SURGERIES FOR CERVICAL INCOMPETENCE.pptx

Cervical incompetence

1. SURGERIES FOR CERVICAL INCOMPETENCE Presented by :- Dr. Sharanpreet kaur Moderator :- Dr Rooprishma kaur

2. CERVICAL INSUFFICIENCY Defined as painless cervical effacement and dilation resulting in second trimester miscarriage or extreme preterm delivery. Normally, the cervix maintains the fetus within the uterine cavity , providing mechanical strength and support and acting as a barrier from ascending infection . A weak cervix will lead to effacement, funneling and dilatation . As the pregnancy progresses in the mid trimester period and the fetus becomes heavier , the pressure and mechanical stress may result in cervical shortening. This also increases the likelihood of ascending infection and activation of the inflammatory process, resulting in a spontaneous preterm birth.

3. ETIOLOGY Congenital Isolated developmental weakness of cervix Associated with uterine anomalies like septate uterus Following in utero exposure to diethylstilbestrol (DES). Connective tissue disorders – Ehlers Danlos and Marfan syndrome are characterized by disorganization of cervical collagen Acquired Due to Previous Cervical Trauma ( i ) Forcible dilatation during termination of pregnancy or dilatation and evacuation in the past (ii) Conization of cervix in the past. (iii) Cauterization of cervix in the past (iv) Amputation of cervix or Fothergill's operation in the past (v) Vaginal delivery through undilated cervix or cervical tear .

4. DIAGNOSIS HISTORY :- Typical history of rupture of membranes followed by quick delivery of a live fetus is very suggestive. Patient may give history of full term delivery followed by preterm delivery and second trimester abortion (gradually descending worsening history). Preterm births are associated with 32% chance of recurrent preterm births. Various studies reported strong correlation between cervical length in the index pregnancy and previous obstetric history.

5. NON PREGNANT STATE:- Internal os may allow the passage of a no.8 Hegar cervical dilator without resistance . Hysterosalpingography can show the typical funneling of internal os in non pregnant state. Uterine abnormalities like bicornuate or septate uterus can be demonstrated.

6. PREGNANCY :- Transvaginal ultrasound is ideal method to followup and detect early incompetence. Normal cervical length at 14 weeks is 30-40mm and internal os diameter < 8mm. CERVICAL INCOMPETENCE – Cervical length < 25mm internal os diameter >8 mm On USG , funneling of the os and the lower uterine segment is V or U shaped instead of normal T or Y shaped CERVICAL INDEX Cervical index = Funnel length +1/ endocervical length It is normally 0.32 . Cervical incompetence = Cervical index >= 0.52

7. When should a history-indicated cerclage be offered? Women with singleton pregnancies and three or more previous preterm births should be offered a history-indicated cervical cerclage. Specific characteristics of the previous adverse event are helpful in the decision to place a history indicated cerclage. (e.g. painless dilatation, rupture of membranes, prior cervical surgery).

8. Who should be offered serial sonographic surveillance with a view to ultrasound-indicated cerclage? Women with a history of spontaneous second trimester loss or preterm birth who have not undergone a history indicated cerclage may be offered serial sonographic surveillance, as those who experience cervical shortening (less than 25mm) may benefit from ultrasound indicated cerclage. An ultrasound-indicated cerclage is not recommended for funnelling of the cervix (dilatation of the internal os on ultrasound) in the absence of cervical shortening to 25 mm or less (the closed length of the cervix). For women with a singleton pregnancy and no other risk factors for preterm birth, insertion of cervical cerclage is not recommended in women who have a short cervix incidentally identified on a late second trimester ultrasound scan

9. ULTRASOUNDS FINDINGS OF CERVIX

10. Regional analgesia is suitable and preferred. After this, the woman is placed in standard lithotomy position. The vagina and perineum are cleaned for surgery, and the bladder is drained. Some operators do not use potentially irritating antiseptic solution if amnionic membranes are exposed and instead use warm saline . For suturing, options include a no. 1 or 2 nylon or polypropylene monofilament suture or 5-mm Mersilene tape During placement, the suture is placed as cephalad along the cervical length as possible, is anchored into the dense cervical stroma, yet avoids the bladder.

11. Emergency cerclage placement with a thinned dilated cervix is more difficult, and tissue tearing and membrane puncture are risks. Gentle replacement of the prolapsed amnionic sac back into the uterus can aid suturing. Options include steep Trendelenburg or filling the bladder with 600 mL of saline through a Foley catheter in the bladder. However, these steps may carry the cervix cephalad and away from the operating field. Instead, membranes can be pushed inward by a wide, moist sponge stick. A Foley catheter can instead be inserted through the cervix, and inflation of the 30-mL balloon can deflect the amnionic sac inward. The balloon is gradually deflated as the cerclage suture is tightened around the catheter tubing, which is then removed. With any of these, simultaneous gentle outward traction created by ring forceps placed on the cervical edges may be helpful. EMERGENCY CERCLAGE

12. TRANSABDOMINAL CERCLAGE Sutures at the uterine isthmus is placed abdominally. Performed less often than transvaginal methods, selected indications include prior transvaginal cerclage failure or severe cervical anatomical defects. The cerclage is left until childbearing completion, and thus cesarean delivery is required. With the procedure, after abdomen entry, sharp dissection in the vesicocervical space allows the bladder to be pushed caudally. At the level of the internal os , a window is made in free space medial to the uterine vessels. This avoids vessel compression by the tightened cerclage. The nearby ureter is identified and avoided. One end of the ligating suture is passed into the right window, and the other is threaded into the left. Per surgeon preference, the knot is tied either in the front or back. The vesicouterine peritoneum is closed with absorbable suture in a running fashion.

13. Almost half of the transabdominal ones were placed prior to conception. The preterm birth rate before 32 weeks was 8 percent in the transabdominal group and 38 percent in each of the transvaginal cerclage groups (Shennan, 2020). Of morbidity, rates of bleeding, adjacent organ injury, uterine perforation, and infection can be greater with transabdominal compared with transvaginal methods.

14. CANDIDATES FOR A TRANSABDOMINAL APPROACH Unable to undergo a transvaginal procedure – This occurs when an extremely short or absent cervix, amputated cervix, marked cervical scarring, or cervical defect makes it technically impossible to apply the cerclage at the appropriate location transvaginally . Failure to deliver a healthy newborn after at least one previous prophylactic transvaginal cerclage -( i.e , history-indicated or ultrasound-indicated but not a physical examination-indicated cerclage [also called rescue or emergency cerclage]).

15. LAPROSCOPIC CERCLAGE Advances in the field of minimally invasive surgery resulted in development of a new approach to cervical cerclage placement. Laparoscopic cerclage offers the benefit of reduced blood loss, reduced postoperative pain, and fewer adhesions, as well as decreased length of hospital stay and overall faster recovery time The laparoscopic approach is equally effective Both laparoscopic and transabdominal approaches resulted in significantly improved fetal salvage rate (75% vs 71%, respectively), but results were not statistically different between the groups in terms of fetal survival, median gestation at delivery, median birth weight, and gestational age at loss.

16. CONTRAINDICATIONS OF CERVICAL CERCLAGE Clinical features of chorioamnionitis Preterm premature rupture of membranes Past or current active vaginal bleeding Uterine contractions Cervix already dilated to more than 4cm Congenital fetal malformations Fetal compromise Fetal death Active preterm labour

17. COMPLICATIONS Slipping or cutting of the stitch through the cervix Chorioamnionitis and infection Rupture of membranes Abortion Premature labour LATER COMPLICATIONS Cervical dystocia Rupture uterus Cervical necrosis

18. POST OPERATIVE CARE Sedation Tocolysis ( Isoxsuprine or ritodrine 10mg 8 hourly for 5-7 days) starting a day before operation can be given though not mandatory. Progesterone supplementation in the form of 17-alphahydroxyprogesterone 250-500mg IM before operation and then weekly till term or 1 inj. Before operation followed by oral natural micronized progesterone 200mg daily or dydrogesterone 10mg twice daily or till term to prevent pre term labor can be given but not proven to be effective Bed rest for about 48 hours and then slowly ambulated. Antibiotic cover is recommended.

19. ADVICE ON DISCHARGE Usual antenatal advice To advise coitus To avoid rough journey To report if there is vaginal bleeding or abdominal pain Periodic USG monitoring of the fetus and cervix REMOVAL OF STITCH The stitch should be removed at 37 completed weeks or earlier if labor pains start or features of abortion appear. With floating head it is preferable to cut the stitch in OT as there is increased chance of cord prolapse. Usually patient goes into labor quickly and delivers vaginally.

20. NON SURGICAL TREATMENT OF CERVICAL INSUFFICIENCY If the patient is not willing for cerclage progesterone injection 17-alpha-hydroxyprogesterone caproate, 500mg IM weekly or oral 200mg twice daily or vaginal natural micronized progesterone 100mg twice daily are given till 37 weeks of pregnancy along with bed rest and abstinence. ROLE OF VAGINAL PESSARY Smith Hodge pessary is effective, inexpensive and easy to implement method. MECHANISM- it alters the cervical canal axis and displaces the weight of uterine content away from cervix posteriorly. It should be inserted at 12-14 weeks and removed at 37 weeks and removed weekly for cleaning and size adjustments.

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