CERVICAL INSUFFICIENCY - GYNAEOBS

 

Cervical Insufficiency

-          Recurrent painless cervical dilatation leading to second trimester loses

-          “The inability of the uterine cervix to retain a pregnancy in the 2^nd trimester in the absence of clinical contractions, labor or both”

 

Pathogenesis

-          Structural cervical weakness ( Leading to recurrent 2^nd trimester losses )

§  Acquired - may be secondary to cervical surgery or uterine surgery

o   (Dilatation , curettage , hysteroscopy )

§  Congenital

o   Nonrecurrent 2^nd trimester looses

§  Decidual infection /inflammation

§  Bleeding at the surface between decidua and placenta

§  Uterine over distension

Clinical findings

-          History of Recurrent 2^nd Trimester pregnancy losses or live births (often before 24 weeks )

-          No / minimal mid symptoms

-          Cervical dilation or effacement on physical examination

RISK FACTORS

-          Cervical trauma (most common) = during labor (spontaneous or iatrogenic), mechanical dilation during gynecologic procedure, tumor treatment

-          Congenital cervical anomalies(rare) genetic disorder affecting collagen synthesis (Ehlers Danlos Syndrome), uterine anomalies, in vitro Diethylstilbesterol

-          Short cervical length –detected on transvaginal USG

 

SYMPTOMS

Begins at 14 to 20 weeks of Gestations

-          Braxton Hicks Contractions

-          Pelvic pressure

-          Premenstrual like cramping / backache

-          Change in vaginal discharge (Volume increase, thickness decrease, color change from normal (white, light yellow) to pink, tan, red spotting)

EXAMINATIONS

-          Cervix = soft, closed with minimal effacement

-          Tocodynamometry = no infrequent contractions

-          Provocative maneuvers (Supra pubic pressure , fundal pressure or Valsalva  maneuver ) reveals fetal membrane in the canal( membrane may prolapse )

Imaging

-          Transvaginal USG             (TVU) (CL <= 25mm)

-          Debris (sludge or biofilm), SLUDGE = fetal squames, vernix, leukocytes, bacteria

-          On Serial USG, CL may decrease

Diagnosis

Past History

§  Past history of >2 consecutive second trimester losses or extremely low term (mostly loss before 24 weeks)

Ultrasound Based diagnosis

§  Obstetrics history of second trimester loss or premature delivery (<28 weeks) and short CL in TVU

§  Serial USG shows CL <= 25 mm in 24 weeks

§  Infections, labor, bleeding excluded

Physical Examination

-          Usually in patients in between 14 to 27 weeks of Gestation

-          Physical examinations= effacement in absence of labor, advanced cervical dilation

-          Membrane may be prolapsed or rupture

-          Labor, infection, and bleeding related to placental abruption or placenta previa should be excluded

-          Exclusion of other differential diagnosis

Diagnosis Exclusion Technique

-          Labor – Tocodynamometry

-          Infection – Urine culture /Urinalysis Culture and amniocentesis (when uterine dilation or membrane effacement confirmed on examination)

-          Bleeding – history, physical and ultrasound examinations

 

When to perform Amniocentesis?

-          When cervix dilated >=2cm or manual or speculum examination (incidence of intraamniotic infection = 20 to 50 %)

-          USG= inflammation finding (debris /sludge /biofilm)

-          Membrane visible or exposed at external Os