CERVICAL INSUFFICIECY

BY DR WILLIAMS EMMANUEL A.
CERVICAL INSUFFICIECY
finition of cervical insufficiency(Mine)
Cervical insufficiency is a condition in pregnancy
where the cervix begins to dilate painlessly and
without initiation of uterine contractions. This is
due to structural and functional weakness in the
cervix. The cervix itself has an inability to hold
pregnancy till term, resulting in bulging of the
amniotic membranes into the vaginal canal and its
rupture culminating in mid- trimester or early
trimester preterm birth/fetal loss.
• Cervical insufficiency has no consistent definition.
• Cervical insufficiency is charactrised by dilatation and shortenin
of the cervix(effacement) before 37 weeks of gestation in the
absence of uterine contractions..
• Most classically associated with painless, progressive dilatation
the uterine cervix, in the second or third trimester resulting in
membrane prolapse, premature rupture of membranes.
• Cervical insufficiency is associated with mid trimester pregnanc
loss or preterm birth;
• Cervical insufficiency arises from the woman’s cervix inability
hold pregnancy till term due to functional or structural defect.
• Cervical insufficiency should be suspected in women with recu
pregnancy loss.
 Evaluating Risk factors

Women who are planning pregnancy should be

evaluated for risks of cervical insufficiency.
• A thorough medical history at initial evaluation
may alert clinicians to risk factors in a first or
index pregnancy
• Detailed evaluation of risk factors should be
undertaken in women following a mid-
trimester pregnancy loss or early premature
delivery, or in cases where such complications
have occurred in a preceding pregnancy.
 Contd.
In women with a history of cervical insufficiency, ,
urinalysis, urine culture and sensitivity and vaginal
cultures for bacterial vaginosis should be taken at
the first obstetric visit and any infection so found
should be treated.
Women with a history of three or more second-
trimester pregnancy loses or extreme premature
deliveries , in whom no specific cause other than
potential cervical insufficiency is identified , should
be offered elective cerclage at 12-14 weeks.
• In women with a classic history of cervical
insufficiency in whom prior vaginal cervical
cerclage has been unsuccessful, a repeat cerclage
should be done.
• Emergency cerclage may be considered in women
in whom the cervix has dilated to < 4cm without
contractions before 24 weeks of gestation.
• Cervical cerclage should be considered in
singleton pregnancies in women with history of
spontaneous preterm birth or possible cervical
insufficiency if the cervical length ≤ 25mm before
24weeks of gestation.
Evidence based research does not support the
use of elective cerclage in multiple gestations
even if there was history of preterm birth.
 Causes of cervical insufficiency
Congenital Causes:
• Congenital uterine anomalies
• Mullerian defects as bircornuate uterus, uterus
didelphys and septate uterus.
• Women who were exposed in utero to
diethylstilboestrioil [DES] may have cervical defects
predisposing to cervical insufficiency. E.g.
• Short cervix flushed with vaginal vault.
• Non-fibrous soft cervical tissue.
• Short cervical canal.
• Abnormal lower uterine segment.
Inherent physiological weakness of the cervix due to its composition.

Theories – deficient collagen and elastic fibres in the cervix.

High turnover rates of collagen in the incompetent cervix with the
collagen not yet fully cross-linked and therefore has low
biochemical strength.
 Acquired Causes of Cervical Insufficiecy
Acquired causes are mostly traumatic events on the cervix.
• [a] Associated with pregnancy.
• Spontaneous vaginal delivery especially precipitate labour
leading to cervical lacerations.
• Operative vaginal delivery e.g. forceps.
• Unrecognised cervical tears at time of occurrence
because they were not associated with much bleeding.
• Excessive and forceful dilatation of the cervix during
termination of pregnancy [most common cause in Nigeria];
• Avoid 2nd trimester termination;
• Avoid terminations >10 weeks gestation by MVA.
• Your cervical dilatation should always be 2mm short of
gestational age.
 CONTD

Bacterial vaginosis a risk factor for adverse

pregnancy outcomes including second trimester
miscarriages, preterm birth.
 Diagnosis of cervical Insufficiency in the non-pregnant state

• There is no diagnostic test for cervical insufficiency.

• Although many tests have reported or used like:
• Assessment of the cervical canal width by
hysterosalpingogram.
• Assessment of the ease of the insertion of cervical
dilators size 9 (Hagar) without resistance’
• The force required to withdraw an inflated Foley
catheter through the internal os.
• The force required to strectch the cervix using an
intracervical baloon: None of these meet the criteria
required for a diagnostic test
 Contd.
• The Foley traction test – force necessary
to pull size 16 Foley balloon catheter filled
with 1ml of water through the internal os is
measured.
• Hysterosalpingography showing:
• dilatation of the internal os and widened
isthmus [so-called inverted Bishop’s cap.
 B. Associated with gynecological procedures

• Cervical amputation as part of Manchester

repair [rare procedure].
• Cone Biopsy.
• LEEP (Loop Electrosurgical Excision
procedure) in the treatment of CIN.
• [Bacteria mediated activity
• Intramniotic or decidua invasion by bacteria
infection can lead to release of cytokines to
modification of collagen + other connective
tissue to insufficiency.
 Contd.
• Diagnosis is based on the exclusion of other causes of
preterm delivery or mid-trimester pregnancy loss.

• In recent practice, transvaginal ultrasonography has been

increasingly used as a demonstrable valid and reproducible
method of cervical assessment and cervical shortening
correlates with risks of preterm delivery.
• Transvaginal scan measurement of the internal os
diameter of greater than 15mm in the first trimester and
20mm in the second trimester is associated with cervical
insufficiency.

• Without a reliable diagnostic test, it becomes necessary to

screen for or predict the likelihood of cervical insufficiency.
 Rule our other causes of recurrent pregnancy loss:
- Diabetes mellitus
- Thyroid dysfunction
- Lupus anticoagulant
- Chromosomal anomalies
- Cervical infections with organisms such as
mycoplasma and ureaplasma.
 CONTD.
The process is based upon the identification and
the recognition of key risk factors in the woman’s
history and in the index pregnancy.
• History of electrosurgical excision procedure
(LEEP) may also present as a factor for cervical
insufficiency. In such patients, there may be a
role for cervical length measurement,
 Management of cervical insufficiency.

Management fall into two categories

1. Those in which it is clear that surgical
intervention in the form of cerclage is
indicated.
2. Those in which a conservative path can be
pursued
Indications for cervical cerclage:

Clinical history or the finding of cervical shortening

and/or dilatation in index pregnancy.
1. Prophylactic cerclage
2. Therapeutic cerclage
 Contraindications to cervical cerclage
• Contraindications to cerclage
• Rupture of fetal membranes
• Gross fetal abnormities on ultrasound.
• Presence of nuchal translucency on ultrasound
• Fetal demise
• Cervix flushed with vaginal vault (bladder could be injured
during the procedure).
• Do urinalysis, culture and vaginal swab culture including for
bacterial vaginosis.
 Removal of cerclage
•Removal of shirodkar’s suture is in theatre while
McDonald’s suture can be removed without anesthesia.
Post Cerclage Management
•Bed rest – may be advised during the first 24hrs followed
by mobilization and increased activity.
Tocolytic and Cerclage - [Post Cerclage treatment]
Complimentary treatment with tocolytics such as
salbutamol, ritodrine and progesterone are often prescribed
during the peri-operative period to keep the uterus
quiescent.
Antibiotics and Cerclage
Give prophylactic antibiotics to prevent infections
especially in [group B] streptococcal positive patients.
 Shirodkar’s technique
•Steps essentially as in McDonald’s except
that at the junction of the rugose the anterior
vaginal wall and smooth cervical mucosa a
transverse incision about 2cm is made just
below the junction and the bladder reflected
away up to the uterovesical pouch, and the
purse string suture applied at this level. The
sutures are covered by peritoneal closure.
 Management of cervical insufficiency by cerclage.

McDonald Procedure
Patient in lithotomy position, cleansed, drapped with sterile linen.
Put under anaesthesia.
Bladder emptied.
Speculum [Sims] is applied to the posterior vaginal wall to retract
it so that the cervix can be visualised.
A sponge holding forceps each applied to the anterior and
posterior lips of the cervix and drawn down.
The junction of the rugose vaginal mucosa with the cervical
mucosa is identified which corresponds to the level of the internal
os.
Placement of the suture is started just below the above
mentioned junction and 4-6 purse-string sutures taken
circumferentially to complete.
 Cerclage Techniques
Techniques in widespread use are:
1] The Shirodkar’s technique [Shirodkar, an Indian
Obstetrician / Gynaecologist].
2] The McDonald’s procedure [more popular]
Both techniques are transcervical procedures commonly
performed as elective prophylactic procedures.
The two procedures have similar outcomes.
The cerclage operation is usually carried out as an elective
procedure in early second trimester [14-16wks]. This is so
that pregnancies which may have terminated
spontaneously in the first trimester presumably because of
chromosomal anomalies would not be maintained by
cerclage.
Do ultrasound to rule out fetal structural anomalies before
cerclage.
McDonald procedure
•Removal of shirodkar’s suture is in theatre while McDonald’s suture
can be removed without anaesthesia.
•Remove cerclage sutures at 37 weeks (before labour commences).
Post Cerclage Management
•Bed rest – may be advised during the first 24hrs followed by
mobilization and increased activity.
Tocolytic and Cerclage - [Post Cerclage treatment]
Complimentary treatment with tocolytics such as salbutamol,
ritodrine and progesterone are often prescribed during the peri-
operative period to keep the uterus quiescent.
Antibiotics and Cerclage
Give prophylactic antibiotics to prevent infections especially in
[group B] streptococcal positive patients.
 Post cerclage management
Patient can be discharged home after a couple of days but not
more than a week.
Cerclage can be done as a day-case procedure.
However, in some cases, the obstetric history is such that both
the doctor and the patient feel more comfortable if the patient
remain in hospital, especially history of previous cerclage
failures.
On discharge, patient must be advised to avoid coitus or
insertion of any object in the vagina.
Avoid strenuous exercises.
Report any vaginal discharge, vaginal or back pressure or
pelvic cramps.
Need to follow the normal antenatal routine but to be examined
every fortnightly to determine the integrity of the cerclage.
 Removal of cerclage

•The cerclage suture is usually removed at

37 weeks of gestation.
•However, removed earlier if there is:
• Excessive vaginal bleeding.
• Intrauterine fatal death.
• Persistent uterine contractions.
• Rupture of the membranes
 Emergency cerclage
Emergency Cerclage
 Done for women without classic history who
are found on routine ultrasound scan to have
cervical effacement and dilatation. Such
women are considered for emergency
cerclage.
Bulging Membranes and Cerclage
 Is another form of Emergency Cerclage.
 Membranes bulging through a partially dilated
cervical os.
• How to put an emergency cerclage. Various techniques
to reduce the membranes back into the uterus and apply
a cerclage.
• [A foley catheter with a 20ml balloon with its tip cut off
short of the balloon is placed against the bulging
membranes and inflated to push the membranes back
into the uterus. Cerclage applied, catheter deflated and
removed.
[b] 6 – 10 stay sutures placed on the edge of the cervix,
traction on them causes the membranes to retrace back
into the uterus, while the patient is in Tredelenburg position.
[c] Bladder distention with up to 1,000ml of normal saline
may lead to retraction of membranes and allow cerclage to
be placed.
Dilated cervix with bulging membranes