cervical

incompetence
Dr.Mohammed Abdalla
Domiat general hospital
 Cervical incompetence is
defined as the inability to
support pregnancy till
term
because of a functional or
structural defect of the
cervix
Mostly the incompetence is
idiopathic 90%….but
it may be secondary to
anatomical, traumatic, or
congenital connective
tissue disorder.
Although the efficacy of cerclage for
cervical incompetence
has never been fully confirmed
in randomized clinical trials ,the role
of cerclage has been expanded to
include women with “risk factors” for
spontaneous preterm birth or
nonreassuring sonographic cervical
findings in the mid trimester.
So, before you send your
patient to the theater for
cerclage your diagnosis
necessities solid criteria
otherwise many will be
unduly done.
But unfortunately there is
no consensus about the
cervical cut off length

< 25mm
Or
< 15mm
 the cervical cut off
length in singleton
pregnancy
Cannot be applied in
multiple pregnancy?
As the risk with CL <25 mm
in multiple pregnancies

is 6-8 times
the risk with the same length
in singleton pregnancies .
35%

4%
 problem
Inconsensus about cutoff
cervical length will result
in the categorization of 5%
to 10% of pregnant women
as having a short cervix.
 As any controversial
issue we have here
white and black faces
but always within the
grey zone, which lies in
between, we fall in
doubt.
 1
White face here is the
women with
irrelevant obstetric
and gynecological
history, as they need
no screening.
 2
The black face of the problem is
represented by those who have
three or more midtrimester
losses or preterm births , the
decision is
a prophylactic cerclage performed
at 13 to 16 weeks
of gestation .
 3
The grey zone is
represented here by those
women of low or moderate
risk, and they need serial
ultrasound screening by
transvaginal
ultrasonography.
 Ultrasound screening
if we are going to screen this group of
patients with mild to moderate risk :
when to start?
what is the ultrasonic criteria
of incompetent cervix?
and when to intervent?
 when to start
TVS should not begin
before 16 weeks
as the upper portion of the
cervix is not easily
distinguished
 ultrasonic criteria of
incompetent cervix
Make sure to use proper technique.
Knowing what to measure .
Know what's normal, and what's
abnormal .
Linking cervical assessment to
gestational age .
 proper technique
patients are asked to empty their bladder .
You should identify at the same sagittal
view the internal os, external os, cervical
canal, and endocervical mucosa.
the probe is slowly withdrawn to avoid
false elongation of the cervix.
The cervical length is measured by
freezing the screen three separate times
with no more than 2 to 3 mm variations.
 proper technique
To recognize funneling the walls of the funnel
are formed by endocervical mucosa.
If the cervical canal is sometimes curved,
therefore, cervical length should be determined
by tracing the length of the cervix or by adding
the sum of two straight sections.
Apply transfundal pressure for 15 seconds,
and record any changes in cervical length or
funneling. “cervical stress test” .
 cm 2

1.2
1.
5
“cervical stress
test”
the walls of the funnel are formed by
endocervical mucosa.
 what's normal
In low-risk women, CL during
pregnancy has a mean of 35 to 40
mm from 14 to 30 weeks.
the lower 10th percentile being
25 mm and the upper 10th (90th
percentile) 50 mm.
 CERVICAL LENGTH (MEAN OR MEDIAN) IN LOW-RISK POPULATIONS IN MIDTRIMESTER

Reference Year N Cervical Length (mm)

Ayers et al 1988 150 52
Podobnik et al 1988 80 48

Andersen et al 1990 125 41

Kushnir et al 1990 24 48

Andersen et al 1991 77 42

Murakawa et al 1993 177 37

Zorzoli et al 1994 154 42

Iams et al 1995 106 37

Iams et al 1996 2915

35
Cook et al 1996 41 41

Tongsong et al 1997 175 42

Heath et al 1998 1252 38

 ?what's abnormal
The discriminatory length
of cervical shortening
varies widely between
25mm to 15mm
 value of cervical
sonography in the
screening of preterm birth
% %
Reference (wks) Cutoff Sensitivity Specificity % PPV % NPV

Iams et al 24 <20
23 97
26 97

Taipale et
al
18–22 ≤25
6 100
39 99

Heath et al 23 ≤15
58 99
52 99

Hassan et 14–24 ≤15

8 99
47 97
al
Low %PPV means
that many undue
cerclages were
done.
high %NPV means
that the test is
reassuring when
negative.
So we cannot rely on
cervical length
alone as a predictor
of incompetence
 What are the most
important?
the progressive shortening
detected by serial sonar,
funneling (width and length),
v-shaped lower uterine segment
and dynamic cervical changes
with fundal or suprapubic
pressure.
1 2

3 4
bulging of the membranes in the vagina. The
fetal lower limb protruded into the vagina.
But how to avoid
undue cerclage
and
how not to miss a
case?
 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.
 Can a cervical
cerclage be used to
prevent preterm
delivery in patients
with a short cervix or
funneling?
 RANDOMIZED STUDIES OF
ELECTIVE CERVICAL CERCLAGE
Delivery <37
Weeks
Year Weeks at % %
Referenc
e
N Indication Cerclage Cerclage Controls

Rush et 1984 194 High risk of 18

al. cervical
32 34
incompetence

Lazar et 1984 506 Moderate risk of <28

cervical
5.5 6.7
incompetence

MRC/RC 1993 1292 Obstetrician 16

OG uncertainty
31 26
 RANDOMIZED STUDIES OF
ELECTIVE CERVICAL CERCLAGE

results of randomized
clinical trials suggest that
cerclage either had a
modest effect on reducing
the rate of preterm delivery
or no effect whatsoever.
 Key points
The high negative predictive
value for preterm birth
associated with a long cervix
and with the absence of
funneling has important clinical
implications in symptomatic
patients.
 Key points
Using TVU to assess CL is an
effective way to predict PTB and
"incompetent cervix," now better
named cervical insufficiency. It's
safe and patients accept the
examination well.
 Key points
Screening frequency should
depend on severity of obstetric
history, with serial TVU of the
cervix having a better predictive
accuracy than one, especially in
high-risk populations.
 Key points
the shorter the cervix, the
higher the risk of PTB, and
the earlier in gestational age
at which the shortening
occurs, the higher the risk.
 Key points
screening high-risk women with
TVU of the cervix and placement
of a cerclage for the short or
funneled cervix should not be
considered standard care until
proven by properly conducted,
large randomized trials
Thank
you