Chapter 11: Cervical Insufficiency/ Cervical Incompetence

Question 1

What is Cervical Insufficiency/ Cervical Incompetence?

Answer 1

the inability of the uterine cervix to retain a pregnancy to term
-a passive, painless cervical dilation in the second trimester, with no labor, bleeding, or chorioamnionitis (infection)

Question 2

How can you get reduced cervical competence?

Answer 2

• Acquired (e.g. after trauma or surgery)

- Congenital (ie. resulting from uterine anomalies or a history of DES (Diethylstilbestrol) exposure

Question 3

Patients History

Answer 3

• have repeated second trimester losses

- hx of recurrent and mid-pregnancy deliveries without presenting contractions, membrane rupture, or infection

Question 4

How to Diagnose

Answer 4

Transvaginal Ultrasound (TVU) cervical length (CL) assessment
>the presence of both criteria--> one or more prior early preterm births and/or second trimester losses along with TVU CL less than 25 mm, or cervical dilation (e.g. greater than or equal to 1 cm) on digital vaginal examination before 24 weeks in the current pregnancy--- may arouse suspicion

Question 5

What has become the “gold standard” for cervical evaluation?

Answer 5

Transvaginal Ultrasonography

Question 6

The Cervix During Pregnancy

Answer 6

during pregnancy, the cervix follows a predictable pattern of effacement and dilation
-effacement begins at the internal cervical os and progresses in a “funneling” manner toward the external cervical os; on ultrasound this process appears as a “Y” shaped “beaking” of the cervical canal sidewalls that develops into a U shaped space; the CL normally remains stable until the early third trimester and shortens progressively

Question 7

Management

Answer 7

• TVU CL screening
• vaginal placement of cerclage, or pursestring suture, that is put beneath the cervical mucosa either at the cervical-vaginal junction (a McDonald cerclage), or at the internal cervical os (a Shirodkar cerclage)

Question 8

The Use of Cerclage

Answer 8

to close the cervix

• usually removed in the office or clinic at 37 weeks of gestation to facilitate vaginal birth
• a new cerclage will need to be placed with subsequent (coming after something in time) pregnancies
• cerclage may be left in place, necessitating a cesarean delivery
• some a cerclage is placed via an abdominal incision

Question 9

Patients who have an Abdominal Cerclage

Answer 9

• must give birth via C-section
• before and after cerclage placement, prophylactic tocolytics (medications used in an attempt to stop labor) may be given to prevent uterine contractions
• bedrest is important and may be placed on home uterine activity monitoring

Question 10

Depending on the gestational age and imminence of delivery, what may be given to decrease the chance of respiratory distress syndrome in premature infants?

Answer 10

-betamethasone
>can help speed up lung development in preterm babies. Betamethasone causes the release of surfactant, a substance that lubricates the lungs so that they do not stick together when the infant breathes.