The document discusses cervical incompetence, detailing two case studies of pregnant women experiencing issues related to short cervical length and the management options, including elective cerclage. It covers definitions, pathogenesis, diagnosis, investigations, and surgical and medical interventions for cervical incompetence, highlighting the importance of timely intervention to improve outcomes. Additionally, various techniques for cervical cerclage and potential complications are explained.

1. Cervical Incompetence
By Dr. Indraneel Jadhav

2. Case I
• 35 year lady, primi at 14+ weeks with C/O 4 months amenorrhea with
ultrasound S/O short cervix planned for elective encirclage
Case II
• 27 year lady, primi at 26+ weeks with C/O intermittent backache and
white discharge per vaginum with ultrasound S/O short cervix for
elective encirclage

3. Case I
• Spontaneous conception. Excellent dates. Taking Folic Acid
• Blood investigations done were normal
• At two and half month recorded high BP recording, persistent on
subsequent ANC visit, Hence started on Labetolol 50mg 1-0-1.
• At 3rd
month was admitted for threatened abortion due to episode of
bleeding – managed conservatively.
• Scan done was normal along with blood test S/O low risk.
• Wanted to continue further ANC’s at Mumbai hence scan done S/O short
cervix.
• N/H/O Excessive vomiting, fever with rash, burning micturation, white
discharge per vaginum, radiation exposure

4. • Medical/ surgical history: k/c/o Hypothyroidism on Thyronorm 100 mcg
1-0-0 .H/O hospitalisation for fever on and off 1 year back – told to have
urinary infection .
• Menstrual history: Cycles regular; LMP: 13/3/17; EDD: 20/12/17;
• Obstetric history: Married since 2 years (non – consanguineous )
,voluntary sub fertility, primigravida
• Family history: Father –DM + HTN , Mother – HTN and thyroid
• Personal History : Not significant
• Dietary history : (sedentary – 2400 kcal) calorie defecit -650 kcal
Protein defecit – 7 gm

5. Examination
• GC Fair
• Height: 154 cm ; Weight: 38Kg BMI : 24 kg/m2
• Vitals stable ,No pallor, icterus, pedal edema
• Cardiovascular system: S1 and S2 heard, no added sounds
• Respiratory system: B/L NVBS heard, no added sounds
• P/A:Inspection : linea nigra seen, No scars, sinuses or dilated veins
Palpation: Uterus just palpable ,No tenderness ,organomegaly, ascites

6. Case II
• Spontaneous conception. Excellent dates. Folic acid taken
• Blood investigations done S/O Thyroid abnormality, started on
thyronorm 25 mcg 1-0-0
• Scan done was normal at 3rd
month along with blood test S/O low risk.
Started on Iron/Calcium
• 5th
month scan done found to be normal.
• At 6th
month came with complaints of low intermittent backache and
white discharge per vaginum,hence ultrasound done S/O short cervix
• N/H/O Excessive vomiting, fever with rash, burning micturation, white
discharge/bleeding per vaginum, radiation exposure,high BP recordings
or high sugars.

7. • Medical/ surgical history:.H/O appendicectomy 4 years back
• Menstrual history: Cycles regular; LMP: 28/12/16; EDD: 02/10/17;
• Obstetric history: Married since 6 months (non – consanguineous )
primigravida
• Family history: Father –DM + HTN , Mother – HTN and thyroid
• Personal History : Not significant
• Dietary history : (sedentary – 2400 kcal) calorie defecit -478 kcal
Protein defecit – 6 gm

8. Examination
• GC Fair
• Height: 140 cm ; Weight: 41Kg BMI : 20.4 kg/m2
• Vitals stable ,No pallor, icterus, pedal edema
• Cardiovascular system: S1 and S2 heard, no added sounds
• Respiratory system: B/L NVBS heard, no added sounds
• P/A:Inspection : linea nigra seen, Appendicectomy scar seen, sinuses or
dilated veins
Palpation: Uterus 24-26 wks, EB +,No tenderness ,organomegaly, ascites

9. Definition
Cervical incompetence is the inability
for the cervix to retain an intra-
uterine pregnancy till term as a result
of structural and functional defects of
the cervix.
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10. Anatomy
10
-Internal os: the opening of the
cervix into the body of uterus.
-External os – its size and shape
varies widely with age, hormonal
state, and whether the woman has
had a vaginal birth. In nonparous
women it appears as a small,
circular opening. Versus being
fish mouthed (meaning wider,
more slit-like and gaping) in
parous women.
In pregnancy, the normal cervical
length is
4 + 1cm.

11. Pathogenesis/ Aetiology
The cervical competence is a specific entity involving not just an
abnormality or defect of cervical collagen, but is also due to either:
1. Absence of the usual cervical musculature in cases of congenital
cervical incompetence, or
2. Injury or damage to the cervical musculature caused by previous
trauma.
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12. Aetiology
- Unknown, Congenital and Acquired.
- Congenital causes include:
- congenital mullerian duct abnormalities (e.g. septate uterus,
bicornuate uterus)
- Connective tissue disorder (Ehlers-Danlos syndrome)
- DES exposure in utero
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13. • Acquired causes include:
Surgical trauma
 Cone biopsy or loop electrosurgical excision procedures
 Repeated forced cervical dilatation asso. with 2nd
trimester D&C
 Previous Manchester repair with cervical amputation.
Obstetric injuries
 Compression necrosis of the cervix due to prolonged 2nd
stage of
labor
 Spontaneous and iatrogenic cervical laceration (e.g. Duhrssen’s
incision)
 Extension of the uterine incision into the cervix during CS
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14. DIAGNOSIS
HISTORY
•Classical presentation:
-Recurrent mid trimester miscarriage
-painless cervical dilatation
-Rupture of membranes/expulsion of fetus
•Preterm delivery
•Elicit other predisposing factors
•Diagnosis based on history is retrospective
•One classical hx may also be suggestive
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15. Investigations (non-pregnant)
• Easy passage of a size 8 Hegar’s/Pratt’s
dilator number 15-17
• Foley’s catheter traction test - size 16 F balloon filled with 1ml of water
(6mm)
• Hysterosalpingography- dilated internal os > 8mm /widened
isthmus( funnel/ Inverted Bishop’s cap)
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16. Investigations (pregnant)
• Weekly or forthnightly cervical assessment- softening effacement
and dilatation.
• Serial ultrasound assessment of the lower uterine segment and
cervix.
• Cervical stress test usually done at 15 –24 weeks (increasing
transfundal intrauterine pressure while monitoring cervical length
and the appearance of funnelling).
• This test is currently recommended for patients with suspected
features of incompetent cervix, undergoing ultrasonography.
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17. ULTRASONOGRAPHY
• Ultrasound is the best technique to measure the cervical opening or
the length of the cervix.
• It provides an objective and reproducible method of measuring the
length of the cervix
• Transabdominal (requires full bladder)
• Transvaginal (more accurate)
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18. Transvaginal Ultrasonography Findings
• ‘Funneling’ of the internal cervical os (at rest or particularly in respond to
transabdominal pressure on the uterine fundus) is the ultrasonographic
appearance of cervical incompetence.
• Y= initial effacement and subsequent V, U visualized on progressive
endocervial change and cervical shortening.
• length of the cervical canal: <2.5cm – risk
• diameter of the internal os:>15 mm in the 1st trimester and > 20mm in
the 2nd
trimester
• protrusion of the fetal membranes through the os
• presence of fetal parts in the cervix or vagina
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19. Transvaginal Sonography
• TVS in contrast to HSG, is
 Non-invasive
 Repeatable over time
 Can be performed during pregnancy
• Negative USS can not exclude CI
• Positive USS during routine screening in pregnant women without
history of pregnancy loss do not necessarily place them at risk, but close
follow up is required.
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20. Investigations (Cont’d)
• In some situation it may be necessary to conduct test to exclude other
causes of recurrent pregnancy losses-
-Diabetes mellitus
-Thyroid dysfuntion
-Lupus anticoagulant
-Chromosonal anomalies
-Cervical infection
• The role of magnetic resonance imaging- cost prohibitive
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21. CERVICAL CERCLAGE
• Evidence-based procedure that reduces perinatal and maternal
morbidity and mortality arising from cervical incompetence.
• The success rate can be high (80-90%) when done early in pregnancy.
• Usually done prior to 18 weeks, but after 13 weeks. Many say between
14-16 weeks.
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22. Cervical Cerclage
INDICATIONS FOR CERCLAGE
•Suspected/confirmed cervical incompetence remains the only acceptable
indication for cervical cerclage.
CONTRA-INDICATIONS
• Uterine contractions
• Uterine bleeding
• Chorioamnionitis
• Premature rupture of membranes.
• Fetal anomaly incompatible with life.
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23. Cervical Cerclage Procedures
Currently, there are five different techniques for performing cervical
cerclage:
1. McDonald procedure.
2. Shirodkar operation.
3. Wurm procedure (Hefner cerclage).
4. Transabdominal cerclage .
5. Lash procedure .
• The two most common are the McDonald and Shirodkar.

24. McDonald procedure

25. Shirodkar Technique
 Developed in 1955
 Vaginal approach to the cervix
 Involved placement of a nonabsorble suture such as fascia lata, silk,
nylon or mersilene tape around the cervix at the internal os.
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26. Wurm procedure
• The Hefner cerclage, also known as the Wurm procedure, is used for
later diagnosis of the incompetent cervix.
• 1st described by Rogers Wurm.
• It is usually done with a U or mattress suture, and is of benefit when
there is minimal amounts of cervix left.
• Done after dislocation of a previous cerclage, partial cervical
dilatation and partial effacement
• Mattress sutures are placed at 12 & 6 o’ clock position and 3 & 9
o’clock position

27. Trans abdominal cerclage
• Developed by Benson and Durfee in 1965
• Post conception/preconception
• Abdomen entered via a midline or Pfannenstiel’s incision
• Cerclage stitch inserted at the cervico isthmic level via avascular window
in the board ligament
• Delivery is by abdominal route
• Method preserved for patients with extremely short cervix, previously
failed vaginal cerclage
• Can be done via laparoscopy
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28. Lash Procedure
• Lash believed there is a structural defect in the anterior cervix at the
time of spontanous abortion.
• performed in non-pregnant state
• wegded shaped segment of the area of defect is removed above the
internal os
• remaining area is sutured with chromic catgut in two layers.
• permanent and requires CS
• success rate as reported by Lash and Lash 86%

29. • Cerclage can be
1. Prophylactic (Elective) cervical cerclage.
2. Emergency (Salvage) cervical cerclage .
Preoperative evaluation.
• Cerclage should generally be delayed until after 14weeks so that early
abortions due to other factors will be completed.
• Obvious cervical infection should be treated,
• cultures for gonorrhea, chlamydia, and group B streptococci are
recommended
• Sonography to confirm a living fetus and to exclude major fetal
anomalies
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30. A. Prophylactic/Elective Cerclage
• A planned cerclage placement after history, examination and
investigations have been done.
• It may be placed prior to pregnancy, but is more commonly
placed between 14 -16 weeks’ gestation.
• The stitch is usually removed around 37 weeks or at the onset of
labour.

31. B. Emergency Cerclage (cont’d)
 Refers to placement of a cerclage in the setting of significant cervical
dilatation and/or effacement prior to 28 weeks’ gestation and in the
absence of labor.
 Preserved for patients without classical features incompetence.
 Patient experiencing features of incompetence in an index
pregnancy: prolapse of membranes, cervical dilatation and
effacement
 Success rate lower than that of elective.
 Higher incidence of infection
 Prolonged hospital stay
 The prognosis is influenced by the gestational age at the time when
the suture is placed.

32. The bulging membrane during emergency
cerclage
• Management options
• Insertion of a foley’s catheter with 20ml balloon with the distal cut
end inserted into the cervical canal and inflated.
• Pre cerclage amniocentesis to remove sufficient fluid to reduce the
bulging membranes can be helpful.
• Overfilling the bladder with 1,000 ml of saline may help by elevating
the membranes out of the operative field.
• Use of 6-10 stay stitches attached to the edges of the cervix with the
patient in deep trendelenburg position. Traction pushes back the
membrane
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33. Post-operatively,
• Antibiotics
• Tocolytics
-controversial except for patients with uterine irritability.
• Bed rest advised for the 1st
24 hours followed by mobilization and
activity
• Discharge after a couple of days advised - studies
have found no benefit for staying more than one week.

34. Removal of cerclage
• Timing: usually b/w 37-38 weeks
• Earlier removal
-excessive vaginal bleeding
-intrauterine fetal death
-persistent uterine contraction
-Rupture of fetal membranes
-chorioamnionitis
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35. Complications Of Cerclage.
EARLY COMPLICATIONS
• Infections (Chorioamnionitis, Vulvovaginitis
• Bleeding
• Anaesthetic complications
• Accidental rupture of fetal membranes
• Premature labour
• Maternal death in the presence of sepsis due to prom
• Deep cervical laceration
• Puerperal pyrexia
• Urinary tract infection
• Cervical amputation.

36. Complications Of Cerclage
LATE COMPLICATIONS
•Fistula formation
•Cervical stenosis
•Scarring- cervical dystocia in labour
•Precipitate labour.
•Preterm deliveries
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37. Medical Management
• Hodge pessaries
-developed by Vitsky in 1961
-properly placed pessaries can cause cervix to
point posteriorly
-alleviate some of the direct pressure on the
cervix
-prevent descent of the fetal head
-best results obtained if inserted at 14 weeks
-success rate 92%
-removal not later than 38 weeks
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38. Medical Management
• Baylor Balloon
-Proposed in 1972
-Double silicon plastic cuff inserted on
cervix to act as cuff.
• Progesterone
-Reduces uterine tone
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