Cervical Incompetence 1

CERVICAL INCOMPETENCE DEFINITION: Cervical incompetence is the inability of the cervix to retain intrauterine pregnancy to term because of deficiency in structure or function resulting to abortion or premature labour. Classically it is described as recurrent, painless, second trimester spontaneous abortion without initial vaginal bleeding. INCIDENCE This is variable from 1 -10 per 1000. It is the commonest cause of habitual abortion in the midtrimester. Brief History In 17TH century a form of cervical tear was first recognised -1865 Gream in lancent published the term cervical incompetence -1902 Hermam treated women by cervical repairs. -1948 Palmer and Lacombe in UK defined cervical incompetence.

-1950 Lash and Lash USA also defined cervical incompetence. -1955 Shirodkar an INDIAN showed series of successful cerclage results using facia lata in pregnant women. -1957 McDonald an American simplified the cerclage procedure using non absorbable suture at the Lower level of the cervix. -1965 Benson advocated for abdominal approach in pregnant women -Wurm an AUSTRALIAN applied 2 mattress sutures at 12/6, 3/9 O’ clocks. AETIOLOGY: This can be Anatomical or Physiological Anatomical: Congenital Mullerian abnormalities –bicornate uterus, uterus didelphys, septate uterus, cervical tags and perforations. Diethylstilboestrol: -Abnormal lower uterine segment -Short cervix that is flushed with the vagina. -Short cervical canal -Few cervical fibrous tissues.

Acquired Anatomical causes: D&C Cone biopsy & amputation of the cervix Lacerations Normal vaginal deliveries Precipitate labour Instrumental vaginal deliveries Infections: Bacterial activities in the cervix release cytokines which digest the collagen fibres Physiological cause: For unexplained reasons the cervix dilates spontaneously CLINICAL FEATURES History of; Recurrent mid-trimester abortions, D&C, Cervical surgeries, Instrumental vaginal deliveries Mucoid vaginal discharges & Rupture of fetal membranes

Examination Speculum examination of the cervix will show effacement and dilated cervical os. Bulging membranes may be seen. Digital examination will confirm the same DIAGNOSIS: Non pregnant state; -History of cervical trauma following gynaecologic & obstetrical injuries. -History of recurrent midtrimester pregnancy losses. -Digital vaginal examination revealing effaced and dilated cervix -Passage of Hegar dilator size 8 starting with larger sizes. -Passage of size 16 Foley’s catheter inflated with 1ml of water. -Cervico-isthmography or hysterography showing funnel shaped canal and Abnormal uterus. MRI In pregnancy. -Ultrasound scan using transviginal probe should measure the internal os -Width and the cervical length. The bladder should be empty during the Procedure.

Criteria for diagnosis – -Length 0f cervix <2 cm. -Width of internal os =7cm with membranes herniating into the cervical canal is an ominous sign. Varma et al -Width of internal os >15mm in the 1st trimester Mahran et al -Width of internal os >20mm in the 2nd trimester. -Cervical canal shortening at 0.41cm/wk between 1524wks -funnelling of the internal os-U or V shape. -bulging of the membranes into the cervical canal.