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Definition Inability of the uterine cx to retain a pregnancy in the absence of contractions or labor Incidence and Prevalence The lack of objective findings.

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Presentation on theme: "Definition Inability of the uterine cx to retain a pregnancy in the absence of contractions or labor Incidence and Prevalence The lack of objective findings."— Presentation transcript:

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2 Definition Inability of the uterine cx to retain a pregnancy in the absence of contractions or labor Incidence and Prevalence The lack of objective findings and clear dx criteria makes the incidence of CI difficult to ascertain

3 Risk Factors Congenital Acquired Congenitally short Cx Mullerian duct abnormalities Deficiencies in Cx collagen & elastin Trauma Cx laceration following SVD Prolonged 2 nd stage of labor Surgical Procedures involving the Cx (D&C, Cone bx) Uterine over distention (multiple gestation, Polyhydramnios)

4 1. Congenitally short Cx most common developmental factor Iams, JD, Goldenberg, RL, Meis, PJ, et al. N Engl J Med 1996; 334:567(level II-2) Risk Factors A. Congenital

5 2. Mullerian duct abnormalities The risk of CI is highest among women with bicornuate & unicornuate uteri A. A. Congenital Risk Factors

6 B. Acquired 1. Trauma Cx laceration following SVD Prolonged 2 nd stage of labor Surgical Procedures involving the Cx (D&C, Cone bx) (although data confirming this association are limited) Iams, JD, Goldenberg, RL, Meis, PJ, et al. N Engl J Med 1996; 334:567.(level II-2) Risk Factors

7 2. Uterine over distention (multiple gestation, Polyhydramnios) 2. Uterine over distention (multiple gestation, Polyhydramnios) Uterine over distention may cause subsequent preterm birth due to Cx shortening from mechanical factors or biochemical changes The only randomized trial evaluating use of elective prophylactic cerlcage in twin pregnancies did not find a benefit Dor, J, Shalev, J, Mashiach, S, et al. Gynecol Obstet Invest 1982; 13:55. (level I) The value of this procedure in higher order multiple pregnancies is controversial Elimian, A, Figueroa, R, Nigam, S, et al. J Matern Fetal Med 1999; 8:119. B. B. Acquired Risk Factors

8 Clinical Manifestations ► The classic presentation of CI is: Cx dilatation and effacement in the 2 nd trimester with fetal membranes visible at or beyond the external os in the absence of contractions. Which maybe asymptomatic or associated with: (sonographic manifestations of CI often occur prior to clinically detectable Cx changes) Vaginal fullness or pressure Spotting or bleeding An ↥ volume of watery, mucousy or brown VD Vague discomfort in the lower abdomen or back

9 Diagnosis Pregnant women There are no tests which can be performed to predict CI in a future pregnancy. Those that have been proposed are inaccurate, inconvenient, or unproven in scientific studies Non-Pregnant women This may be based upon historical, clinical or sonographic criteria (non has been validated in well designed studies)

10 Diagnosis Pregnant women Historical features of CI 1.Hx of two or more 2 nd trimester pregnancy losses 2.Hx of losing each pregnancy at an earlier gestational age 3.Hx of painless Cx diltation of up to 4-6 cm 4.Absence of clinical findings consistent with placental abruption 5.Hx of Cx trauma caused by  Cone bx  Intrapartum Cx lacerations  Excessive, forced Cx dilatation during TOP Harger JH. An evidance based analysis. Obstet Gynecol 2002;100: (level II-2)

11 Clinical criteria A digital examination should always be performed to evaluate the Cx in cases of CI, followed by TVS if the clinical examination is not diagnostic Clinical findings include → significant premature Cx effacement and/or dilatation (> 2cm) specially with prolapse of fetal membranes into or completely through the endocervical canal (hourglassing) Diagnosis Pregnant women

12 Sonographic features US of the Cx is more accurate and reproducible than D/E The most consistent image of the Cx is obtained by TVS performed at ≥ 16 wks Noninvasive stress techniques as : transfundal pressure, coughing and standing have been used to elicit US Cx changes Serial US assessment of Cx length in women between wks has been correlated with PTD Iams, JD, Goldenberg, RL, Meis, PJ, et al. N Engl J Med 1996; 334:567(level II-2) Diagnosis Pregnant women

13 Treatment approaches Non-surgical modalities Modified activity Bed rest Pelvic rest IM hydroxyprgesteron Vaginal pessaries Have not achieved wide spread acceptance and have not yet been proved to be effective Surgical (cerclage) Newcomer J. Ostet Gynecol Surv 2000; 55: (level III) The rational for surgery is that cerclage compensate for inherent Cx weakness & the only indication is the prevention of CI during pregnancy Cx cerclage is the standard treatment for CI, despite little data from randomized trials proving efficacy MRC/RCOG Working Party on Cervical Cerclage. Br J Obstet Gynaecol 1993; 100:516 (level I). Lazar, P, Gueguen, S, Dreyfus, J, et al. Br J Obstet Gynaecol 1984; 91:731. (level I)

14 Contraindications to Cerclage Maternal factors: Fetal factors: Premature labor Premature rupture of membranes Abruption of placenta Intraamniotic, cervical, or vaginal infection Medical condition that precludes administration of anesthesia or continuation of pregnancy Fetal demise Fetal anomaly incompatible with extrauterine life Nonreassuring fetal status GA > 24 to 28 wks Treatment approaches Surgical

15 To reinforce the Cx at the level of the internal os; a 2ry effect is to lengthen the Cx Cervical Cerclage Transvaginal Transabdominal Treatment approaches Surgical Objective Procedure

16 Transabdominal cerclage has not been shown to be more effective than TV, and it is a more morbid procedure that requires a laparotomy and subsequent C/S delivery. As such, it should be reserved for women with CI who have either failed previous TV cerclages or in whom a TV cerclage is technically impossible to perform due to extreme shortening, scarring, or laceration of the cx. Treatment approaches Surgical Indications and contraindications Cervical Cerclage Transabdominal

17 Treatment approaches Surgical

18 McDonald: a purse-string suture placed around the Cx as cephalad as possible & without dissection of the bladder or rectum. Treatment approaches Surgical Transvaginal Cervical Cerclage

19 Shirodkar: is performed using a 5 mm Mersilene tape placed around the Cx at the level of the internal os after surgically reflecting the UB anteriorly & the rectum posteriorly. Treatment approaches Surgical Transvaginal Cervical Cerclage

20 ACOG practice bulletin number 47, October 2003: Obstet Gynecol 2003; 102:875. ACOG practice bulletin number 47, October 2003: Obstet Gynecol 2003; 102:875. Treatment approaches Surgical Preoperative preparation General issues An US examination should be performed proximate to the procedure to determine if there are gross fetal structural anomalies. Cultures for gonorrhea and chlamydia should also be taken if the patient is at risk. Antibiotic treatment should be initiated, as appropriate, if cultures are positive and treatment should be completed prior to elective cerclage placement. Cervical Cerclage

21 The routine use of periop antibiotics for prophylactic or emergency cerclage remains controversial, and is not generally recommended due to insufficient evidence of benefit. There is also no proven benefit to postop antibiotic administration. Treatment approaches Surgical Preoperative preparation General issues Testing for GBS is not required. Confirmation of fetal viability, is mandatory immediately before and after the procedure. ACOG practice bulletin number 47, October 2003: Obstet Gynecol 2003; 102:875. ACOG practice bulletin number 47, October 2003: Obstet Gynecol 2003; 102:875. Cervical Cerclage

22 Patients are maintained on reduced activity and pelvic rest (eg, no coitus, tampons, or douching) for one week and then liberalize activity based upon the individual's clinical circumstances. Treatment approaches Surgical Prophylactic cerclage is typically an ambulatory surgery procedure. The patient may be discharged after recovery & when she is able to ambulate & void. Acetaminophen alone provides adequate analgesia for most women. They should be told to expect some spotting, cramps, and dysuria which will abate within a few days. There is no evidence that coitus adversely affects perinatal outcome in patients with a cervical cerclage. Cervical Cerclage / post op care:

23 Alternatively, hospitalization and/or antenatal corticosteroids may be considered if the Cx is dilating & effacing & preterm delivery appears likely. O'Brien, JM, Hill, AL, Barton, JR. Ultrasound Obstet Gynecol 2002; 20:252. Treatment approaches Surgical Postoperative Care All women are followed as outpatients on a regular basis with frequent visits for cervical checks. US assessment of the Cx (at least four weeks post op) may also be useful for predicting those patients at highest risk for preterm delivery after the procedure, although the utility of post-cerclage cervical length measurement is controversial Rust, OA, Atlas, RO, Meyn, J, et al. Does cerclage location influence perinatal outcome?. Am J Obstet Gynecol 2003; 189:1688.

24 Whether to remove the cerclage in the setting of PPROM is controversial A Shirodkar cerclage does not have to be removed if cesarean delivery is anticipated and future pregnancies are planned Cerclage removal The cerclage is removed electively at 37 to 38 weeks or immediately with the onset of premature labor to avoid cervical laceration and/or uterine rupture Treatment approaches Surgical

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