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MANAGEMENT OF CERVICAL INCOMPETENCE

INTRODUCTION

HISTORY: - mostly retrospective

- mid-trimester abortions

- pre-term labour

- uterine malformations

- in-utero use diethystilbesterol

- vaginal deliveries – repeated vaginal deliveries, high parity,

precipitate labour, operative vaginal deliveries with injuries to

the cervis, prolonged vaginal deliveries due to mechanical

difficulties as in delivery of macrosomic babies.

- Excessive or forceful dilatation of the cervix.

- Amputation of the cervix

- Cone biopsy

PHYSICAL EXAMINATION/INVESTIGATIONS

IN NON-PREGNANT STATE

- Ease of passage of size 8 Hager dilator

- Foley traction test

- HSG – dilated internal os and widened isthmus.

Usefulness of these tests are doubtful.

Evidence of torn cervix are more useful in the diagnosis.


IN PREGNANCY

High index of suspicion.

In cases in which the patient had a previous mid-trimester abortion or early

third trimester but without the classic history – serial digital cervical

examination.

Accidental discovery of effacing cervix during routine vaginal examination.

Ultrasound scan – more accurate than serial digital examinations.

- length of the cervix.

- Width of the cervix.

- Dilatation of the internal os and endocervical canal.

- And response of these parameters to stress such as a trans-

fundal pressure, coughing or standing are all useful in

confirming the diagnosis.

- Guzman et al – progressive shortening of the endocervical

canal length to less than two cm. Or single length of less then

two cm. Between 15 and 24 wks. Gestation competent

cervix had a non-significant rate of endocervical shortening of

0.0 cm per week while incompetent cervix had a rate of 0. cm

per week.

- Wong et al – greater than decrease in cervical length in the

upright position compared to the supine position was

associated with a significantly risk of preterm delivery when


compared with those with less than decrease in cervical

length(87. versus ,p,0.00 .). Also found That when a cervical

length of less than cm was combined with postural change,

the the sensitivity for prediction of preterm delivery was 00 .

- Mahram suggested that an internal Os diameter of 15mm or

more in the first trimester or 20mm or more in the second

trimester was diagnostic of incompetent cervix.

- Varma et al considered an endocervical canal width of greater

than 7mm with herniation of amniotic membrane an ominous

sign.

THE SERIAL USS WILL SAVE A NUMBER OF WOMEN FROM

UNNECESSARY INTERVENTIONS

Other tests to exclude other causes of recurrent pregnancy losses:

Diabetes mellitus

Thyroid dysfunction

Lupus anticoagulant

Chromosomal anomalies

Cervical infections with organisms such as mycoplasma and ureaplasma


TRE ATME NT
In women with classic history:
Usefulness of surgical procedures are questioned
CE RCL AGE TE CH NI QUES
Timing of the procedure:
(i) preconception – Lash and Lash - 1950
(ii) during pregnancy
- Cervical cerclages- transvaginal or
transabdominal
- The transvaginal techniques: – the Shirodkar’s,
McDonald’s procedures and the Wurn’s
procedure.
- McDonald procedure is the preferred method.
- As an elective procedure in early second trimester
(14 – 16 weeks).
- Before the cerclage, ultrasound scan should be
performed to rule out fetal structural anomalies.
Pregnancies which may have terminated
spontaneously in the first trimester presumably
because of fetal chromosomal anomalies are not
maintained by cervical cerclages.
Also after the first trimester anaesthetic agents
are better tolerated by the foetus.
CON TR AI NDI CATIO NS
- Uterine bleeding
- Ruptured membranes
- Uterine contractions
- Major Fetal anomalies
- Vaginal or cervical infections – this should
be treated before the cerclage.
Sutures used:
Anaesthesia:
MCD ONALD P ROC ED URE
- Patient is placed in a lithotomy position and after
cleaning and draping the bladder is emptied.
- A speculum (sims or Auvald) is applied to retract
the posterior vaginal wall and enable the cervix to
be visualized.
- 2 sponge – holding forceps, each applied to the
anterior and posterior cervical lips and the cervix
drawn down.
- The junction of the rugose anterior vaginal
mucosa with the smooth cervical mucosa is
identified, which corresponds approximately to the
level of the internal os.
- Placement of the cerclage suture is stated just
below the above mentioned junction (in order to
avoid the bladder) and four or six bites are taken
circumferentially to complete a purse – string.
- The first bite is taken starting from just before 12
O’clock and with the last bite the needle comes
out just after 12 O’clock. The suture is placed
deep into the cervical tissue, but not through the
endocervical canal.
- The needle is then removed and the suture pulled
and knotted tight enough anteriorly to almost
close the internal os; about four throws are used
for the knot and the suture ends left long (2-3cm)
to facilitate identification and manipulation when it
comes to removal.

SH IRODKAR P ROCED URE


- The initial steps in this procedure up to the
identification of the junction of the rugose anterior
vaginal mucosa with smooth cervical mucosa are
the same.
- A transverse incision about 2cm long is made just
below the junction and the bladder dissected
away by blunt dissection using the gloved finger
until the uterovesical peritoneal fold is reached.
- The cervix is then pulled forward toward the
symphysis pubis, the junction of the rugose
posterior vaginal mucosa with the smooth cervical
mucosa is identified and another transverse
incision about 2cm long made just below the
identified junction.
- In the original procedure, an aneurysm needle
was used to pass the suture submucosally round
the cervix, from the posterior incision, into the
anterior.
- In current practice a large atraumatic needle
may be used to achieve the same results.
- The knot is tied anterioly anchored to the cervix
with a couple of 3-0 silk sutures and the vaginal
mucosa repaired with the knot buried. The suture
is anchored to the cervix posteriorly with a single
3 – 0 silk suture and the posterior vaginal mucosa
repaired.

POST CE RCLA GE M ANAGE MENT


- Perioperative antibiotic therapy is advisable.
- Use of tocolytics in the perioperative period is
controversial.
- Bed-rest may be advised for the first 24 hours.
- Patient may be discharged home after a couple of
days.
- However, in some cases the obstetric history is
such that both the doctor and the patient feel
more comfortable if the patient remained in
hospital – especially when there have been
previous cerclage failures.
- On discharge, they are advised to avoid coitus or
the insertion of any object in the vagina.
- They may gradually resume normal activity but
must avoid strenuous physical activity.
- They are advised to report any increased vaginal
discharge, vaginal or backpressure or pelvic
cramps.
- Routine antenatal clinic attendance schedule -
may be examined every fortnightly or so to
determine the intergrity of the cerclage.
- Removel - 37 – 38 weeks gestation. However it is
removed earlier if there is:
Excessive vaginal bleeding, intra-uterine fetal death,
persistent uterine contractions, rupture of the
membranes.
With McDonald’s suture removal can be performed
without anesthesia, but with Shirodkar’s because of
the need to incise the vaginal mucosa and dissect in
order to access the suture, general anesthesia may
be required.

EMER GE NC Y CER CLA GE


Indications:- cervical effacement and dilatation without
uterine activity detected in index pregnancy.
- while managing conservatively with serial digital
examination or ultrasound scan cervical
incompetence is diagnosed.
The fetal salvage rates of emergency cerclage are
considerably less than those of the elective
procedure.
The incidence of complications, often due to infection
is high.
Many patients require prolonged hospitalization or
bed rest and few reach full term.
In spite of these, it is recommended as it may be the
only way of prolonging pregnancy in the situations in
which they are required.

PRE -O PER ATI VE PREP AR ATIO N


After the diagnosis, pt is placed on bed rest in the
trendelenburg position and uterine activity closely
monitored.
An ultrasound is performed to evaluate the foetus and
tocolytics administered if necessary.
No contraindication to insertion of cerclage suture.
Cervical cultures should be obtained to rule out
infection with specific organisms such as beta
haemolytic streptococci.
Prophylactic antibiotic is given and 24 hours delay is
also observed, so that cerclage is not inserted in a
woman who is on the process of aborting
spontaneously.
BUL GI NG ME MB RAN ES AND
CE RCL AGE
Is a problem in emergency cerclages.
(A) - A foley catheter with 20ml balloon in which the
distal and has seen cut off flush with bulb may be
used. The inflated bulb holds the membranes away
from the internal os while the cerclage suture is
placed after which the bulb is deflated and the
catheter removed.
(B) - Use of 6-10 stay sutures placed at the edges of
the cervix (with the patient in deep trendelenburg
position) traction on which causes the membranes to
move back into the uterine cavity.
(C) - Bladder distension with up to 1000ml of normal
saline may lead to a retraction of the membranes into
the uterine cavity and allow cervical cerclage.
(D) - An infatable bag has also been used to reduce
bulging fetal membranes
(F) - Trans-abdominal amniocentasis to temporarily
reduce amniotic fluid volume and tension and assist in
spontaneous reduction of fetal membrane prolapse.

TR ANS -A BDO MIN AL CE RVI CA L CER CL AGE


(TACC)
Beneficial in patients with cervices that either are
extremely short, congenitally deformed, deeply
lacerated (impossible to pass a vaginal suture) or
previously failed trans-vaginal cerclage procedures.
Pre-conceptional procedures: between 10 and 14
weeks, after ultrasound has confirmed fetal viability.
A midline sub-umbilical or a pfannenstiel incision.
The uterovesical peritoneal fold is incised transversely
at its reflection onto the uterus and the bladder flap
carefully dissected downwards by blunt dissection,
taking care to avoid injury to the venous plexuses
present laterally.
The uterus is brought up into the abdominal incision.
The uterine artery on one side of the cervix is
visualized splitting into ascending and descending
branches; the relative avascular space medial to the
branches of the uterine artery but lateral to the cervix
is identified and enlarged.
A 5mm mersilene tape swedged onto a needle is
placed through the avascular space from anterior to
posterior.
The same process is repeated on the order side, this
time passing the suture from posterior to anterior.
The band is tied snugly anteriorly in the region of the
internal os with a single knot and the free ends of the
knot secured to the tape by no 3-0 silk sutures placed
about 1-2cm from the knot.
The bladder flap and the abdomen are closed
routinely.
Caesarean section is required for delivery, the cervical
cerclage is left in place for future pregnancies.
Where a preterm fetus needs delivery, laparotomy
may be required to divide the band.
Laparoscopy
COM PLI CA TIO NS
- Haemorrhages.
- Cervical trauma, uterine contractions and rupture
of fetal membranes which is more likely to occur
during emergency cerclage.
- Post-operative complications include:
infections(chorioamnionites) and suture
displacement.
- Other late complications are – fistula formation
and cervical stenosis
- Scaring may cause cervical dystocia in labour, or
result in deep cervical lacerations, which may
extend to the broad ligament.
- Puerperal pyrexia is more in patients with
cerclages.
- Potential fetal sequelae include prematurity,
sepsis and intra-uterine death.