CERVICVAL SHORTENING / CERVICAL INSUFFICIENCY

Preterm birth (PTB), defined as birth before 37 weeks of gestation, is the leading cause of
perinatal morbidity and mortality. PTB is a major cause of long-term health problems in
neonates, including respiratory distress syndrome, chronic lung disease (bronchopulmonary
dysplasia), infection, intraventricular hemorrhage, and severe neurologic deficit. In the
absence of reliable clinical predictors of PTB, obstetric care providers should focus their
attention on the 2 best and most widely accepted methods of identifying women at high risk
of PTB in both nullipara and multipara: fetal fibronectin and cervical length measurements.
It has been suggested that the process of cervical shortening begins with dilatation of the
internal os leading to funneling and progressive shortening of the CL. Cervical shortening
may leads to the diagnosis of Cervical Insufficiency.Cervical insufficiency is the inability of
the cervix to retain fetus, in the absence of uterine contractions or labor (painless cervical
dilatation), owing to a functional or structural defect. It is cervical ripening that occurs far
from the term. Cervical insufficiency is rarely a distinct and well defined clinical entity but
only part of a large and more complex spontaneous preterm birth syndrome.

Etiology
Cervical insufficiency usually occurs during the middle of the second or early third trimester,
depending upon the severity of insufficiency. Cervical incompetence may be congenital or
acquired. The most common congenital cause is a defect in the embryological development
of Mullerian ducts. In Ehlers-Danlos syndrome or Marfan syndrome, due to the deficiency in
collagen, the cervix is not able to perform adequately, leading to insufficiency.
The most common acquired cause is cervical trauma such as cervical lacerations during
childbirth, cervical conization, LEEP (loop electrosurgical excision procedure), or forced
cervical dilatation during the uterine evacuation in the first or second trimester of pregnancy.
Although some degree of cervical shortening may be explained by normal biologic variance,
it is likely that most cases of cervical shortening result from pathologic processes such as
inflammation, hemorrhage, premature uterine contraction, or uterine overdistension.
However, in most patients, cervical changes are the result of infection/inflammation, which
causes early activation of the final pathway of parturition.
Epidemiology

Epidemiologic studies suggest an approximate incidence of 0.5% in the general obstetric

population and 8% in women with a history of previous mid-trimester miscarriages. Wide
variation in the incidence of cervical incompetence has been reported, which is likely due to
real biologic differences among the study population, the criteria used to establish the
diagnosis, and reporting bias between general practitioners and referral centers.

Diagnosis
Most of the women have no symptoms or only mild symptoms beginning in the early second
trimester. These include abdominal cramping, backache, pelvic pressure, vaginal discharge
which increases in volume, vaginal discharge which changes from clear to pink, and spotting.
The diagnosis of incompetent cervix is usually made in three different settings:
 1. Women who present with a sudden onset of symptoms and signs of cervical
insufficiency
2. Women who present with a history of second-trimester losses consistent with the
diagnosis of cervical incompetence (history-based)
3. Women with endovaginal ultrasound findings consistent with cervical incompetence
(ultrasound diagnosis)
The digital or speculum examination reveals a cervix that is dilated 2 cm or more, effacement
greater than or equal to 80%, and the bag of waters visible through the external orifice (os) or
protruding into the vagina. The diagnosis is frequently made on the basis of history
retrospectively after multiple poor obstetrical outcomes have occurred.
The gold standard for the measurement of CL in pregnancy is transvaginal ultrasonography
(TVS) using sterile technique, which has many advantages when compared with digital
examination. TVS is objective, reproducible, and acceptable to patients. Cervical changes
such as dilatation of the internal cervical os with funneling (beaking) of the membranes can
be easily appreciated by TVS, but not by digital examination. Moreover, TVS appears to be
safe and does not increase the risk of ascending infection even in patients with preterm
premature rupture of membranes (PROM).
A number of sonographic features of the cervix on TVS have been correlated with PTB,
including funneling of the membranes and the presence of debris within the adjacent amniotic
fluid, but the most consistent association is with the so-called residual CL, which refers to the
measurement of closed cervix (canal length) between the internal os and external os. The CL
measurement should be acquired in the sagittal view using TVS while the bladder is empty
and without excessive pressure applied by the transvaginal probe. This measurement has an
interobserver variation of 5% to 10%.It has been suggested that the process of cervical
shortening begins with dilatation of the internal os leading to funneling and progressive
shortening of the CL. Dr. Jay Iams has described the appearance of the cervix on TVS over
time as a progression of the letters T, Y, V, and U (Trust Your Vaginal Ultrasound)
representing the progressive increasing funneling and decreasing CL
The diagnosis of cervical insufficiency is challenging because of the lack of objective
findings and clear diagnostic criteria. Cervical ultrasound has emerged as a proven, clinically
useful screening and diagnostic tool in the selected population of high-risk women based on
an obstetrical history of a prior (early) spontaneous preterm birth. The transvaginal
ultrasound typically shows a short cervical length, less than or equal to 25 mm, or funneling,
ballooning of the membranes into a dilated internal os but with the closed external os.

Treatment
Many nonsurgical and surgical modalities have been proposed to treat cervical insufficiency.
Certain nonsurgical approaches, including activity restriction, bed rest, and pelvic rest have
not proven effective in the treatment of cervical incompetence and their use is discouraged.
Another nonsurgical treatment to be considered in patients at risk of cervical insufficiency is
the vaginal pessary. The evidence is limited for a potential benefit of pessary placement in
select high-risk patients.
Surgical approaches include transvaginal and transabdominal cervical cerclage. The two
types of this commonly used vaginal procedure include McDonald and modified Shirodkar.
McDonald involves taking four or five bites of number 2 monofilament suture as high as
possible in the cervix, trying to avoid injury to the bladder or the rectum, with a placement of
a knot anteriorly to facilitate the removal. The Shirodkar procedure involves the dissection of
the vesical-cervical mucosa in an attempt to place the suture as close to the cervical internal
os as close, otherwise, as possible. The bladder and rectum are dissected from the cervix in a
cephalad manner, the suture is placed and tied, and mucosa is replaced over the knot.
Nonresorbable sutures should be used for cerclage placement using the Shirodkar procedure.
During an emergency, the cerclage patient is placed in Trendelenburg position and a bag of
membranes is deflected cephalad back into the uterus by placing a Foley catheter with a 30
mL balloon through the cervix and inflating it. The balloon is deflated gradually as the
cerclage suture is tightened.
Transabdominal cerclage with the suture placed at the uterine isthmus is used in some cases
of severe anatomical defects of the cervix or cases of prior transvaginal cerclage failure. It
can be performed laparoscopically, but it generally requires laparotomy for initial suture
placement and subsequent laparotomy for removal of the suture, delivery of the fetus, or
both.