Cervical Incompetence

Cervical Incompetence is a medical condition in which the cervix fails to retain the conceptus during pregnancy, cervical length is less than 25 mm. In this condition premature effacement (Shortening of the vaginal portion of the cervix and thining of the walls)and dilatation (widening) of the cervix is not caused by labour but rather by structural weakness in the cervix itsel. This may cause miscarriage or preterm birth during 2nd trimester 20-25% of the preterm deliveries between 16-28weeks is because of Cervical Incompetence.

Aetiology

Surgical Trauma :
a) Conization cervical biopsy resulting in substantial loss at connective tissue.
b) Traumatic damage to the structural integrity of cervix (repeated forced cervical dilatation associated with D & C.
Congenital disorders- congenital mullerian duct abnormalities e.g. septate uterus. Bicornuate uterus. Idiopathic
Hormonal influence
Connective tissue disorder as the function of cervix during pregnancy depends on the regulation of connective tissue metabolism. Col lagen is the main component of cervical matrix.
DES (Diethylstilbestreol) exposure in utero which can cause anatomical defects.

Symptoms :

Women with incompetent cervix typically present with ”silent“ cervical dilatation(minima uterine contractions) between 16to 28 weeks.
Cervical dilatation is 2cm or more and minimal symptoms.
When cervix reaches 4cm or more active uterine contractions or rupture of membranes may occur.

Diagnostic Criteria :

Manually
Cervical Sonography - Short cervical length -Cervical tunneling
Passage of 6-8 Hegar's dilator beyond the internal os
Premensural hystero - cervicography shows funnel shaped shadow

Sonography Finding:

Funneling of the cervix with the changes in forms T,Y,V,U (Correlation between the length of the cervix and the changes in the cervical internal OS)
Cervical length < 25mm
Protrusion of the membranes.
Presence of fetal parts in the Cervix or vagina

Treatment:

Surgical approach of the cervix using a vaginal (cervical carclage ) Or abdominal app, other alternatives that have been considered are:-

1. Bed rest : Foot end is raised
2. The use of vaginal passaries to elevate and close the cervix.

Surgical approaches to cervical incompetence is at present t mainstay of treatment Prophylactic Sutures may be placed at 12-16 weeks when there is a clear history. Success rate is high in this case Therapeutic suture are placed when there is clinical or ultrasound evidence of Cl

Rescue suture are those inserted as an emergency when the cervix is essaced and internal os is dilated often with the membranes bulging into the vagina (Hour glass appearance of sonography ).Success rate is low with high complication rate (Rupture of membranes infection and bleeding)

Carclage Procedure :

1 - Mc Donald procedure
2 - Shirodkar operation
3 - Wurm procedure
4 - Transabdominal cerclage
5 - Lash procedure

The most common and easily done procedure is Mc Donald procedure .It is done with a 5mm band of permanent suture which is placed high on the cervix and cervix is closed using 4 or S bites with the needle to create a purse string around the cervix .Cerclage is removed at 37 weeks of gestation or on the onset of labor.

Contraindications :

1 - Uterine contractions
2 - Uterine bleeding
3 - Chorioamnionitis.
4 - Premature rupture of membranes.
5 - Fetal anomaly incompatible with life

In our day to day practice. We are handling high risk pregnancies which occur because of long standing infertility of the patients.
We feel proud in informing you that such patients are successfully delivering healthy babies . and it gives us immense satisfaction & pleasure.