I.

INTRODUCTION

Incompetent cervix is a condition in which a woman’s cervix begins to

open, or dilate, in the second trimester of pregnancy. The cervix is called
“incompetent” because it isn’t able to stay closed long enough to allow a
pregnancy to reach full term.

Many women are diagnosed with an incompetent cervix after they have
suffered from one or more second trimester pregnancy losses, or after they
deliver a very preterm baby. Other women are diagnosed with an incompetent
cervix after a cervical ultrasound shows that their cervix is beginning to open
early in pregnancy.

If an incompetent cervix is diagnosed in a pregnant woman, many

physicians will place a cerclage, or a stitch in the cervix, to help it stay closed
until the baby is fully developed.

Also Known As: Cervical insufficiency

Cervical insufficiency, means that a woman’s cervix is weakened and

begins dilating and opening too early in the pregnancy. When this premature
dilation is not detected in time, cervical insufficiency can cause a pregnancy loss
or birth of a preterm infant. The outcome of a preterm delivery depends on when
the baby is born, with earlier birth being more likely to result in pregnancy loss.

Incompetent cervix is diagnosed in I in 2000 pregnancies, and has been

determined as the cause of approximately 15% of all recurrent pregnancy loss.
II. OBJECTIVES

1. To know what incompetent cervix is.

2. to have knowledge about the subject matter.
3. to have proper teachings and to distinguish which is fact from which is
false.
4. to interpret and understand all knowledge gained about incompetent
cervix.
5. to pass my duty in sapang palay by doing required research.
6. to not feign ignorance about subject.
7. to be ready if such a case arises in the present or perhaps in the future.
8. to achieve growth by added knowledge for the betterment of my chosen
career path.
9. To notice and point out different names given by specialists on cervical
incompetence (i.e. incompetent cervix etc.)
 III. ANATOMY AND PHYSIOLOGY

 Embryologically, the body and cervix of the uterus are derived from fusion
and recanalization of the paramesonephric (Mullerian) ducts, a process
that is complete by the 5th month of pregnancy.
 Histologically, the cervix consists of fibrous connective tissue, muscle, and
blood vessels. Muscular connective tissue constitutes approximately 15%
of the cervical stroma, but is not uniformly distributed throughout the
cervix, constituting approximately 30%, 18%, and 7% of the upper, mid,
and lower thirds of the cervix, respectively (2).
 Conversely, the fibrous connective tissue content of the cervical stroma
increases as one moves from the external os to the uterine corpus, and it
this component that is believed to confer tensile strength to the cervix.
Defects in tensile strength are thought to lead to premature cervical
dilatation and pregnancy loss.
Physical evidence (- Or + Prepregnancy physical findings (
 Ability to introduce a number 8 Hegar dilator or equivalent through
the internal os when patient is not pregnant.
 Hysterosalpingogram demonstrating cervical funneling.
 Clinical evidence of extensive obstetric or surgical trauma to cervix.
 IV. PATHOPHYSIOLOGY

What is going on in the body?

The normal cervix begins to open after about nine months of pregnancy. It
starts to open only in response to uterine contractions just before birth. But an
incompetent cervix begins to open and thin out before contractions have begun
and before a pregnancy has reached term. The cause is a weakness in the
cervix. The weakened cervix opens because of growing pressure from the uterus
as pregnancy progresses.

What are the causes and risks of the condition?

Following are factors that increase the likelihood of an incompetent cervix:

• an abnormally formed cervix or uterus because of a birth defect, which

may occur, for example, if a woman's mother took a drug called
diethylstilbestrol, or DES, while she was pregnant
• damage to the cervix, such as during a previous birth
• previous surgery on the cervix, such as a cervical biopsy, a LEEP
procedure or a dilatation and curettage, or D&C
 V. SIGNS AND SYMPTOMS

Unfortunately, cervical insufficiency usually has no symptoms in the first

affected pregnancy. The cervix dilates without the woman necessarily noticing
any contractions, and then the waters break and the baby is born – sometimes
too early to have a chance at survival. Women may have some spotting or
bleeding, but usually by the time the condition is detected, it is too late to stop the
preterm birth.

Women with incompetent cervix typically present with "silent" cervical

dilation (i.e., with minimal uterine contractions) between 16 and 28 weeks of
gestation. They present with significant cervical dilation (2 cm or more) and
minimal symptoms. When the cervix reaches 4 cm or more, active uterine
contractions or rupture of membranes may occur.
 VI. DIAGNOSTIC TEST

Diagnosis is determined by a history of repeated miscarriages, an internal

pelvic examination, and by ultrasound scanning. The use of ultrasonography has
been very helpful with the diagnosis, and is made when the cervical os (opening)
is greater than 2.5 cm, or the length has shortened to less than 20 mm. A vaginal
ultrasound can be very helpful in diagnosing and incompetent cervix. Sometimes
funneling is also seen, this is where the internal portion of the cervix, internal os
(portion of the cervix closer to the baby) has begun to efface. The external os will
be unaffected if diagnosed in time. An incompetent cervix may also be corrected
in a non-pregnant woman.
 VII. MEDICAL MANAGEMENT

The cerclage is basically a method of strengthening of the cervix by

placing a circumferential suture at the level of the internal cervical os. A cerclage
can be placed either vaginally (most common) or abdominally (less common).
There are different modifications of the vaginal cerclage, such as McDonald
cerclage, Shirodkar cerclage, etc. Although they differ in surgical techniques,
these operations are considered equally efficacious, and allow for possible
vaginal delivery. The abdominal cerclage, as the name may imply, requires major
abdominal surgery with subsequent delivery via cesarean section. This approach
is usually reserved for patients who have failed vaginal cerclage, or who have
either a significant anatomical cervical deformity or an atrophied cervix for which
the vaginal approach is not feasible.

Despite the fact that prophylactic cerclage is considered the standard

treatment of incompetent cervix, the best and most effective treatment is yet to
be determined through clinical randomized trials. Nevertheless, patients with
classic history of incompetent cervix should be offered cerclage. Patients who
have received prophylactic cerclage may be followed with serial sonographic
studies to detect and monitor any ongoing cervical changes. In patients where
past obstetric history is concerning or suspicious for cervical incompetence,
conservative but close management, i.e., bed rest, serial sonographic evaluation
of the cervix, may be offered.
before cerclage – length of cervical canal , width of isthmus , funneling of upper
part of cervical canal with protrusion of the membranes(when the cervical os
(opening) is greater than 2.5 cm, or the length has shortened to less than 20 mm.
Sometimes funneling is also seen )
After cerclage – determine exact site of cerclage,proximal cervical canal
segment length above cerclage ,distal cervical canal segment length below
cerclage,internal os diameter ,funneling if present , and protrusion of
membranes)

Kinds of enclarge (Known cases)

Lash cerclage
 is the only type that is placed prior to pregnancy. In cases where there has
been extensive cervical trauma or an anatomical defect, this stitch can be
used. It is permanent and requires a cesarean delivery.
Shirodkar technique
 With the Shirodkar technique, the vaginal mucosa membrane is elevated.
A band of homologous fascia or narrow band of some material such as
Mersilene is wrapped around the internal os and tied. The vaginal mucosa
is then restored to its original position and sutured.
 The Shirodkar can be both permanent (requiring a cesarean section) or it
can be removed near term. This stitch is started at a 12 o’clock position,
worked through the cervix to a 6 o’clock position, ending back in the 12
o’clock position on the other side of the cervix. It is also pulled tightly and
tied to keep the cervix closed. How the stitch is tied off determines
whether it will be removed or if it is permanent.
McDonald technique
 a simpler procedure, a non-absorbable suture in placed around the cervix
high on the cervical mucosa
 stitch is weaved in and out of the cervix and pulled tightly and tied to keep
the cervix closed.
The Hefner cerclage

when incompetent cervix is diagnosed later in pregnancy. It has an added benefit

when there is little cervix to work with. This cerclage is removed closer to term as
well.
also know as the Wurm procedure, is used for later diagnosis of the incompetent
cervix. It is usually done with a U or mattress suture, and is of benefit when there
is minimal amounts of cervix left.

Transabdominal cerclage

 is not frequently performed

 is only indicated for those patients with previous failed cervical cerclages,
shortened or amputated cervix, and/or deep traumatized cervix
 The surgical technique -- caudal reflection of the bladder, placement of an
encircling A 5mm wide mercilene tape medial to the uterine vessels in an
avascular space above the junction of the cervix and the uterine isthmus
without dissection or tunneling among broad ligament vessels above the
cardinal and uterosacral ligaments , and tying of the knot posteriorly.
 This prevents erosion of the knot into the base of the bladder and allows
for removal via posterior colpotomy in an emergency situation.
 VIII. NURSING MANAGEMENT

Patients who have received prophylactic cerclage usually assume modified

physical activities. Although standardized monitoring plans are lacking, close
prenatal visits and serial sonographic cervical monitoring may be beneficial.
When the gestational age reaches 36-37 weeks, the cerclage may be removed in
the office, and the patient may then be followed expectantly. In cases of
abdominal cerclage, delivery is usually accomplished via cesarean section after
documentation of fetal lung maturity at 36-37 weeks.
Theres no guarantee that a cerclage will prevent a pregnancy loss; however,
in most instances it will prolong the pregnancy, often enabling a woman to carry
to term. You may be at risk for incompetent cervix if you have had a previous
pregnancy loss in the second trimester, if you have had surgery on your cervix,
or if you have had multiple pregnancy terminations
The woman will need to be followed closely throughout her pregnancy to
check on the condition of the cervix. Prenatal visits will be more frequent than
usual. The woman should tell her healthcare provider right away if she has any
contractions or leaking of fluid from the vagina. Any other new or worsening
symptoms should also be reported to the healthcare provider.
Most needed by patient
1. consult physcisian atleast 2x every week for new findings if any.
2. bed rest more than average sleep.
3. hygiene control
4. health teachings given by the nurse in charge.
REFERENCES
Gail Hendrickson, RN, BS,Adam Myers, MD ; university of Illinois Medical Center
at Chicago © 2006

Dr Muhammad El Hennawy Ob/gyn specialist Rass el barr central hospital and

dumyat specialised hospital Dumyatt – EGYPT

www.geocities.com/mmhennawy

http://www.moondragon.org/obgyn/disorders/incompetentcervix.html

http://uimc.discoveryhospital.com/main.php?id=2047

http://www.pregnancy.org/article/incompetent-cervix