cervical incompetence moh abdalla
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Dr.Mohammed AbdallaDr.Mohammed AbdallaDomiat general hospitalDomiat general hospital
cervicalcervical
incompetenceincompetence
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Cervical incompetence isCervical incompetence is
defined as thedefined as the inability toinability tosupport pregnancy tillsupport pregnancy till
termterm
because of a functional orbecause of a functional orstructural defect of thestructural defect of the
cervixcervix
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Although the efficacy of cerclage for
cervical incompetence
has never been fully confirmedin randomized clinical trials ,the role
of cerclage has been expanded toinclude women with risk factors for
spontaneous preterm birth or
nonreassuring sonographic cervicalfindings in the mid trimester.
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So, before you send your
patient to the theater forcerclage your diagnosis
necessities solid criteriaotherwise many will be
unduly done.
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But unfortunately there isBut unfortunately there is
no consensus about theno consensus about thecervical cut off lengthcervical cut off length
< 25mm< 25mm
OrOr< 15mm< 15mm
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the cervical cut offthe cervical cut off
length inlength in singletonsingletonpregnancypregnancy
Cannot be applied inCannot be applied in
multiplemultiple pregnancy?pregnancy?
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As the risk with CL
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Inconsensus about cutoff
cervical length will resultin the categorization of 5%
to 10% of pregnant womenas having a short cervix.
problem
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As any controversialAs any controversial
issue we have hereissue we have herewhite and black faceswhite and black faces
but always within thebut always within thegrey zone, which lies ingrey zone, which lies in
between, we fall inbetween, we fall indoubt.doubt.
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White face here is thehere is thewomen withwomen with
irrelevant obstetricirrelevant obstetricand gynecologicaland gynecological
history, ashistory, as they needthey needno screening.no screening.
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The black face of the problem isof the problem isrepresented by those who haverepresented by those who have
three or more midtrimesterthree or more midtrimester
losses or preterm births , thelosses or preterm births , thedecision isdecision is
a prophylactic cerclage performeda prophylactic cerclage performedat 13 to 16 weeksat 13 to 16 weeks
of gestationof gestation ..
2
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The grey zone isrepresented here by those
women of low or moderaterisk, and they need serial
ultrasound screening bytransvaginalultrasonography.
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Ultrasound screeningUltrasound screening
if we are going to screen this group ofif we are going to screen this group of
patients with mild to moderate risk :patients with mild to moderate risk :
when to start?when to start?what is the ultrasonic criteriawhat is the ultrasonic criteria
of incompetent cervix?of incompetent cervix?and when to intervent?and when to intervent?
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when to startwhen to start
TVS should not begin
before 16 weeksas the upper portion of the
cervix is not easily
distinguished
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ultrasonic criteria ofultrasonic criteria of
incompetent cervixincompetent cervixMake sure to use proper technique.Make sure to use proper technique.
Knowing what to measure .Knowing what to measure .Know what's normal, and what'sKnow what's normal, and what's
abnormal .abnormal .
Linking cervical assessment toLinking cervical assessment to
gestational age .gestational age .
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proper technique
patients are asked to empty their bladder .patients are asked to empty their bladder .You should identify at the same sagittalYou should identify at the same sagittal
view the internal os, external os, cervicalview the internal os, external os, cervical
canal, and endocervical mucosa.canal, and endocervical mucosa.the probe is slowly withdrawn to avoidthe probe is slowly withdrawn to avoid
false elongation of the cervix.false elongation of the cervix.
The cervical length is measured byThe cervical length is measured byfreezing the screen three separate timesfreezing the screen three separate times
with no more than 2 to 3 mm variations.with no more than 2 to 3 mm variations.
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proper technique
To recognize funneling the walls of the funnelTo recognize funneling the walls of the funnelare formed by endocervical mucosa.are formed by endocervical mucosa.
If the cervical canal is sometimes curved,If the cervical canal is sometimes curved,
therefore, cervical length should be determinedtherefore, cervical length should be determined
by tracing the length of the cervix or by addingby tracing the length of the cervix or by addingthe sum of two straight sections.the sum of two straight sections.
Apply transfundal pressure for 15 seconds,Apply transfundal pressure for 15 seconds,
and record any changes in cervical length orand record any changes in cervical length or
funneling. cervical stress test .funneling. cervical stress test .
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cm 2
1.5
1.2
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cervical stresscervical stresstesttest
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the walls of the funnel are formed by
endocervical mucosa.
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what's normalwhat's normal
In low-risk women, CL duringIn low-risk women, CL during
pregnancy has a mean ofpregnancy has a mean of35 to 4035 to 40
mm from 14 to 30 weeksmm from 14 to 30 weeks..the lower 10th percentile beingthe lower 10th percentile being
25 mm and the upper 10th (90th25 mm and the upper 10th (90th
percentile) 50 mmpercentile) 50 mm..
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3812521998Heath et al
421751997Tongsong et al
41411996Cook et al
3529151996Iams et al
371061995Iams et al
421541994Zorzoli et al
371771993Murakawa et al
42771991Andersen et al
48241990Kushnir et al
411251990Andersen et al
48801988Podobnik et al
521501988Ayers et alCervical Length (mm)NYearReference
CERVICAL LENGTH (MEAN OR MEDIAN) IN LOW-RISK POPULATIONS IN MIDTRIMESTER
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9747998151424Hassan etal
995299581523Heath et al
99391006251822Taipale etal
97269723
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Low %PPV meansLow %PPV means
that many unduethat many undue
cerclages werecerclages were
done.done.
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high %NPV meanshigh %NPV meansthat the test isthat the test is
reassuring whenreassuring when
negative.negative.
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So we cannot rely onSo we cannot rely oncervical lengthcervical length
alone as a predictoralone as a predictor
of incompetenceof incompetence
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the progressive shorteningthe progressive shortening
detected by serial sonar,detected by serial sonar,funneling (width and length),funneling (width and length),v-shaped lower uterine segmentv-shaped lower uterine segment
and dynamic cervical changesand dynamic cervical changeswith fundal or suprapubicwith fundal or suprapubicpressure.pressure.
What are the most
important?
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1 2
3 4
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bulging of the membranes in the vagina. The
fetal lower limb protruded into the vagina.
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But how to avoidBut how to avoidundue cerclageundue cerclage
andand
how not to miss ahow not to miss acase?case?
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RISK ASSESMENT>=3 unexplained
second-trimester losses
or preterm deliveries.
Elective Cerclage
at 14-16 wk.
No riskfactor
routine ultrasound
screening of the
cervix is not
recommended
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Can a cervicalCan a cervical
cerclage be used tocerclage be used to
prevent pretermprevent pretermdelivery in patientsdelivery in patients
with a short cervix orwith a short cervix orfunneling?funneling?
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263116Obstetricianuncertainty
12921993MRC/RCOG
6.75.5
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results of randomizedresults of randomized
clinical trials suggest thatclinical trials suggest that
cerclage either had acerclage either had a
modest effect on reducingmodest effect on reducing
the rate of preterm deliverythe rate of preterm deliveryor no effect whatsoeveror no effect whatsoever..
RANDOMIZED STUDIES OFELECTIVE CERVICAL CERCLAGE
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Key pointsKey pointsThe high negative predictiveThe high negative predictive
value for preterm birthvalue for preterm birth
associated with a long cervixassociated with a long cervixand with the absence ofand with the absence of
funneling has important clinicalfunneling has important clinicalimplications in symptomaticimplications in symptomatic
patients.patients.
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Using TVU to assess CL is anUsing TVU to assess CL is an
effective way to predict PTB andeffective way to predict PTB and
"incompetent cervix," now better"incompetent cervix," now betternamed cervical insufficiency. It'snamed cervical insufficiency. It's
safe and patients accept thesafe and patients accept theexamination well.examination well.
Key pointsKey points
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Screening frequency shouldScreening frequency should
depend on severity of obstetricdepend on severity of obstetric
history, with serial TVU of thehistory, with serial TVU of thecervix having a better predictivecervix having a better predictive
accuracy than one, especially inaccuracy than one, especially inhigh-risk populations.high-risk populations.
Key pointsKey points
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screening high-risk women withscreening high-risk women with
TVU of the cervix and placementTVU of the cervix and placement
of a cerclage for the short orof a cerclage for the short orfunneled cervix should not befunneled cervix should not be
considered standard care untilconsidered standard care until
proven by properly conducted,proven by properly conducted,large randomized trialslarge randomized trials
Key pointsKey points
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ThankThankyouyou