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Cervical incompetence
Cervical incompetence, also called cervical insufficiency, is a condition where the cervix begins to dilate and efface before pregnancy has reached term, often resulting in miscarriage. Risk factors include a history of preterm birth, multiple abortions, cervical procedures, or congenital uterine abnormalities. Diagnosis involves a history of second trimester losses and physical exam findings of cervical shortening or dilatation. Treatment options during pregnancy include bed rest, progesterone supplementation, cerclage procedures to reinforce the cervix, and sometimes pessary devices. The goal is to prevent premature dilation and maintain the pregnancy until full term.
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Presentation submitted by Nikita Sharma on cervical incompetence to Mrs. Savita Mam, highlighting academic affiliation.
Cervical incompetence is defined as an abnormal cervix that dilates before term, leading to potential miscarriage.
Identifies risk factors including short cervical length, previous childbirth injuries, and uterine abnormalities.
Covers congenital and acquired causes of cervical incompetence including D&C and multiple pregnancies.
Explains the underlying mechanisms of how cervical incompetence develops during pregnancy.
Lists common symptoms such as backache, pelvic pressure, and changes in vaginal discharge observed between 14-20 weeks.
Diagnosis through patient history, internal examination, and various tests indicating cervical changes and incompetence.
Discusses management strategies such as counseling, hysteroscopic resection, and endocrine dysfunction treatment.
Describes patient care, ultrasound monitoring, progesterone therapy, and specific treatments for various conditions.
Details circlage procedures (Shirodkar and McDonald) for reinforcing a weak cervix, including indications and risks.
Discusses abdominal cerclage, alternatives like bed rest, progesterone injections, and the use of vaginal pessaries.
Cites resources including a textbook and online references related to cervical incompetence.
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Cervical incompetence
- 1. CERVICAL INCOMPETENCE SUBMITTED TO: MRS.SAVITA MAM ASSISTANT PROFESSOR DEPTT. OF OBG NURSING DMCH, CON, LUDHIANA SUBMITTED BY: NIKITA SHARMA MSC (N) 1ST YEAR ROLL NO.- 9
- 2. CERVICAL INCOMPETENCE Definition: Acervix that has an abnormal tendency to dilate and so may not be able to keep a fetus from being spontaneously aborted (miscarried). (OR) Cervical incompetence is also called cervical weakness or cervical insufficiency, is a medical condition of pregnancy in which the cervix begins to dilate (widen) and efface (thin) before the pregnancy has reached term
- 3. RISK FACTORS RISK FACTORS SHORT CERVICAL LEGTH REPEATED ORLATE TERM ABORTION INJURY FROM PREVIOUS CHILDBIRTH REPEATED ABORTION UTERINE ABNORMALITY EXPOSURE TO DRUG E.G-DES TWIN OR MULTIPLE PREGNANCY PRIOR MISCARRIAGE AND D&C OR LEEP
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- 8. SIGN AND SYMPTOMS Appearstypically between weeks 14 and 20 of pregnancy, and include the following: Sign & symptoms A backache A sensation of pelvic pressure Premenstru al like cramping Braxton- Hicks-like contractions Light vaginal bleeding/ spotting A change in vaginal discharge
- 9. DIAGNOIS • History: Repeatedmid-trimester painless cervical dilatation (without apparent cause) and escape liquor amnii followed by painless expulsion of the products of conception is very much suggestive or: • The nature of previous abortion process • Histology of placenta or karyotyping of the conceptus, if available. • Any chronic illness. • Internal examination: (interconceptional period): Bimanual examination reveals presence of unilateral or bilateral tear and/ or gapping of the cervix up to the internal os.
- 10. INVESTIGATIONS(INTERCONCEPTIONAL PERIOD) • Passage no.6-8 Hegar dilator : beyond the internal os without any resistance and pain and absence of internal os snap on its withdrawal specially in premenstrual period indicate incompetence.
- 11. Premenstrual hystero-cervicography: • showsfunnel shaped shadow. The internal os is supposed to be tight due to action of progesterone during this phase of cycle. Similar funnel shaped shadow may be found if hysterography is done in the proliferative phase even with a competent cervix.
- 12. During pregnancy • Clinicaldigital: Painless cervical shortening and dilatation • Sonography: Short cervix< 25mm, Funneling of the int. os> 1cm. • Speculum examination: detection of dilatation of internal os with herniation of the membranes.
- 13. DIAGNOSTIC TESTS • Bloodglucose (fasting and postprandial), VDRL, Thyroid function test, ABO and Rh Grouping, Toxoplasma antibodies IgG & IgM • Autoimmune screening: Lupus anticoagulant and anticardiolipin antibodies • Serum LH on D2/D3 of the cycle • Ultrasonography: to detect congenital malformation of uterus, polycystic ovaries and uterine fibroid • Hysterosalpinography: in the secretory phase to detect cervical incompetence, uterine synechiae and uterine malformation • Which is supported by hysteroscopy or laproscopy • Karyotyping • Endocervical swab to detect chlamydia, mycoplasma and bacterial vaginosis.
- 14. TREATMENT INTERCONCEPTIONAL PERIOD: • Toalleviate anxiety and to improve the psychology- Counselling- they should be assured that even after 3 consecutive miscarriages, the chances of successful pregnancy is high (70%). However the success rate depends upon the underlying etiology and the maternal age. • Hysteroscopic resection: of uterine septa, synechae and submucous myomas improves the pregnancy outcomes. • Uterine unification operation (metroplasty): is done for cases with bicornuate uterus. • Chromosomal anomalies: Genetic counselling is undertaken, karyotyping of the products of conception from future miscarriage is mandatory. couples with chromosomal translocations or inversion is counselled for preimplantation genetic diagnosis(PGD) or perinatal diagnosis (amniocentesis or CVS) in subsequent pregnancy or pregnancy with donor gametes.
- 15. CONTINUE….. • Hyper secretionof LH: as seen in PCOS cases, is suppressed with GnRH analogue therapy. Subsequently ovulation induction with Gonadotropins improves the pregnancy outcomes. • Endocrine dysfunction: Control of diabetes and thyroid disorders are done. Subclinical diabetes and or thyroid disease need not to be treated. • Genital tract infections: are treated appropriately following culture of cervical and vaginal discharge. Empirical treatment with doxycycline, erythromycin is cost effective.
- 16. DURING PREGNANCY: • Reassuranceand tender loving care to remove stress and improves uterine blood flow. • Ultrasound: should be used at the earliest to detect a viable pregnancy. This will influence further management. If the fetus is viable ultrasonographically at 8–9 weeks, only 2–3% are lost thereafter and similarly fetal loss is only 1% after 16 weeks of viable fetus. • Rest—Patient should take adequate rest and to avoid strenous activities, intercourse and traveling.
- 17. CONTINUE….. • Progesterone therapy: incases with luteal phase defect and recurrent miscarriage is given with natural micronized progesterone 100 mg daily as vaginal suppository. It is started 2 days after ovulation. Once pregnancy is confirmed, progesterone supplementation is continued until 10–12 weeks of gestation. Progesterone is necessary for successful implantation and continuaion of pregnancy. This is due to its immunomodulatory role. hCG stimulates corpus luteum to produce progesterone.
- 18. CONTINUE…… • Antiphospholipid antibodysyndrome (APS): Women are treated with low-dose aspirin (50 mg/day) and heparin (5,000 units SC twice daily) up to 34 weeks. Unfractionated heparin and low molecular weight heparin (LMWH) are equally effective and safe. • Circlage operation: for cervical incompetence is to be performed . • Chromosomal anomaly—Prenatal diagnosis by amniocentesis is done. Preimplantation genetic diagnosis in blastomere stage is another option .Only then the few balanced embryos are transferred and there is successful pregnancy.
- 19. CONTINUE….. • Immunotherapy: Useof paternal cell (leukocytes) immunization, third party donor leukocytes, trophoblast membranes, corticosteroids or IV immunoglobulins does not improve live birth rate. Immunotherapy is no longer used in women with unexplained recurrent miscarriage. It may increase maternal morbidity (anaphylactic shock).
- 20. CONTINUE….. • Inherited thrombophilias:Antithrombotic therapy improves the pregnancy outcome. Heparin (5,000 IU SC twice daily) or low molecular weight heparin (enoxaprin) SC once daily (preferred) is effective. Heparin is given up to 34 weeks. • Medical complications in pregnancy: Hemoglobinopathies, SLE, cyanotic heart disease are advised to delay pregnancy until the disease is optimally treated. During pregnancy, specific management is continued . • Unexplained: Despite different investigations, about 40–60% of recurrent miscarriages remain unexplained. However, ‘tender loving care’ (TLC) and some supportive therapy improves the pregnancy outcome by 70%.
- 21. MANAGEMENT OF CERVICALINCOMPETENCE • Circlage operation: Two types of operation are in current use during pregnancy each claiming an equal success rate of about 80–90%. The operations are named after Shirodkar (1955) and McDonald (1963). • Principle: The procedure reinforces the weak cervix by a non-absorbable tape, placed around the cervix at the level of internal os. • Time of operation: In a proven case, prophylactic circlage should be done around 14 weeks of pregnancy or at least 2 weeks earlier than the lowest period of previous wastage, as early as the 10th week. Emergency (rescue) circlage can be done when the cervix is dilated and there is bulging of the membranes.
- 22. CONTINUE….. • Case selection:Circlage operation is done mainly in cases where careful history and physical examination suggest cervical incompetence (history indicated circlage) as it remains a diagnosis of exclusion. • Clinical observation is supported with sonographically detected short cervical length (<25 mm), with or without funneling of the internal os (ultrasound indicated circlage). Prior to operation, fetal growth and anomaly (aneuploidy) scan should be done by sonography.
- 23. STEPS OF SHIRODKAR’SOPERATION • Step I: The patient is put under light general anesthesia and placed in lithotomy position with good exposure of the cervix by a posterior vaginal speculum. The lips of the cervix are pulled down by sponge holding forceps or Allis tissue forceps. Step II: A transverse incision is made anteriorly below the base of the bladder on the vaginal wall and the bladder is pushed up to expose the level of the internal os. A vertical incision is made posteriorly on the cervicovaginal junction.
- 24. CONTINUE….. Step III: Thenonabsorbable suture material—Mersilene (Dacron) or Ethibond tape is passed submucously with the help of an aneurysm needle or cervical needle so as to bring the suture ends through the posterior incision.
- 25. CONTINUE….. • Step IV:The ends of the tapes are tied up posteriorly by a reef knot. The bulging membranes, if present, must be gently reduced beforehand into the uterine cavity. The anterior and posterior incisions are repaired by interrupted stitches using chromic catgut.
- 26. McDONALD’S OPERATION • Thenonabsorbable suture (Mersilene) material is placed as a purse- string suture as high as possible (level of internal os) at the junction of the vaginal epithelium and the smooth vaginal part of the cervix below the level of the bladder. The suture starts at the anterior wall of the cervix. • Taking successive deep bites (4–5 sites), it is carried around the lateral and posterior walls back to the anterior wall again where the two ends of the suture are tied. The operation is simple having less blood loss, and has got a good success rate. There is less formation of cervical scar and hence less chance of cervical dystocia during labor.
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- 28. Postoperative care: (1) Thepatient should be in bed for at least 2–3 days. (2) Weekly injections of 17α-hydroxyprogesterone caproate 500 mg IM are given in women with history of prior preterm delivery. (3) Isoxsuprine (tocolytics) 10 mg tablet may be given thrice daily to avoid uterine irritability. Advice on discharge: (a) Usual antenatal advice. (b) To avoid intercourse. (c) To avoid rough journey. (d) To report if there is vaginal bleeding or abdominal pain. (e) Periodic ultrasonographic monitoring of the fetus and the cervix.
- 29. CONTINUE…. Removal of stitch:The stitch should be removed at 37th week or earlier if labor pain starts or features of abortion appear. If the stitch is not cut in time, uterine rupture or cervical tear may occur. If the stitch is cut prior to the onset of labor, it is preferable to cut it in operation theater as there is increased chance of cord prolapse especially in the cases with floating head. Contraindications: (i) Intrauterine infection (ii) Ruptured membranes. (iii) Presence of vaginal bleeding. (iv) Severe uterine irritability. (v) Cervical dilatation greater than 4 cm. (vi) Fetal death or defect
- 30. CONTINUE….. Complications: (i) Slipping orcutting through the suture. (ii) Chorioamnionitis. (iii) Rupture of the membranes. (iv) Abortion/preterm labor. (v) Cervical lacerations during delivery. (vi) Cervical scarring and dystocia requiring cesarean delivery.
- 31. ABDOMINAL CIRCLAGE A Mersilenetape is placed at the level of the isthmus between the uterine wall and the uterine vessels. The tape is tied anteriorly. This is done between 11 weeks and 13 weeks following laparotomy.
- 32. Disadvantages: (i) Increased complicationsduring operation. (ii) Subsequent laparotomy for delivery or removal of the tape (if needed). Indications: cases where cervix is hypoplastic or where prior vaginal cerclage has failed. A similar procedure can be done laparoscopically during the nonpregnant state.
- 33. Alternative to cervicalcerclage: (nonsurgical) • may be bed rest alone to avoid pressure on the cervix. • Injection of 17α-hydroxyprogesterone caproate 500 mg IM weekly is given as cervical incompotence is considered as a continum of preterm birth syndrome. • Use of vaginal pessary, when cervix is found short on ultrasound, is found helpful.
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- 35. BIBLIOGRAPHY • Textbook ofobstetrics. New Central Book Agency (p) Ltd. Publishers. 7th edition. Pageno.-168-172 • https://www.abclawcenters.com/practice-areas/prenatal-birth- injuries/premature-birth-and-prevention/incompetent-cervix/ • https://www.slideshare.net/dilu172/cervical-incompetence-72234949