542 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Incompetent Cervix*
VAUGHAN C. MASON, M.D.
Director, Department of Obstetrics and Gynecology,
AND
RALPH A. DE CHABERT, M.D.
Chief Resident, Department of Obstetrics and Gynecology,
Sydenham Hospital, New York, N. Y.
INTRODUCTION
EVERY active obstetrician has been confronted
with the vexing problem of the so-called
"habitual aborter." The usual treatment was bed
rest, sedation and hormones af equivocal value.
A condition known as the "incompetent cervix"
has been recognized as one of the causes of habit-
ual abortion. The physician should be constantly on
the alert for this condition, since it can be treated
with good results.
In 1902, Herman' noted that cervical lacerations
caused repeated abortions. Child in 1922,2 Palmer
and Lecomme in France3 and Shirodkar in India in
19484 and Lash in the United States in 1950'5 re-
ported on cervical incompetence. However, most
of the literature on this condition has been pub-
lished in the past four or five years. It consists
mostly of descriptions of the various methods of
diagnosis, treatment, and management of the pa-
tient with an incompetent cervix. The purpose of
this paper is not to decide which are the best diag-
nostic and therapeutic methods, but to present the
best known ones and several cases of cervical in-
competence which we have encountered in our hos-
pital. Lash`5 reported on incidence of 1:300 and
Fisher6 of 1:540 pregnancies. Baden defines cervi-
cal incompetence as "any condition of the uterine
cervix that permits sufficient painless dilatation to
allow spontaneous rupture of the membrances and
subsequent onset of labor prior to the end of the
36th week of gestation."7 This condition usually
appears in the middle trimester of pregnancy rather
than in the last, as the hydrostatic pressure of the
forewaters is greater at this time. In the third tri-
mester, the presenting part, wedged in the pelvis,
tends to decrease this pressure.
*Read at the 67th Annual Convention of the National Medi-
cal Associat-on, Chicago, Ill., August 13-16, 1962.
NOVEMBER, 1963
ETIOLOGY
The causes of incompetent cervix are numerous
and must be determined in order to select the
proper method of treatment.
Many predisposing factors exist, such as trau-
matic dilatation of the cervix during curettage; cer-
vical lacerations involving the isthmus; precipitous
traumatic deliveries; high amputations of the cer-
vix, which probably remove most of the connective
tissue essential in maintaining the integrity of the
cervix; low cervical and vaginal caesarean sections.
A rare cause of cervical incompetency is the so-
called muscular cervix reported by Roddick,8 who
found that the histological picture in these cases
showed a relative lack of fibrous tissue. Cervical
incompetency may also be associated with certain
developmental abnormalities such as a bicornate
uterus and other uterine congenital malformations.
Hunter, Henry and Judd9 described the physiologi-
cal or dysfunctional incompetency. They were not
able to demonstrate a defect of the internal os by
palpation or by the usual diagnostic methods such
as balloons, dilators and hysterosalpingography.
They were able to demonstrate this type of in-
competency using hysterosalpingography only after
irrigation of the vagina and cervical canal with the
enzyme bromelain.* This procedure is usually car-
ried out at the estimated time of ovulation.
DIAGNOSIS
The diagnosis of the incompetent cervix is based
on a history of three or more consecutive abortions
occurring during the middle trimester of pregnan-
cy, characterized by painless, bloodless dilatation
of the cervix, followed by the onset of labor which
may or may not be preceded by spontaneous rup-
* Bromelain, a proteolytic enzyme, is derived from the pine-
apple plants, and generally used in accelerating tissue re-
pair and reducing tissue inflammation, however the mode
of action is not clearly understood.
VOL. 55, No. 6 Incompetent Cervix
ture of the membranes. The diagnosis may also be
made in the non-pregnant state by the introduction
of a uterine dressing forceps or a No. 8 Hegar
dilator through the internal os, which would not
be possible if the cervix were not incompetent, or
by hysterosalpingography as previously described.
Other valuable diagnostic aids include the palpa-
tion of a defect in the anterior or lateral wall of
the cervix advocated by Lashl0 or the insertion of
a Foley catheter into the uterus and filling it with
1 ml. of water before traction is applied to test the
cervical competency.
However, these diagnostic aids are not perfect
as cervical incompetency can be demonstrated in
patients without a history of repeated abortions
and who have had normal deliveries. Also they are
not always convenient since most patients are seen
in the pregnant state and because of the difficul-
ties and costs involved. Possibly the best method of
diagnosing this condition is the visualization of
cervical dilatation by speculum examinations, once
a week from the 12th to the 36th week of preg-
nancy. By the 12th week most patients with a his-
tory of repeated abortions probably due to causes
other than cervical incompetency would have
aborted.
TREATMENT
The choice of treatment will depend naturally
on the underlying cause, the degree of cervical
dilatation and the duration of pregnancy.
In the late pregnancies, conservative therapy
should be considered since prolonging the preg-
nancy would be beneficial to the fetus. This treat-
ment consists essentially of bed rest (either in the
supine or Trendelenburg position), sedation and
uterine muscle relaxants.
Vitsky"l described the so-called simple treatment
for the incompetent cervix. This consists of insert-
ing a Smith Hodge pessary, which aids in main-
taining cervical competency by changing the in-
clination of the cervical canal and by increasing
the tension exerted on the uterosacral ligaments,
which through their continuity with the anterior
cervical fascia, causes a sling-like effect which re-
sults in compression of the cervical canal.
If conservative therapy fails, then surgical treat-
ment should be employed. The aim of this therapy
is to restore the normal calibre of the isthmus
either by excision of the defect in the non-pregnant
patient, or by closure of the cervix.
543
Once surgical repair is determined necessary, the
patient should receive daily antimicrobial creams
or vaginal suppositories in addition to the uterine
muscle relaxants and sedation. If there is ruptured
membranes, bleeding, or signs of infection, then
surgery is definitely contraindicated. Surgical treat-
ment should be instituted immediately, as the cer-
vical dilatation may progress beyond the point
where trachelorrhaphy may not be feasible. In the
non-pregnant patient either the Lash procedure'0
which consists of a wedge excision of the defect
when one is present, or the Shirodkar procedure,
which consists of encircling the cervix at the level
of the internal os with polyethylene, Mersilene or
silk sutures could be used. In the pregnant patient
the procedure consists essentially of closing the
cervix either at the level of the internal os (Shirod-
kar) ,4 mid-cervical (McDonald) 12, external os
(central os or bridge tracheloplasty). E. W. Page13
of San Francisco recently introduced a procedure
which consists of external wrapping of the cervix
with a band of gauze and talc at the level of the
internal os which causes scarification. According to
him, this technique does not interfere with fer-
tility or normal dilation during labor.
COMPLICATIONS
The complications following surgical repair of
the incompetent cervix are usually not serious and
could be either non-specific such as infection and
hemorrhage or specific, e.g. failure to prevent ha-
bitual abortion, induced infertility and rupture of
the uterus. Dunn et al14 reported a case of a death
following surgical repair. This was caused by E.
coli septicemia with acute necrotizing myocarditis.
The post-operative management of these patients
will depend on the technique used, on the stage
of gestation, and on the general condition of the
patient. We feel that all patients should be placed
on prophylactic antibiotics, uterine muscle relax-
ants, such as Lutrexint which we prefer, and anti-
microbial vaginal creams. Early ambulation is pos-
sible with the internal and mid-cervical os proce-
dures. The procedures, at the level of the external
os as a rule do not permit early ambulation.
In our series of five cases, the diagnosis of cer-
vical incompetency was based on the history of
painless dilatation of the cervix during the second
trimester of pregnancy.
t Lutrexin is a protein-like relaxing factor, isolated from the
ovary and affects uterine contractions and water balance.
544 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
As all of these patients were first seen in the
pregnant state, this was the only possible method
of diagnosis available. However, in two of the
cases, following the abortion, hysterosalpingograms
were performed. The effectiveness of this method
as a diagnostic aid was proven.
CASE REPORTS
Case 1. Twenty-five year old gravida II, para 0 abortus
I, whose last menstrual period was on February 7th,
1961, was admitted on July 27 because of a sensation of
pressure on the vagina. When examined, the cervix was
approximately 4 cm. dilated with the membranes pro-
truding through the vulva. The corpus corresponded to
the period of amenorrhea. The fetal heart sounds were
good. The past history revealed that this patient had had
a spontaneous abortion in 1960 when she was 16 weeks
pregnant, preceded by painless dilation of the cervix and
followed by rupture of the bulging membranes and sub-
sequent expulsion of the fetus. From the time of admis-
sion the patient was placed on strict bed rest, sedation,
uterine muscle relaxants, systemic antibiotics and anti-
microbial vaginal supositories. During this time there
were no uterine contractions or vaginal bleeding. How-
ever, the cervix remained dilated with the membranes
protruded. Two days later (July 29) cervical repair was
performed by encircling the cervix with a Mersilene
suture as high up as possible without advancing the
bladder since the degree of dilatation made this proce-
dure rather difficult. The membranes were replaced and
the cervix completely closed. Post-operatively, the patient
was placed on bed rest for eight days and received
Terramycin, Lutrexin and Furacin vaginal suppositories.
She was then ambulated under observation for one week
in the hospital. Vaginal examinations on several occa-
sions showed the cervix to be closed and the sutures still
in place. The post-operative course in the hospital was
uneventful and the patient was discharged on the 16th
post-operative day.
On August 27, she was readmitted because of vaginal
bleeding which was thought to be of traumatic origin.
A speculum examination revealed the source of bleeding
to be from the suture site. On the 28th of August, ap-
proximately 24 hours after admission, the patient started
having irregular uterine contractions which subsided with
heavy sedation. Several hours later the contractions
started again and became progressively stronger. This was
followed by avulsion of the suture which permitted dila-
tation of the cervix and expulsion of an immature infant
weighing 2 lbs. 31/2 oz. The infant expired approximate-
ly two hours after birth.
As the diagnosis of this case was based entirely on
the history, it was decided to prove cervical incompeten-
cy by hystero-salpingogram. On May 29, 1962, a hystero-
salpingogram was made, which showed the internal cer-
vical os to dilate easily under pressure, compatible with
the diagnosis of cervical incompetency.
Case 2. This 26-year-old gravida II, para 0, abortus I,
whose LMP was January 30, 1961, was admitted because
of vaginal spotting for two days. Past history revealed
NOVEMBER, 1963
that the patient had aborted at approximately 20 weeks
in 1959. On examination, the corpus uteri was palpable
at the level of the umbilicus. Fetal movements were
observed, although no heart tones were audible. There
were no uterine contractions. Speculum examinations re-
vealed a partially effaced cervix, 3 cm. dilated, through
which the membranes were protruding. The patient was
placed on bed rest, sedation, uterine muscle relaxants
and antibiotics. On the 11th of August, a circlage was
performed using Mersilene suture. In this case, because
of the degree of effacement and the amount of bleeding,
an attempt to advance the bladder sufficiently to place
the suture at the level of the internal os was abandoned,
and a mid-cervical rather than internal os circlage was
performed. On August 13 approximately 48 hours after
the procedure, the patient started having irregular uterine
contractions; these subsided with heavy sedation. How-
ever, on the following day the contractions started again
followed by a rupture of the membranes. Several hours
later the temperature became elevated and since it was
evident that it would be impossible to save the preg-
nancy, the suture was removed. Adequate contractions
dilated the cervix, and a premature stillborn infant
weighing 1 lb. 111/2 oz. was expelled. The patient was
discharged on the fifth post-operative day in good condi-
tion. In May, 1962, she returned to register in the pre-
natal clinic at which time examination revealed the uterus
to be approximately 14 weeks size and the cervix closed.
The patient was admitted to the hospital in order that
cervical repair could be done before the dilatation of the
cervix. On May 31, 1962, a Shirodkar procedure was per-
formed in the usual manner. The patient was ambulated
on the third post-operative day. On August 6, her last
clinic visit, examination revealed the uterus to corre-
spond to a 24 week gestation. Fetal heart sounds good
and the cervix closed. Her pregnancy continued to un-
eventful termination.
Case 3. This 33-year-old, Gravida IV, Para 0, Abortus
III, whose LMP was October 10, 1960, was admitted on
February 26, 1961, because of a history very suggestive
of cervical incompetency. The patient had had abortions
in 1957, 1959 and 1961. Each time she had proceeded
to 16 weeks gestation and in each case there was pre-
mature rupture of the membranes, followed by a pain-
less dilation of the cervix with expulsion of the fetus.
Dilatation and curettage was performed in 1957 and
1961.
Examination revealed corpus uteri approximately 16
weeks size; the cervix 80 per cent effaced; approximately
4 cm. dilated and membranes protruding through the
cervix. The patient had been told of her condition and
had been advised to register in the prenatal clinic or
with a private physician as soon as she became pregnant,
in order that a cervical repair could be performed before
dilation of the cervix. However, on her first visit the
cervix had already started dilating. Immediately follow-
ing admission the patient was placed on bed rest in
Trendelenberg position, Furacin vaginal suppositories,
Terramycin, phenobarbital and Lutrexin. A 48 hour
period of observation was decided upon as there was a
possibility of this patient's going into labor and surgical
VOL. 55, No. 6 Incompetent Cervix
repair would have been futile. With conservative therapy
there were no uterine contractions, no vaginal bleeding
and the temperature remained flat. On March 2, 1962,
the patient was scheduled for a cervical repair. However,
examination revealed the cervix to be completely dilated
with the membranes and fetal parts protruding through
the cervix. Cervical repair was obviously contraindicated.
Several hours later the patient started having mild uterine
contractions and passed a stillborn fetus weighing 9 oz.
The post-partum course was uneventful and the patient
was discharged on the fifth day in good condition. A
hysterosalpingogram was performed in July, 1962 which
showed cervical dilatation under pressure again com-
patible with cervical incompetency.
Case 4. This 29-year-old Gravida II, Para 0, Abortus
1, whose LMP was November 9, 1960, was admitted on
March 24, 1961 to have a cervical repair. In June, 1960
this patient had had a spontaneous abortion following
rupture of the bag of waters. At this time she was 18
weeks pregnant. The diagnosis of incompetent cervical
os was considered. With the second pregnancy, a vaginal
examination was performed every two weeks from the
time of her first prenatal visit. A vaginal examination on
March 24, 1961, prior to admission to the hospital re-
vealed the cervix to be partially effaced, approximately
3 cm. dilated with the membranes bulging through the
cervix. The corpus uteri corresponded to a 16 weeks'
gestation. On March 25, 1961 a modified Shirodkar pro-
cedure was performed. The cervix was encircled with
# 2 black silk sutures at the level of the internal os.
The membranes were replaced and the cervix closed.
During the procedure there was excessive bleeding from
the operative area; however, following the closure of the
vaginal mucosa, the bleeding subsided. The post-operative
course was characterized by a purulent vaginal discharge,
temperatures ranging from 98 degrees to 101 degrees F.
On the 14th post-operative day, the membranes ruptured,
and three days later the patient developed mild uterine
contractions. On the following day, the suture was re-
moved and the patient passed a stillborn fetus weighing
1 lb.-5 ozs. The follow-up of this case was not possible
as the patient has been delinquent in her clinic visits.
Case 5. This 20-year-old gravida III, para 0, abortus
II, LNMP June 25, 1961, was admitted to this hospital
on September 6, 1961 for elective repair of an incom-
petent cervix. Past history revealed that the patient had
had two spontaneous abortions at 20 and 24 weeks in
1959 and 1960. Both cases were characterized by painless
dilatation of the cervix followed by expulsion of the
products of conception. On admission the cervix was
found to be closed, shortened; approximately 1 inch long.
The uterus was enlarged to 12 weeks' size gestation.
On September 7, 1961 a cervical repair was performed.
Due to the bleeding encountered, the bladder could not
be advanced enough to place the Mersilene suture at the
level of the internal os, therefore a McDonald rather
than a Shirodkar type procedure was performed. The
suture was passed through an incision in the posterior
surface of the cervix just below the level of the internal
os, through the cervical tissue on both sides and then
tied anteriorly. The suture was anchored anteriorly and
545
posteriorly with black silk. The post-operative course
was uneventful and patient was discharged on the seventh
day.
On March 8, 1962 the patient was admitted in labor
with uterine contractions of five minute intervals. The
cervix was closed; the corpus corresponded to 36 weeks
gestation. Approximately two hours after admission the
patient was delivered of an infant weighing 6 lbs. 3 oz.
by low cervical caesarean section. The post-operative
course was uneventful and the patient and infant were
discharged on the seventh day in good condition.
SUMMARY
Cervical incompetency is not as rare as one may
be made to believe, since an incidence of between
1:300 and 1:540 pregnancies has been reported.
The causes of the incompetent cervix are numerous
and may be divided into three types; functional,
congenital and acquired, such as, cervical lacera-
tions, amputations, and defects. In all of our cases
cervical incompetency was of the congenital type.
The diagnosis can be based either on the clinical
history of repeated abortions occurring in the sec-
ond trimester of pregnancy characterized by pain-
less dilation of the cervix or by demonstration of
incompetency with the aid of various diagnostic
methods.
It is our feeling that the diagnosis based on the
clinical history is more practical and more accurate
as most patients are first seen in the pregnant state.
Laboratory methods are costly and often impracti-
cal, since some instances of cervical incompetency
can be demonstrated in patients with apparently
normal cervices.
The treatment of the incompetent cervix de-
pends on the state of dilatation of the cervix and
the period of gestation. Conservative therapy is
the method of choice in late pregnancies. Surgical
procedures can be performed in either the non-
pregnant patient, or the pregnant patient. In the
non-pregnant patient, either the Lash or the
Shirodkar procedure is recommended. In the preg-
nant patient, provided there is no bleeding or in-
fection and the membranes are intact, cervical re-
pair should be carried out as soon as possible. The
closure of the dilated cervix can be effected by
procedures performed at the level of the internal
os, mid-cervical or external os. The procedure of
choice is the Shirodkar at the level of the internal
os, however we have observed that when the cervix
is dilated beyond 4 cms. this procedure is made
more difficult and our results have not been satis-
(Concluded on page 561)
VOL. 55, No. 6 Integration Battlefront
Negro dentists and physicians practicing in the south-
ern states and in some rural communities in the North
have found it virtually impossible to become members of
these organizations. They have not been able to join as
active participants because of the strict requirement that
they must be members in good standing in a local society
of the organizations. Such membership has been denied
them on account of their race.
The major consequence of depriving them of member-
ship in these organizations is that they are denied the
benefits otf association in professional experience and
learning, with the effect that they are handicapped in
achieving and maintaining the levels of competence of
other practitioners, thus increasing the possibility that a
large segment of the American population may receive
inferior medical and dental care.
Neither the ADA nor the AMA has taken a strong
stand against their members who practice discrimination
in the selection of patients and the rendering of care
and treatment.
(Mason and Chabert, from page 545)
factory. Therefore, we recommend repair in the
pregnant patient before dilatation begins.
There are many types of suture material avail-
able such as polyethelyne tubing, fascia, umbilical
tape, silk and Mersilene, which we prefer. Pre-
operatively and immediately post-operatively, the
patient should be on bed rest, sedation, anti-
microbial vaginal creams or suppositories, uterine
muscle relaxants and prophylactic antibiotics.
(James, from page 537)
14. MORRIs, L. E. and M. J. THORNTON, and J. W.
HARRIS, Comparison of the Effect of Pituitrin, Pito-
cin and Ergonovine on Cardiac Rhythm during Cyclo-
propane Anesthesia for Parturition. Am. J. Obst. &
Gynec., 63:171, 1952.
15. GREENHILL, J. P. Present-day Evaluation of Cesarean
Section. S. Clin. North America, 33:87, 1953.
16. ACKEN, H. S. Fetal Mortality in Cesarean Section.
Am. J. Obst. & Gynec., 53:927 ,1949.
17. DIDDLE, A. W. and V. GIBBS, and S. LAMBETH,
Fetal Mortality and Prematurity with Repeat Ab-
dominal Delivery. Am. J. Obst. & Gynec., 77:719,
1959.
PLEASE PAY YOUR DUES
NOW FOR 1964
561
We denounce the lethargy and apathy of the ADA and
the AMA for not keeping pace with the rest of America
in the eradication of all vestiges of racial segregation
and discrimination.
We take note of those members of both the ADA and
the AMA who, through their own sense of decency and
fair-mindedness, have worked to open their local groups
to all races regardless of color or creed, and of all the
members of the said organizations who do not them-
selves practice any racial discrimination.
We call upon our branches to keep fully aware of the
existence of any such discrimination or segregation as
practiced by their local hospitals, sanitaria and nursing
homes, as well as by individual practitioners, and to
keep the National Office advised thereof and of branch
efforts to eliminate such practices.
We further call upon our branches and the National
Office to render appropriate support and encouragement
to members of the medical, dental and other professions
who are endeavoring to rid their organizations of racial
discriminatory practices.
Delivery by caesarean section at term is the
method of choice. Five cases during a period of
eight months at our hospital have been treated and
reported. Four of these cases were treated surgical-
ly, one was repaired twice for a total of five pro-
cedures.
One patient was delivered by caesarean section
leaving the suture in place.
One pregnancy under observation is still intact.
(Legal Counsel, from page 566)
because of the newspaper article and some of his col-
leagues questioned him on the child's death. This evi-
dence supported a finding that serious doubt was cast on
plaintiff's professional ability and reputation. In light of
this evidence the court believed that the award of gen-
eral damages was not excessive. Hanley v. Lund 218
ACA No. 3, p. 659.
In the Physician's Legal Brief (Vol. 5, No. 5, July,
1963), published by Schering Pharmaceutical Company,
the editor cites a case where "a patient seeking to recover
for an accident injury assigned a portion of the proceeds
of the suit to the physician who treated him and notified
his lawyer to that effect. When the fee was not forthcom-
ing, the physician filed suit against the attorney charged
with disbursing the funds.
"The lower court dismissed the suit, but the state su-
preme court reversed that verdict and ordered payment.
The upper court ruled that when the patient's attorney
and the insurance carrier fail to pay the physician his
assigned fee, they are liable. Citation: Moskowitz, Su-
preme Court, Appellate Term, Second Dept."