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THE INCOMPETENT

CERVIX
PRESENTED
BY
DR T.K. NYENGIDIKI
SENIOR REGISTRAR
INTRODUCTION
• Repetitive reproductive disappointment
• Frustration and Hopelessness, especially
in this environment
• Obstetrician faced with diagnostic
difficulty because absence of strict
diagnostic criteria and the anxiety of
patient.
• Relatively good results.
History
• Classical presentation:
-Recurrent mid trimester miscarriage
-painless cervical dilatation
-Rupture of membranes/expulsion of fetus
• Preterm delivery
• Elicit other predisposing factors
• Diagnosis based on history is retrospective
• One classical hx may also be suggestive
Investigations – non pregnant
• Easy passage of a size 8 Hegar’s/Pratt’s
dilator 15-17
• Foley’s catheter traction test - size 16 F balloon
filled with 1ml of water (6mm)
• Hysterosalpingography- dilated internal os >
6mm /widened isthmus( funnel/ Inverted Bishops
cap)
• Cervical compliance test (Zlatnik/ Burmeister)-
physical cervical assessment
-has three parameter with the 1st two having
scores from 0-2 and the last 0&1.
-canal cannula ratio during hysteroscopy :< 1.5 ,
1.5-1.9,>1.9.
continued
-degree of force needed for insertion of a size 8
hegars’s dilator : Would not pass, little force or no
force.
-Catheter traction force < 700g>
-Score range 0-5
-Higher scores more likely preterm delivery.
• Cervical resistance index ( Anthony )-Simple strain
gauge .Low in women with Hx of C.I.
• Limitations – Hx suggestive of cervical
incompetence.
Investigations -pregnant state
• Weekly or forthnightly cervical
assessment- softening effacement and
dilatation
• Serial ultrasound assessment of the lower
uterine segment and cervix
-length of the cervical canal: <2.5cm-risk
-diameter of the internal os:>15 mm in the
1st trimester and > 20mm in the 2nd
trimester
-Prolapse of the fetal membrane thro os
-All parameters are tested against stress :
transfundal pressure, standing & coughing
Ultrasound continued
• Transvaginal ultrasound preferred
-empty bladder
- Identification of anatomical landmarks of
the external and internal os
TECHNICAL DIFFICULITIES
1.Cervix may be falsely normal if the bladder is
over distended
2.Increased intrauterine pressure may give false
impression of incompetence
3.Transducer angulation and pressure- artificial
distortions
4. Contraction in the lower uterine segment can
give a false impression
5.Cervical Os is dynamic
TREATMENT
SURGICAL /MEDICAL

SURGICAL
-Cerclage procedures
-Bridging procedure
-Repair procedures
-Sacrification procedures
CERCLAGE PROCEDURES
• Most common
• Principle
-encircling the cervix with resilient band
like material –purse string
-maintaining the integrity of the internal os
-Disallowing dilatation and effacement
VARIATIONS
• Various methods exist but variations in
- purse string material
-differences in location
-timing of the procedure
Shirodkar’s procedure
-Developed in 1955
-Vaginal approach to the cervix
-Involved placement of a nonabsorble suture
such as fascia lata, silk, nylon or mersilene tape
around the cervix at the internal os.
-The suture lies completely beneath vaginal and
cervical mucosa.
Procedure
-The junction between the anterior vaginal wall
rugose with the smooth cervical mucosa is
identified.
-Transverse incision 2cm long is made at the
junction and the bladder bluntly dissected until
the uterovesical peritoneum is identified.
-A atraumatic needle is passed submucosally in
the cervix postero-anteriorly and knoted
- The vaginal mucosa thereafter sutured
anterioposteriorly
• Original idea was to leave stitch in situ and opt for
caesarean section
• Success rates 80%

• McDonald Procedure
-Most commonly used in this centre
-In lithotomy position cervix is visualized using a sim’s
speculum
-The anterior and posterior lips held with sponge holding
forceps
-The junction between the anterior vaginal rugose and
smooth cervical mucosa is identified- internal os
-Placement of the suture is done just below this point
-Four bites in the substance of the cervix are taken
circumferentially purse string
• First bit taken just before 12 o’clock and last just after 12
0’clock
• The needle removed and the knotted up to four times
with the knot left 2-3 cm long
Advantages over shirodkar
• Greater technical ease
• Fewer complications
• Comparatively reduced incidence of
C/section
• No need for anaesthesia during removal
Complications of cerclage
• Infections
• Bleeding
• Anaesthetic complications
• Accidental rupture of fetal membranes
• Vesico vaginal fistula
• Premature labour
• Maternal death in the presence of sepsis
due to prom
Bridging procedures
• Involves bridging the opposite walls of the
cervix with an unyielding material
• Wurm’s procedure
-Ist described by Rogers Wurm
-Done in later pregnancy
-Done after dislocation of a previous cerclage,
partial cervical dilatation and partial effacement
-Mattress sutures are placed at 12 & 6 o’ clock
position and 3 & 9 o’clock position
• Baden and Baden procedure
-1cm on the anterior and posterior
surfaces of the cervix are debrided.
-The two surfaces are sutured together
Repair procedures
• Lash and Lash procedures
-Believed there is a structural defect in the
anterior cervix at the time of spontanous
abortion.
-wegded shaped segment of the area of defect
is removed above the internal os
-Remaining area is sutured with chromic catgut
in two layer.
-Success rate as reported by lash and lash 86%
Scarification procedures
• Barnes Procedure
-upper cervix is scarified circumferentially
with electroconization
-Increasing tensile strength of the cervix
• Page procedures
- external cervical scar in shape of long
coil or spirals
ALL ARE HISTORICAL!
Timing of procedure
• Originally Shirodkar favoured
preconception or post-conception
placement.
• Barter et al advocated 14-16 week
placement
-Technical ease of procedure
-Chance for natural selection
-
Emergency cerclage
• Transcervical cerlage performed as an
emergency
• Preserve for patients without classical features
incompetence
• Patient experiencing features of incompetence in
an index pregnancy :prolapse of membranes,
cervical dilatation and effacement
• Success rate lower
• Higher incidence of infection
• Prolonged hospital stay
Transabdominal cervical cerclage
• Developed by Benson and Durfee in 1965
• Post conception/preconception
• Abdomen entered via a midline or pfannenstiel’s
incision
• Cerclage stitch inserted at the cervico isthmic
level via avascular window in the board ligament
• Delivery is by abdominal route
• Method preserved for patients with extremely
short cervix, previously failed vaginal cerclage
The bulging membrane during
emergency cerclage
• Obstetrician is confronted with a bulging
membranes during emergency cerclage
• Management options
-insertion of a foley’s catheter with 20ml balloon
with the distal cut end inserted into the
cervical canal and inflated.
-use of 6-10 stay stitches attached to the edges
of the cervix with the patient in deep
trendelenburg position. Traction pushes back
the membrane
Bulging membranes
• Bladder distension with 1000mls of normal
saline
• Use of inflatable bags
• Transabdominal amniocentesis with
evacuation of 150mls of amniotic fluid.
Preoperative preparation
• Vigorous preparation with use of chemical antiseptics
should be discouraged
• Copious irrigation of vagina under direct vision normal
saline or ringer’s lactate. Povidine iodine preparation
also advised.
• Microbial culture
- cervical/urine culture
Anaesthesia
• Various forms of anaesthesia had been
used
• Inhalational, spinal and general
anaesthesia.
• Different views
• opponents of GA –excessive coughing
• Proponents of inhalational anaesthesia
- relaxation of the uterus
Post operative instruction
• Antibiotics
-cefoxitin, amoxicillin, ampicillin and clindamycin,
erythromycin.
• Tocolytics
-controversial except for patients with
uterine irritability.
• Bed rest advised for the 1st 24 hours followed by
mobilization and activity
• Discharge after a couple of days advised - studies
have found no benefit for staying more than one week

Removal of cerclage
• Timing: usually b/w 37-38 weeks
• Earlier removal
-excessive vaginal bleeding
-intrauterine fetal death
-persistent uterine contraction
-Rupture of fetal membranes
Medical management
• Hodge pessaries
-Developed by Vitsky in 1961
-properly placed pessaries can cause cervix to
point posteriorly
-alleviate some of the direct pressure on the
cervix
-preventing descent of the fetal head
-Best results obtained if inserted at 14 weeks
-Success rate 92%
-Removal not later than 38 weeks
Medical management cont.

• Baylor Balloon
-Proposed in 1972
-Double silicon plastic cuff inserted on
cervix to act as cuff.
• Progesterone
-Reduces uterine tone
-Studies by Sharma showed a 92% success rate
when it used alone compared to 82% with
surgery and 47% -surgery alone
Advice at discharge
• Avoid coitus
• Avoid insertion of any substance into vagina
• Gradually resume normal activity but avoid
strenuous activity
• Report any increased vaginal discharge, vaginal
or back pressure or pelvic cramps
• Follow routine antenatal clinic attendance but
may need to be examined forthnightly to
determine the integrity of the cerclage

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