Cervical Incompetence: Dr. Mohammed Abdalla Domiat General Hospital

Cervical
incompetence
Dr. Mohammed Abdalla
Domiat general hospital
Condition in which the cervix
fails to retain the conceptus
during pregnancy.
Cervix length less than ??
Premature ripening of the cervix.
Definition
Etiology
 Idiopathic (most)
 Congenital disorders (congenital mullerian
duct abnormalities.
 DES exposure in utero.
 Connective tissue disorder (Ehlers-Danlos
syndrome.
 Surgical trauma (conization, (repeated cervical
dilatation associated with termination of
pregnancies).
Basic parameters
Although cervical length can
be measured
transabdominally and
transperineally,
transvaginal assessment is
most accurate
Basic parameters
• Standard cervical measurements use the
"white stripe" of the internal cervical os as an
anatomic landmark for proper caliper
placement
• Anderson found an average length of
45 ± 7 mm at 14 to 30 weeks,
• Iams et al found a mean cervical length of
35 ± 8 mm at 24 weeks'
Defining the short cervix
The discriminatory
length of cervical
shortening varies widely
between 26mm (Iams et al )
to 15mm (Hassan et al )
so, the progressive shortening
and other cervical qualities
such as funneling (and
measurement of the residual
cervix if funneling is present),
v-shaped lower uterine segment ,
and dynamic changes with
fundal or suprapubic pressure.
Are the most important.
role of routine ultrasound
screening of the cervix
in low-risk women
lacks enough discriminatory power
to recommend routine use.
ACOG Practice Bulletin No. 48November 2003

role of ultrasonography in evaluating
women who have had a previous
pregnancy loss
is limited to
populations
at greatest risk
role of ultrasonography in evaluating
women who have had a previous
pregnancy loss
serial TVS should not begin

before 16 to 20 weeks
as the upper portion of the cervix
is not easily distinguished

In whom is a cerclage
indicated?
Elective Cerclage
confined to patients with

three or more otherwise unexplained
second-trimester pregnancy losses
or preterm deliveries.
Elective Cerclage
performed at 13 to 16 weeks
of gestation
after ultrasound evaluation
of fetal viability
Urgent, or therapeutic,
cerclage
for women who have

serial ultrasonographic changes
consistent with a short cervix
or evidence of funneling.
1 2
3
4
Urgent, or therapeutic
cerclage
In patients with a history of fewer than
three second-trimester pregnancy
losses, urgent cerclage is not
supported by evidence-based
studies, and further transvaginal
ultrasound surveillance may be the
more judicious approach.
short cervix before 20
weeks of gestation
the examination should be
repeated because of the inability
to adequately distinguish the cervix
from the lower uterine segment in
early pregnancy

short cervix at or after 20
weeks of gestation
should prompt assessment of the fetus for
anomalies, uterine activity to rule out
preterm labor, and maternal factors to
rule out chorioamnionitis….. Regular
evaluations may be performed

Cervical change noted before
fetal viability is a better
indication for cerclage than if it
is identified after fetal viability
has been achieved.
Emergency cerclage may be
considered in women if clinical
chorioamnionitis or signs of
labor are not present.
short cervix In the third
trimester
If the patient is in labor, tocolytic
therapy may delay delivery long
enough to promote fetal lung
maturation with maternal
glucocorticoid therapy.
trimester
The presence of chorioamnionitis
is grounds for immediate

delivery and the use of
broad-spectrum
antibiotics
trimester
If labor or chorioamnionitis is not present,
modification of activity, pelvic rest,
tobacco cessation, and expectant
management may be considered.
Cerclage in the treatment of women
with cervical insufficiency after
determining fetal viability has not been
adequately assessed.
Role of perioperative antibiotics and
tocolytics association with cerclage
placement
• The use of unnecessary antibiotics may lead to
the development of resistant strains of bacteria
and other morbidity for the patient and her fetus.
• No randomized studies have shown that use of

tocolytic therapy after cerclage is effective. The
lack of clear benefit for these adjunctive
treatments suggests that these drugs should be
used with caution.
RISK ASSESMENT
>=3 unexplained <3 unexplained
No risk
second-trimester losses
factor second-trimester losses
or preterm deliveries. or preterm deliveries.
routine ultrasound
screening of the
Elective Cerclage cervix is not routine ultrasound
at 14-16 wk. recommended screening of the cervix
is done at 16-20 wk.
Urgent cerclage if noted before serial ultrasonographic changes

fetal viability after fetal and consistent with a short cervix
maternal evaluation or evidence of funneling.
Transabdominal
cerclage
an alternative
approach to the
incompetent cervix
•If cervix is absent or severely shortened,
•if congenital or traumatic defects
•if the transvaginal approach is not feasible
or has failed.
Indications of transabdominal
cerclage
Timing of placement
It is most often
placed at Preconception
OR
transabdominal
10 to 14 weeks cerclage
gestation placement
Preconception transabdominal
cerclage placement
has many practical benefits:
• easier .
• smaller incision.
• Safer to fetus.
• Can be done laparoscopically.
• The overall live birth rate for prophylactic
transabdominal cerclage approaches 90%,
in whom transvaginal cerclage has been
unsuccessful.
• When cerclage is performed on an
emergent basis-rather than
prophylactically-the success rate drops to
less than 60% due to the increased risk of
rupturing the membranes during the
procedure or trapping the membranes
below the level of the cerclage.
Techniques
• 1-select an incision that affords optimal
visualization of the operative field with
minimal manipulation of the uterus.
• 2-Preconception placement can be
performed through a small Pfannenstiel
incision or using a laparoscopic
approach.
Techniques
• 3-open the peritoneal cavity and pack the
bowel away from the operative field.
• 4- Create a bladder flap at the level of the
internal os
• 5-extend the incision laterally to the broad
ligament to maximize exposure of the uterine
vessels.
Techniques
• 6- assistant gently lift the uterus from
the pelvis by cradling the fundus
anteriorly and posteriorly between the
hands,
• 7- Identify the avascular space that is
medial to the uterine artery and adjacent
to the uterus by gentle lateral traction of
the vessels with the fingers
Techniques
• 8- using blunt needles to which
the band is attached, Pass a
5-mm polyester band around
the circumference of the
uterus at the level of the
internal os.
Techniques
• 9- Ensure that the band is flattened
circumferentially around the cervix before tying it
snugly against the anterior aspect of the uterus at
the level of the internal os with 6 single square
knots
• 10- Secure the tails of the knots to the polyester
band or adjacent tissues using a small-gauge silk
suture to minimize irritation of the bladder.
• 11- Close the bladder flap inward to minimize
adhesions to the suture.
cerclage
placement
Adverse effects
*Suture displacement,
*rupture of membranes,
*and chorioamnionitis
are the most common complications
associated with vaginal cerclage
placement,
*Transabdominal cerclage can be
complicated by:
• rupture of membranes .
• chorioamnionitis.
• intraoperative hemorrhage.
• known risks associated with laparotomy.
Life-threatening complications of
uterine rupture and maternal
septicemia are extremely rare
but have been reported with all
types of cerclage.
Thank you

Cervical Incompetence: Dr. Mohammed Abdalla Domiat General Hospital

Uploaded by

Copyright:

Available Formats

Cervical Incompetence: Dr. Mohammed Abdalla Domiat General Hospital

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Cervical Incompetence: Dr. Mohammed Abdalla Domiat General Hospital

Uploaded by

Copyright:

Available Formats

What are the different types of cerclage procedures?

What are some of the complications associated with cerclage procedures?

Cervical

ACOG Practice Bulletin No. 48November 2003

serial TVS should not begin

ACOG Practice Bulletin No. 48November 2003

confined to patients with

for women who have

ACOG Practice Bulletin No. 48November 2003

ACOG Practice Bulletin No. 48November 2003

is grounds for immediate

• No randomized studies have shown that use of

Urgent cerclage if noted before serial ultrasonographic changes

You might also like