and effacement before week 24 of pregnancy without painful contractions, vaginal bleeding, water breaking (ruptured membranes) or infection.

7. INVESTIAGTIONS PREMENSTRUAL HYSTEROCERVICOGRAPHY : It mainly show the typical funneling of the internal os . NON PREGNANT STATE : The internal os allows the passage of a No.8 Hegar’s cervical dilator or Folley’s catheter filled with 1ml water without resistance.

8. IN PREGNANCY : - Transvaginal ultrasound is the ideal method to follow up and detect early incompetence. - The normal cervix length at 14 weeks is 35-40 mm and the internal os diameter is less than 20 mm. A cervical length less than 30 mm and a internal os diameter more than 20mm is suggestive of cervical incompetence. - Funneling of the os on USG also indicates cervical incompetence.

9. Ultrasound showing funnelling of the internal os in cervical insufficiency

10. LAB TESTS If the fetal membranes are visible and an ultrasound shows signs of inflammation but you don't have symptoms of an infection,test a sample of amniotic fluid (amniocentesis) to diagnose or rule out an infection of the amniotic sac and fluid (chorioamnionitis) -Blood glucose(fasting and post prandial),VDRL,Thyroid function test, ABO - Serum LH on D2/D3 cycle -Hyterosalpinography in the secretory phase detect –cervical incompetence, uterine malformation.

11. MANAGEMENT The management is surgical by means of a cervical cerclage.The diagnosis is difficult and cervical cerclage is quite often performed unnecessarily. Cervical cerclage is usually delayed up to 12-14 weeks so that miscarriage due to other causes can be eliminated or it should be done atleast 2 weeks earlier than the lowest period of earlier wastage(not earlier than 10 weeks). SONOGRAPHY should be done prior to cerclage to confirm a live fetus and to rule out anomalies. If there is infection,it should be treated.

12. TYPES OF CERCLAGE : History indicated cerclage Ultrasound indicated cerclage Rescue cerclage

13. Types of operation done during pregnancy with a success rate of about 80-90% The opertions are named after : Shirodkar McDonald Wurm procedure Transabdominal cerclage Lash procedure Principal : The procedure reinforces the weak cervix by a non – absorbable tape, placed around the cervix at the level of internal os . Preoperative evaluation should include the following   Fetal ultrasound assessment for viability, gestational age, and any identifiable anomalies Clinical evaluation to exclude active bleeding, preterm labor, and PPROM Consideration of amniocentesis to rule out a subclinical intraamniotic infection, particularly in women with cervical dilatation at the time of presentation

14. SHIRODKAR CERCLAGE It is mainly the vaginal approach to cervix. Involved placement of a non-absorbable suture such as fascia lata,silk or nylon or mersilene tape around the cervix at the internal os . The suture lies completely beneath vaginal and cervical mucosa. The junction between the anterior vaginal wall rugose with the smooth cervical mucosa is identified. Transverse incision 2cm long is made at the junction and the bladder bluntly dissected until the uterovesical peritoneum identified. An atraumatic needle is passed submucossaly in the cerivx posteroanteriorly and knotted. The vaginal mucosa thereafter sutured anteroposteriorly . The operation is techincally more involved and takes longer to perform

15. Material of choice – Mersilene tape with two needles

16. McDonald Procedure In the lithotomy position cervix is visualized using a Sim’s speculum. The anterior and posterior lips held with sponge holding forceps. The junction between the anterior vaginal rugose and smooth cervical mucosa is identified – internal os Placement of the suture is done just below the point. Four bites in the substance of the cervix are taken circumferentially purse string. First bite taken just before 12’0 clock and last just after 12’0 clock The needle removed and the knotted up to four times with the knot left 2-3 cm long.

17. Sim’s speculum

18. Women who may have incompetent cervix and require treatment can be divided into 4 groups: Women who present with H/O painless cervical dilatation and bag of waters is visible through external os Managed by - Rescue cerclage operations.

19. Women with cervical changes visible by USG McDonald stitch / Shirodkar cerclage Women with risk factors for incompetent cervix. Rest.No need for prophylactic cerclage.

20. Women the incompetent cervix and failed vaginal cerclage. Abdominal cerclage

21. Post Operative Care Antibiotics - cefoxitin,amoxicillin,ampicillin Tocolytics - patients with uterine irritability Bed rest for 1 st 24 hrs followed by mobilization and activity

22. CONTRAINDICATIONS Intra uterine infection. Ruptured membranes. H/O vaginal bleeding. Severe uterine irritability.

23. COMPLICATIONS EARLY COMPLICATIONS : Infections ( Chorioamnionitis,Vulvovaginitis ) Bleeding Premature labour Deep cervical laceration. LATE COMPLICATIONS : Fistula formation Cervical stenosis Preterm deleveries