Cervical insufficiency + Cord Presentation:

PATHOPHYSIOLOGY: Cervical Insufficiency is premature dilation of the cervix and describes a weak, structurally defective cervix that
spontaneously and painlessly dilates in the absence of contractions in the second trimester. Incidence is less than 1%, but causes up to 25% of
second trimester losses. Can progress to PROM and preterm birth. The exact cause is unknown Linked to the cervix having less collagen and
more smooth muscle but can also associated with cervix length and preterm birth.

SIGNS & SYMPTOMS: DIAGNOSIS:

Cervical insufficiency is often asymptomatic until premature Usually, cervical insufficiency is not identified until after preterm
delivery occurs, however some can have earlier symptoms: delivery occurs for the first time.
a. Vaginal pressure 1. Transvaginal ultrasonography at ≥ 15 to 16 wk for women with
b. Vaginal bleeding or spotting symptoms or risk factors
c. Nonspecific abdominal or lower back pain 2. Fetal fibronectin (fFN) testing
d. Vaginal discharge Suggestive ultrasonographic findings include:
e. Cervix may be soft, effaced, or dilated. a. Cervical shortening to < 2.5 cm
b. Cervical dilation
c. Protrusion of fetal membranes into the cervical canal

TREATMENT:
Cerclage: Cerclage (reinforcement of the cervical ring with nonabsorbable suture material)
Cerclage appears to prevent preterm delivery in patients with ≥ 2 prior 2nd-trimester fetal
losses. For other patients, the procedure should probably be done only if all of the following are
present:
a. Patients have a history that strongly suggests cervical insufficiency.
b. Cervical shortening is detected by ultrasonography before 22 to 24 wk gestation
c. Patients have a history of preterm deliveries.
Evidence suggests that cerclage may help prevent preterm delivery in women who have a
history of idiopathic preterm delivery and whose cervix is < 2.0 cm long.

However, not recommend cerclage placement for women with a short cervix who do not have a history of preterm delivery, as it has not been
shown to be beneficial in this population. Moreover, cerclage is not recommended for twin pregnancies with a short cervix, as this has been
associated with an increased risk for preterm birth.
Dulay, A. (2017, October). Cervical Insufficiency - Gynecology and Obstetrics. Retrieved March 18, 2019, from https://www.merckmanuals.com/en-
ca/professional/gynecology-and-obstetrics/abnormalities-of-pregnancy/cervical-insufficienc