Cervical Insufficiency

Mona Prasad DO, MPH

Jay Iams MD
Basics
Description
Classic:
o Painless cervical dilation leading to midtrimester loss, often repetitive:
Anatomically dysfunctional cervi
Current:
o !unction of cervi not c"aracteri#ed $y a$ility to maintain pregnancy
alone:
Cervical function is a continuum%
O$stetric "istory and cervical lengt" via ultrasound contri$ute
Age&'elated !actors
Preterm delivery occurs more often at etremes of reproductive age% Cervical
insufficiency does not specifically seem to $e affected $y age%
(pidemiology
Incidence of cervical insufficiency is uncertain given lac) of clear diagnostic
criteria%
Indirect estimate of cervical insufficiency determined $y num$er of cerclages
placed: *+*,-.--- pregnancies
'is) !actors
History of recurrent midtrimester pregnancy loss /0-1
2tructural ris) factors:
o Congenital:
Congenitally s"ort cervi
M3llerian duct a$normality
In utero D(2 eposure
o Ac4uired:
Cervical lacerations follo5ing vaginal delivery
Prolonged -nd stage of la$or
Cervical in6ury at time of cesarean section
2urgical procedures to cervi /mec"anical dilation or
coni#ation1
o 7terine overdistention:
Multiple gestation
Poly"ydramnios
Bioc"emical ris) factors:
o Increased levels of relain
o Deficiencies in cervical collagen
o Infection:
Cervical or upper genital tract infection may lead to
inflammation8 cyto)ine and prostaglandin release may lead to
cervical softening and effacement%
9enetics
9enetic defects in collagen synt"esis may predispose to cervical insufficiency:
("lers&Danlos syndrome
Pat"op"ysiology
: pat"5ays lead to a common outcome of cervical s"ortening and dilation:
Congenital
;oss of tissue
Infection, inflammation
Primary cervical disease
Associated Conditions
Preterm delivery
C"orioamnionitis
Premature rupture of mem$ranes
Diagnosis
2igns and 2ymptoms
History
2uspect if o$stetric "istory of:
o 2"ort la$ors
o Progressively earlier deliveries
o Advanced dilation prior to la$or
Current "istory of:
o <aginal fullness or pressure
o <aginal spotting or $leeding
o Increased volume of 5atery, mucousy or $ro5n disc"arge
o <ague lo5 $ac) pain, lo5 a$dominal pain
P"ysical (am
<ital signs, maternal temperature s"ould $e normal
A$sence of fundal tenderness or C<A tenderness
=ocometry to evaluate presence of contractions
2terile speculum eam to:
o (clude ruptured mem$ranes
o (clude vaginitis, cervicitis
o Identify visual dilation of t"e cervi
o Identify "ourglassing mem$ranes
2terile digital eam:
o (valuate cervical dilation and effacement
=ests
>o current tests are availa$le for use in a nonpregnant female to predict cervical
insufficiency in a future pregnancy%
;a$s
CBC
7A
Amniocentesis:
o ?"en clinical suspicion of intrauterine infection is "ig"
o 2end fluid for 9ram stain, culture, protein, and glucose
Imaging
=A72:
o (valuate via$ility of fetus
o (valuate estimated 9A
o (valuate presence of fetal anomalies
o >ot good to assess cervi
Cervical sonograp"y:
o C"aracteristics of cervical insufficiency:
2"ortening to -@ mm or less
Dilation of internal os
!unneling of mem$ranes into endocervical canal
Differential Diagnosis
Infection:
o 7=I+Pyelonep"ritis
o <aginitis
o C"orioamnionitis
Preterm la$or
Premature rupture of mem$ranes
Placental a$ruption
Musculos)eletal lo5 $ac) pain
'ound ligament pain
=reatment
9eneral Measures
Optimal treatment for cervical insufficiency is not determined% Currently, no clinical
evidence t"at any intervention proves to prolong pregnancy%
Pregnancy&2pecific Issues
'is)s for Mot"er
If etiology of cervical insufficiency is intrauterine infection, mot"er is at ris) for
sepsis%
'is)s for !etus
If cervical insufficiency results in delivery, fetus "as t"e attendant ris)s of
prematurity% (treme prematurity may result in neonatal deat"%
2pecial ="erapy
Complementary and Alternative ="erapies
Modified activity:
o Bedrest
o Pelvic rest
Pessaries
P%ABC
Medication /Drugs1
*C.Hydroyprogesterone, -D@ mg:
?ee)ly IM in6ections 5ee)s *B.AB
Prevents preterm $irt" in 5omen 5it" prior preterm $irt"8 not studied in
5omen 5it" cervical insufficiency
2urgery
Cerclage:
Purse&string stitc" around t"e cervi to reinforce t"e presumed 5ea) cervi
Multiple types:
o MacDonald: =ransvaginal approac"
o 2"irod)ar: =ransvaginal approac"
o A$dominal: 'e4uires laparotomy
!ollo5up
Disposition
Issues for 'eferral
Once t"e diagnosis of cervical insufficiency is made, evaluation $y a perinatologist is
recommended% It may $e necessary to o$tain consultation in order to ma)e t"e
diagnosis%
Prognosis
Prognosis is unpredicta$le% Depends upon degree of cervical insufficiency identified,
possi$ility of underlying inflammation, and contri$uting o$stetric "istory:
In 5omen 5it" prior preterm $irt", cervical lengt" of E-D mm $efore -:
5ee)s "as a positive predictive value for preterm delivery of DDF%
Cervical cerclage "as not $een demonstrated to prolong pregnancy%
Cervical cerclage placed in t"e presence of underlying inflammation may lead
to increased ris) of preterm delivery%
Complications
Complications of cervical insufficiency:
o Preterm delivery or midtrimester loss
Complications of cervical cerclage:
o Iatrogenic rupture of mem$ranes
o C"orioamnionitis
o 2uture displacement
o Hemorr"age
Patient Monitoring
Mot"er
?"en diagnosis of cervical insufficiency is made:
Activity modification:
o Bedrest, pelvic rest
o Inpatient or outpatient
2erial 72 evaluation of cervi:
o (very - 5ee)s until A: 5ee)s
Administration of corticosteroids to en"ance fetal lung maturity:
o ?"en cervical lengt" E-D mm
Bo5el regimen to prevent "ard stools and ecessive <alsalva
If cerclage present and patient is candidate for vaginal delivery: 'emove
cerclage AD.AB 5ee)s
!etus
'outine fetal surveillance via 72 is not indicated 5it" t"e diagnosis of cervical
insufficiency%
Bi$liograp"y
ACO9 Practice Bulletin >o% :,% Cervical Insufficiency% O$stet 9ynecol%
-@@A8*@-:*@G*.*@GG%
Creasy 'H, et al%, eds% Maternal&!etal Medicine Principles and Practice, Dt" ed%
P"iladelp"ia: 2aunders8 -@@:%
Jo"nson J, et al% Cervical Insufficiency% Availa$le at: 555%uptodate%com% Accessed
**+@*+@B%
'omero ', et al% ="e role of cervical cerclage in o$stetric practice: Can t"e patient
5"o could $enefit from t"is procedure $e identifiedI Am J O$stet 9ynecol%
-@@B8*G::*G%
2a)ai M, et al% (valuation of effectiveness of prop"ylactic cerclage of a s"ort cervi
according to interleu)in&, in cervical mucus% Am J O$stet 9ynecol% -@@B8*G::*:*G%
<idaeff AC, et al% !rom concept to practice: ="e recent "istory of preterm delivery
prevention% Part I: Cervical incompetence% Am J Perinatol% -@@B8-A:A*A%
Miscellaneous
A$$reviations
J C<AKCostoverte$ral angle
J D(2KDiet"ylstil$estrol
J 9AK9estational age
J =A72K=ransa$dominal ultrasound
J =<72K=ransvaginal ultrasound
J 7=IK7rinary tract infection
Codes
ICDG&CM
BD:%D Cervical incompetence
Patient =eac"ing
J 2igns 5"ic" may indicate cervical insufficiency:
. 7terine contractions
. ;o5, dull $ac)ac"e
. Menstrual&li)e cramps
. Pelvic pressure
. C"ange in vaginal disc"arge
J Activity modification:
. ;evel I:
J ,.*@ "ours of sleep at nig"t
J * "our of rest, in t"e morning and afternoon
J ;ig"t "ouse"old c"ores
J >o eercise or strenuous activity
J 2"ort 5al)s /-.A $loc)s1 if desired
J 2"ort s"opping trips, to a movie, or out to dinner on occasion
J ?or) limitation
. ;evel II:
J ,.*@ "ours of sleep at nig"t
J 'est most of t"e day
J May get up to s"o5er or use t"e restroom
J ?ill need "elp 5it" "ouse)eeping, laundry, and grocery s"opping
J >o 5al)ing, eercise, or sports
J ?or) cessation
. ;evel III:
J ,.*@ "ours of sleep at nig"t
J 'est in $ed all day
J May get up to s"o5er or use t"e restroom
J >o stairs
J ?ill need "elp 5it" all "ome c"ores
J Meals in $ed
J ;eave "ouse only for doctor visits