CERVICAL INCOMPETENCE

n CERVICAL INCOMPETENCE

n  SUB TOPICS

n   Introduction

n   Definition

n   The disorder

n   Aetiological factors

n   Presentation

n   Diagnosis

n   Management

n   Complications

n   Contraindications

n   Prognostic factors

n   Conclusion

n  INTRODUCTION

n   Cervical incompetence  is an obstetric disorder that  usually follow TOP, the incidence has been gradually increasing over the years and this is because of the  increasing incidence of therapeutic  abortions.

n   The incidence is about 1 in 500 pregnancies, in some tertiary health centers ,an incidence of 1 in 100 pregnancies has been reported this is higher in  women with previous abortion and in high order multiple pregnancies, (in triplet gestation it is about 10% -15%)

n  INTRO. CONTD.

n  It  is the commonest cause of second trimester abortion accounting for about 33% of all second  trimester abortions.

n  DEFINITION

n  Cervical incompetence , is defined as the inability of the cervix to maintain a pregnancy to term due to functional or structural  defect.

n  THE DISORDER

n   There is a weakness or a destruction of the sphincteric mechanism of the internal os.

n   With increasing GA  the intrauterine pressure from the  growing fetus and increasing amniotic fluid vol.  exceed the “closure pressure” of the internal os, this  xticlly occurs  in the absence of uterine contractions.

n   There is a painless, mechanical dilatation of the internal os of the cervix that culminates in expulsion of the products of conception.

n  AETIOLOGICAL FACTORS

n  CONGENITAL-

n  Congenitally short cervix

n  Collagen dxs (Ehlers Danlos  synd., SLE, etc)

n  Uterine anomalies

n  Use of DES by a pregnant woman

n  AETIOLOGICAL FACTORS CONTD

n   ACQUIRED-

n   Repeated cervical dilatation (D&C)

n   Precipitate labour

n   Instrumental delivery

n   Cervical laceration

n   Delivery of macrosomic babies

n   Bearing down in labor b/4 FCD

n   Cervical amputation as in Manchester repair

n   Conization of the cervix (cone biopsy)

n  PRESENTATION

n  Recurrent mid trimester abortion,  usually after 14 wks that is usually not associated with pain or  significant bleeding. There is usually associated passage of show (operculum) and there may be associated urgency or frequency of  micturition.

n  Occasionally the aborteus may still be in an intact gestational sac

n  DIAGNOSIS

n   This can be  suspected clinically based on a  history of recurrent mid-trimester abortion , that is characteristically not associated with pain and with little or no bleeding.

n   Definitive diagnosis is by any of the following tests ;

n   Hegar’s test

n   Traction test

n   HSG

n   USS*  (uss with pressure on the uterine fundus may show a dilated and effaced cervix and or descent                 of the fetal membranes)

n  MANAGEMENT

n  History

n  Of  interest will be any hx of D&C

n   Hx of delivery of macrosomic babies

n  Hx of instrumental delivery

n  Hx of previous labors to r/o precipitate labor

n  Hx of any gynae surgery that involved the  amputation or resection of the cervix (Manchester repair)

n  MGT CONTD.

n  Treatment -

n  Medical- use  of  cervical pessaries (Smith –Hodge, ring)

n  Surgical-  Cervical cerclage (CC );this is the definitive treatment ,it is normally done btw 14 & 20 wks. The  techniques used include the following :

n  MGT CONTD.

n  McDonald's technique (purse string suture)

n  Shirodkar’s technique (skin or fascia suture)

n  Wurm’s technique (right angle mattress suture)

n  Repair by Lash & Lash technique

n  POST OP MGT.

q   Bed rest  for 24 – 48hrs with the foot of the bed elevated.

q  Sedatives.

q  Analgesics for the pain.

q  Tocolytics to prevent preterm contractions depending on the  risk.

q  Prophylactic antibiotics

n  COMPLICATIONS OF CC

n  Haemorrhage

n  ROM

n  Injury to the bladder

n  VVF

n  Anesthetic complications

n  Iatrogenic infections

n  Rupture of the uterus (if  cerclage is not removed in labour)

n  CONTRAINDICATIONS TO CC

n  Gestational age < 12wks or > 28wks

n  PROM

n  IUFD

n  Active phase of labour

n  Abruptio placenta

n  Intrauterine infection

n  APH

n  Fetal Congenital anomaly

n  PROGNOSTIC FACTORS

n  How high the suture is placed

n  Accuracy of diagnosis

n  Cervical dilatation at insertion of the suture

n  Extent of the defect

n  Stage of pregnancy

n  CONCLUSION

n  It should be noted that about 30% - 40% of perinatal deaths  occur in pregnancies which terminate  btw 20 & 28 wks and cervical incompetence is a major contributor, hence  any plan to  effectively reduce perinatal mortality must include preventive measures to avoid cervical incompetence and to manage it appropriately when it has accurately been diagnosed.

n  impt

n   Cc could be transvaginal or transabdominal (cervico-isthmic jxn)

n   Cc is done btw 14 and 16 wks, to r/o fetal congenital anomalies and to allow for adequate delineation of the cervix

n   The sutures are removed at 38wks or earlier if there are indications for it ;

n   vaginal bleeding                                                                                                                                                                     rupture of membranes                                                                   preterm labour or miscarriage

      IUFD

      chorioamnionitis

n   Success  rate is btw  40% and  90%

n   1 in 4 women with CI have no history of cervical injury

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Posted by : Unknown July 14, 2015 Tags : NEWS

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