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WACS > CERVICAL INCOMPETENCE > Flashcards

CERVICAL INCOMPETENCE Flashcards

1
Q

Define cervical incompetence

A

CI is defined as a painless dilation of cervix in the absence of uterine contractions resulting in second or early third trimester delivery

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2
Q

T/F: There is an inability to hold the weight of the pregnancy resulting in bulging of the amniotic membranes into the vaginal canal leading to rupture of the membranes and preterm labour/fetal loss

A

T

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3
Q

T/F: Usually occurs in the 2nd trimester

A

T

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4
Q

Dimensions of the ectocervix

A

3cm long
2.5cm wide

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5
Q

In pregnancy the normal cervical length measured from internal to external os is

A

4cm +/- 1cm

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6
Q

T/F: Risk factors can broadly be classified into congenital and acquired

A

T

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7
Q

Apart from the acquired and congenital risk factors, 2 other risk factors are – and –

A
  1. Recurrent 2nd trimester losses
  2. History of incompetent cervix in a previous pregnancy
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8
Q

5 congenital risk factors for cervical incomptence

A
  1. Congenitally short Cx
  2. congenital cervical hypoplasia or
    aplasia
  3. Mullerian duct abnormalities
  4. Deficiencies in Cervical collagen
    & elastin - Connective tissue
    disorders (Ehlers-Danlos
    syndrome)
  5. DES (diethylstilbestrol) exposure
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9
Q

2 acquired risk factors for cervical incompetence

A
  1. Cervical injury
    -multiple D&C
    -Cervical laceration at SVD
    -Prolonged 2nd stage of
    labour
    -surgical trauma
    -cone biopsy
    -cervical cautery (to remove
    growths or stop bleeding)
  2. Uterine over distention (multiple gestation, Polyhydramnios)
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10
Q

Cervical incompetence affects –% of the obstetric population

A

1%

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11
Q

% of 2nd trimester miscarriages (16 - 24 wks) attributed to cervical incompetence

A

15 - 20%

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12
Q

T/F: sonographic manifestations of CI often occur prior to clinically detectable Cervical changes

A

T

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13
Q

5 clinical manifestations of cervical incompetence

A

The classic presentation of CI is:
Cx dilatation and effacement in the 2nd trimester with fetal membranes visible at or beyond the external os in the absence of contractions. Which maybe asymptomatic or associated with:
Vaginal fullness or pressure
Spotting or bleeding
An ↥ volume of watery, mucous or brown VD
Vague discomfort in the lower abdomen or back

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14
Q

T/F: In non-pregnant woman there are no tests which can be performed to predict CI in a future pregnancy

A

T

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15
Q

In pregnant women diagnosis may be based upon –, –, and – criteria

A

historical, clinical or sonographic

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16
Q

5 historical criteria for the diagnosis of cervical incompetence

A
  1. History of two or more 2nd
    trimester or early 3rd trimester
    pregnancy losses
  2. History of losing each pregnancy
    at an earlier gestational age
  3. History of painless cervical
    dilatation of up to 4-6 cm
  4. Absence of clinical findings
    consistent with placental
    abruption
  5. History of cervical trauma caused by
    -Cone biopsy, LLETZ
    -Intrapartum cervical
    lacerations
    -Excessive, forced cervical
    dilatation during TOP
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17
Q

How many 2nd trimester miscarriages qualify for a historical diagnosis of cervical incompetence

A

2 or more

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18
Q

T/F: Early 3rd trimester losses is a historical criteria for CI

A

T

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19
Q

History of painless cervical dilation up to –cm is a historical criteria for the diagnosis of CI

A

4 - 6cm

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20
Q

3 causes of cervical trauma leading to a historical diagnosis of CI

A
  1. Cone biopsy, LLETZ
  2. Intrapartum cervical lacerations
  3. Excessive, forced cervical dilatation during TOP
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21
Q

T/F: A digital examination should always be performed to evaluate the Cervix in cases of CI

A

T

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22
Q

Which dilator is used in the clinical diagnosis of CI

A

Size 8 Hegar dilators

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23
Q

3 clinical criteria for the diagnosis of CI

A

A digital examination should always be performed to evaluate the Cervix in cases of CI, followed by TVS if the clinical examination is not diagnostic (subjective)

Clinical findings include → significant premature Cervical effacement and/or dilatation (> 2cm) specially with prolapse of fetal membranes into or completely through the endocervical canal (hourglassing)

Cervix admits size 8 Hegars dilator freely.

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24
Q

The most consistent image of the cervix is obtained by – performed at – wks

A

TVS
≥ 13wks

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25
Q

T/F: transfundal pressure is more effective than standing in eliciting cervical changes during USS

A

T

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26
Q

T/F: Serial Ultrasound assessment of cervical length in women between 24-28 wks has been correlated with pre-term delivery

A

T

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27
Q

Noninvasive stress techniques used in eliciting USS cervical changes are –, – and –

A

Transfundal pressure
Coughing
Standing

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28
Q

On TVS the normal shape of the endocervical canal on saggital view is

A

T shaped

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29
Q

The shape of the endocervical canal on initial effacement is

A

Y shape

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30
Q

After the Y shape of the endocervical canal, the subsequent shapes are – and –

A

V and U visualized on progressive endocervical change and cervical shortening

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31
Q

4 sonographic findings for CI

A
  1. Funneling
  2. Cervical length < 25mm
  3. Protrusion of membranes
  4. Presence of fetal parts in cervix or vagina
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32
Q

Pneumonics for funneling

A

Trust - T shape
Your - Y shape
Vaginal - V shape
Ultrasound - U shape

33
Q

T/F: If a patient presents with significant cervical dilation (2 cm or more) she may have minimal symptoms. (ie. Pelvic pressure, minimal contractions)

A

T

34
Q

T/F: When the cervix reaches 4 cm or more, active uterine contractions or rupture of membranes may occur

A

T

35
Q

4 non surgical treatment of CI

A
  1. Bed rest
  2. Pelvic rest - limit coitus
  3. IM Hydroxyprogesterone
  4. Vaginal pessaries
36
Q

Define cerclage

A

Surgical purse string type suture used to reinforce the cervix.

37
Q

Timing for cerclage

A

13-16 weeks GA after fetal viability established on ultrasound

38
Q

Indication for urgent/therapeutic cerclage

A

urgent/therapeutic cerclage indicated for patients that have serial ultrasound changes consistent with short cervix or funneling.

39
Q

T/F: Efficacy of cerclage is well proven

A

F
Cerclage- is the standard treatment for CI, despite little data from randomized trials proving efficacy

40
Q

Size of mersilene tape used for the modified shirodkar cerclage procedure

A

5mm

41
Q

Indication for the modified shirodkar procedure (1955)

A

Reserved for patients that have had failure with the Mcdonald procedure

42
Q

At what level of the cervix is the mersilene tape placed in the modified shirodkar procedure

A

At the level of the internal os

43
Q

Describe the modified shirodkar procedure

A

Performed using a 5 mm Mersilene tape placed around the Cervix at the level of the internal os after surgically reflecting the urinary bladder anteriorly & the rectum posteriorly

44
Q

Describe the McDonald cerclage procedure (1963)

A

Purse-string suture placed around the cervix as cephalad as possible & without dissection of the bladder or rectum
Its tightened to reduce the cervical canal to 5-10mm

45
Q

T/F: The mersilene tape is placed at the level of the internal os for the McDonald procedure

A

F. Purse-string suture placed around the cervix as cephalad as possible

46
Q

T/F: Which of the cerclage procedures (shirodkar/Mcdonald) does not require dissection of the bladder or rectum

A

McDonald

47
Q

T/F: In the McDonald procedure the cervical canal is sutured close

A

F.
Its tightened to reduce the cervical canal to 5-10mm

48
Q

The transabdominal cerclage was developed by – and – in what year

A

Benson and Durfee in 1965

49
Q

Timing for transabdominal cerclage

A

Post conception or preconception

50
Q

Incision for transabdominal cerclage

A

Midline or pfannenstiel

51
Q

Level of the stitch in transabdominal cerclage

A

Cervico-isthmic level via avascular window in the broad ligament

52
Q

T/F: Delivery following transabdominal cercalge is always via CS

A

T

53
Q

2 indications for transabdominal cerclage

A

Reserved for women with extremely short cervix and women with previously failed vaginal cerclage

54
Q

T/F: The transabdominal cerclage can be done laparoscopically

A

T

55
Q

T/F: Lash believed that there is a structural defect in the anterior cervix at the time of spontaneous abortion

A

T

56
Q

When is the Lash procedure performed

A

In the nonpregnant state

57
Q

T/F: The Lash procedure is permanent and the delivery is via CS

A

T

58
Q

Success rate as described by Lash and Lash

A

86%

59
Q

Describe the Lash procedure

A

Wedged-shaped segment of the area of defect in the anterior cervix is removed above the internal os and the remaining area is sutured with chromic catgut in two layers

60
Q

List the surgical techniques for the management of CI

A

Modified Shirodkar cerclage (1955)
McDonald cerclage(1963)
Transabdominal cerclage
Lash procedure

61
Q

T/F: no significant difference in prevention of PTB was observed using Shirodkar or McDonald’s procedures

A

T
Odibo et al (2007)

62
Q

T/F: Blood loss is more with the McDonald technique compared the Shirodkar procedure

A

F.
More with Shirodkar

63
Q

T/F: The McDonald type of cerclage is more widely used because the application is easier to perform

A

T
Chen (2017) and Berghella (2002)

64
Q

T/F: Rodriguez et al (2018) found Shirodkar cerclage is associated with improved pregnancy prolongation, lower PTB rates, and better neonatal outcomes compared with McDonald cerclage.

A

T

65
Q

T/F: Hessami (2021) in a systematic review and meta-analysis of pregnancy outcomes following McDonald versus Shirodkar cervical cerclage for prevention of preterm labour concluded that McDonald cerclage is associated with a shorter duration of pregnancy, lower mean birth weight and increased risk of PPROM and NICU admission compared to the Shirodkar procedure. But no significant difference was observed between both groups in terms of cesarean delivery and perinatal/neonatal death.

A

T

66
Q

The surgical procedure accepted today as the standard of care is

A

The McDonald procedure

67
Q

5 issues noted with the McDonald procedure

A
  1. Poor depth due to the Size of
    the Mersilene Tape Needle
    (65mm)
  2. Slipping of the stitch [the
    cerclage fell out spontaneously]
  3. Compression of the Uterine
    artery as the stitch wraps over
    the artery at 3 and 9 o’clock
    positions.
  4. Laceration of the Cervix due to
    multiple bites
  5. Difficulty with application in
    short and small size cervix
68
Q

The Ikechebelu method is also known as –

A

Triangular 3 bites technique

69
Q

Describe the triangular 3 bites technique (Ikechebelu method)

A

Sutures are placed at the 4, 8 and knotted at the 12 0’clock positions avoiding the branches of the uterine arteries at the 3 and 9 0’clock positions.

70
Q

When is the cerclage removed electively

A

At 37 - 38 weeks

71
Q

When should the cerclage be removed as an emergency

A

Immediately with the onset of premature labour to avoid cervical laceration and/or uterine rupture

72
Q

T/F: Cerclage must be removed with PPROM

A

F
Controversial

73
Q

What types of cerclage should not be removed

A

A Shirodkar or abdominal cerclage does not have to be removed as cesarean delivery is anticipated and if future pregnancies are planned

74
Q

5 maternal contraindications to cerclage

A
  1. Premature labour
  2. Premature rupture of
    membranes
  3. Continuing vaginal bleeding
  4. Intra-amniotic, cervical, or
    vaginal infection
  5. Medical condition that precludes
    administration of anesthesia or
    continuation of pregnancy
75
Q

4 fetal contraindications to cerclage

A
  1. Fetal demise
  2. Fetal anomaly incompatible with
    extra-uterine life
  3. Non-reassuring fetal status
  4. GA > 24 to 28 wks
76
Q

5 intraoperative complications of cerclage

A

Rupture of membranes
Suture displacement
Chorioamnionitis
Haemorrhage
Trauma to surrounding organs – urinary bladder, urethra

77
Q

3 postoperative complications of cerclage

A

Increased risk of caesarean section
Preterm delivery
Chorioamnionitis

78
Q

Cerclage is for which class of women

A

Cervical length <2.5cm or advanced cervical changes on physical examination before 24 weeks gestation in women with either
One or more pregnancy losses / births at 14-34 weeks
Other significant risk factors for CI

79
Q

History-indicated cerclage is recommended for which class of women

A

For women with two or more consecutive 2nd trimester pregnancy losses or three or more early preterm births who have risk factors for CI and in whom other causes of preterm births have been excluded — we recommend history indicated Cervical Cerclage

WACS (19 decks)

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