1 / 64

Cervical Insufficiency (Cervical Incompetence) aka “too easy out”

Cervical Insufficiency (Cervical Incompetence) aka “too easy out”. Brian McCulloch MD Maternal – Fetal Medicine March 5, 2011 . CERVICAL INSUFFICIENCY HISTORY. FIRST RECOGNIZED IN 1658 BY COLE AND CULPEPPER THE MANAGEMENT HAS BEEN MORE SO SURGICAL THAN MEDICAL

coy
Download Presentation

Cervical Insufficiency (Cervical Incompetence) aka “too easy out”

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Cervical Insufficiency (Cervical Incompetence)aka “too easy out” Brian McCulloch MD Maternal – Fetal Medicine March 5, 2011

  2. CERVICAL INSUFFICIENCY HISTORY FIRST RECOGNIZED IN 1658 BY COLE AND CULPEPPER THE MANAGEMENT HAS BEEN MORE SO SURGICAL THAN MEDICAL ABRAHAM LASH AND HIS BROTHER WORKING HERE IN CHICAGO REMOVED A PIECE OF TISSUE FROM THE Cx ISTHMUS AREA IN THE NON PREGNANT STATE (THIS LEFT ~ 45 % INFERTILITY )

  3. CX INSUFFICIENCY HISTORY V.N. SHIRODKAR FROM BOMBAY INDIA IN 1955 ADVOCATED ENCIRLING THE INCOMPETENT CERVIX WITH FASCIA LATA. HE PLACED THE SUTURE MEDIAL TO THE BLOOD VESSELS

  4. CERVICAL INCOMPENTENCE HISTORY IAN MCDONALD FROM MELBOURNE AUSTRLIA IN 1957 COMPILED 70 CASES MOSTLY BETWEEN 20 – 24 WEEKS NO SUCCESS LESS THAN 20 WEEKS NO TOCOLYSIS EVEN TRIED TO TIE AMNION PERFORATIONS

  5. ANATOMY OF THE CERVIX EMBRYLOGICALLY IT IS DERIVED FROM THE FUSION OF THE MULLERIAN DUCTS AND SUBSEQUENT CENTRAL ATROPHY THE CERVIX IS PRIMARILY FIBROUS TISSUE WITH SOME MUSCLE THE PROXIMAL CERVIX MAY HAVE UP TO 29 % MUSCLE AND THE DISTAL PORTION LESS THAN 10 %

  6. ANATOMY OF THE CERVIX DURING PREGNANCY THE MUSCULAR UTERINE ISTHMUS DISTENDS AND ELONGATES BETWEEN 12 TO 20 WEEKS BEFORE 15 WEEKS CERVICAL MEASUREMENTS ARE DIFFICULT ON ULTRASOUND AND NOT RECOMMENDED

  7. NON PREGNANT CERVICAL EVALUATION FOR INSUFFIENCY NON PREGNANT CERVICAL TEST ARE INACCURATE OR UNPROVEN ANDNOTRECOMMENDED TO Dx INSUFFICENCY HEGAR DILATOR SIZE 8 TRACTION TEST USING AN INFLATED FOLEY CATHETER INTERNAL OS MEASUREMENT >8mm ON HYSTEROSALPINGOGRAM

  8. If a Non – Pregnant HSG or a Sonohysterogram or a MRI does diagnose a septum or anatomic abnormality then it can help alert the clinician to the possibility of a cervical issue or a factor leading to preterm delivery .

  9. INCIDENCE OF CERVICAL INSUFFIENCY ONE PER 222 DELIVERIES TO ONE PER 182 DELIVERIES ACOG PRACTICE BULLETIN 2004 OTHER AUTHORS HAVE A WIDER RANGE OF 1 IN A THOUSAND TO 1 IN A HUNDRED LUTHERAN GENERAL HOSPITAL CERCLAGE STATISTICS 1989 78 1990 62 1991 48 2006 64

  10. Definition of cervical incompetence Gradual painless dilatation and effacement of the cervix with bulging and later rupture of the membranes Typically short labor Progressively shorter labors with subsequent deliveries Progressively earlier deliveries

  11. Warning signs and symptoms of cervical incompetence Vaginal or lower abdominal pressure Frequent urination Increased vaginal discharge (watery) Bloody or mucus discharge

  12. Causes of incompetent cervix Congenital Mullerian anomalies with the highest risk with bicornuate and unicornuateutrei Abnormal uterine shape Also abnormal cervical muscular content( Ehlers – Danlos syndrome )

  13. Causes of incompetent cervix Acquired incompetence Traumatic cervical procedures (cone bx) Cone bx’s with a height of > 2 cms is a risk factor Obstetrical cervical lacerations Iatrogenic Embryological Drug induced (DES) (about 25 % have structural defects)

  14. PRETERM BIRTH THE INCIDENCE OF PRETERM BIRTH IN THE USA HAS BEEN INCREASING FROM 9.4 % IN 1981 TO 12.7 % in 2007 Martin Nat. Vital Stat. Rep 2009;57:1 - 102 RELIANCE ON RISK FACTORS ALONE WILL FAIL TO IDENTIFY MORE THAN 50 % OF PREGNANCIES THAT DELIVER< 37 WEEKS CREASY AJOG 1980 MERCER AJOG 1996

  15. METHODS OF EVALUATING THE CERVIX DIGITAL EXAMINATION SPECULUM EXAM TRANSABDOMINAL ULTRASOUND TRANSPERINEAL OR TRANSLABIAL ULTRASOUND TRANSVAGINAL ULTRASOUND

  16. Ultrasound assessment of the cervixVincenzo Berghella MD 2003 Trans abdominal scanning needs a full maternal bladder and can therefore elongate the cx length can be very difficult to see the external os

  17. Transperineal cervical measurements Gas of the rectum will hamper visualization of the cx especially the external os

  18. Transvaginal technique Enlarge the image so that it occupies about two thirds of the total image Obtain 3 images and record the shortest. Transfundal pressure should be for about 15 seconds Generally sonographers should be supervised for about 50 procedures.

  19. Cervical Scan Technique • Check the Equipment • Appropriately cleaned w/ soap & water + soaked • Use 5 to 7 MHz endovaginal probe • Don’t use 8 MHz – poor tissue penetration • Make sure the image is set to “EV” (endovaginal ) • Not Obstetrical or Abdominal • Empty Maternal Bladder • Void just before the exam • If bladder is seen to be large, stop exam & void again

  20. DIGITAL CERVICAL EXAM CONSISTENTLY UNDERESTIMATES THE CERVICAL LENGTH COMPARED TO VAGINAL PROBE ULTRASOUND HIGHLY SUBJECTIVE NON- STANDARDIZED

  21. HIGH RISK WOMEN SERIAL DIGITAL EXAMS IN THE MID TO LATE SECOND TRIMESTER IS USEFUL IF THE EXAM REMAINS NORMAL UNFORTUNATELY ABNORMAL CERVICAL FINDINGS ARE ASSOCIATED WITH ONLY 12 - 20 % OF HIGH RISK PRETERM DELIVERES AND EVEN LESS IN THE LOW RISK PATIENTS ~ 4 %

  22. ULTRASOUND OF THE CX THERE IS A STRONG REPRODUCIBLE INVERSE CORRELATION BETWEEN CX LENGTH AND PRETERM DELIVERY IF THE CX LENGTH IS LESS THAN 10 % (25 mm) THERE IS A 6 FOLD INCREASED RISK OF DELIVERY PRIOR TO 35 WEEKS IAMS NEJM 1996;334:567-57

  23. IAM’S CRITERIA FOR DX OF CX INSUFFICIENCY PROGRESSIVE CX SHORTENING TO 20 mm OR LESS FUNNEL LENGTH >16 mm OR FUNNELING >40 % MEASUREMENTS MUST BE OBTAINED TRANSVAGINALLY

  24. CX LENGTH AND PRETERM BIRTH WHY IS LENGTH RELATED TO PRETERM DELIVERY ? OCCULT CONTRATIONS BIOLOGIC VARIATION LOWER TRACT INFECTION UPPER TRACT INFECTION

  25. CX LENGTH CX LENGTH OF LESS THAN 15 mm AT 23 WEEKS OCCURS IN LESS THAN 2 % OF LOW RISK WOMEN WHEN THIS DOES OCCUR IT IS PREDICTIVE OF PTD < 28 WEEKS IN 60 % OF CASES < 32 WEEKS IN 90 % OF CASES

  26. Where to Put the Calipers? • Where the anterior and posterior walls of the canal touch • Spend enough time to see whether a small echolucent area is stable or is going to open up YES NO

  27. SERIAL TV ULTRASOUND MEASUREMENTS ARE NECESSARY BERGHELLA’S STUDY IN JAMA IN 2001 SHOWED A SENSITIVITY OF 69% BUT IF ONLY THE INITIAL MEASUREMENT WAS USED (16-18 wks) THEN THE SENSITIVITY WENT DOWN TO 19%

  28. CERCLAGE OUTCOME VIABLE DELIVERY RATE OF 70 – 90 % A LOWER RATE OF DELIVEY PRIOR TO 33 WEEKS (13 % COMPARED TO CONTROL OF 17 %) General a higher rate of tocolysis usage 34% vs 27 % Higher puerperal infections 6% vs 3 %

  29. CERCLAGE FOR SHORT CX LENGTH 2005 META-ANALYSIS CERLAGE GROUP HAD LESS DELIVERIES BEFORE 37 WEEKS BUT NO DIFFERENCE LESS THAN 35 WEEKS CERCLAGE HELPED IF CX LENGTH WAS <25mm’s BUT IT DID NOT CHANGE THE OUTCOME IF VERY SHORT CX <15mm’s TWINS HAD A INCREASED DELIVERY LESS THAN 35 WEEKS AND A HIGHER PERINATAL MORTALITY

  30. ACOG PRACTICE BULLETIN NUMEROUS STUDIES HAVE CONFIRMED THE ASSOCIATION OF CERVICAL SHORTENING AND PTB REVIEW OF 35 STUDIES HAD SHOWN SENSITIVITY FROM 68 – 100 % SPECIFICITIES FROM 44 – 79 %

  31. ULTRASOUND AND CERVICAL LENGTH PROSPECTIVE STUDY OF 2900 WOMEN AT 24 AND AGAIN 28 WEEKS (LEVEL II-B STUDY ) 40mm RR=2.8 PTD 35mm RR =3.52 30mm RR =5.39 26mm RR= 9.57 22mm RR=13.88 13mm RR=24.94

  32. ULTRASOUND AND CERVICAL LENGTH VAGINAL PROBE MEASUREMENTS CAN SUPPORT A DIAGNOSIS OF CERVICAL INCOMPETENCE BUT SHOULD NOT BE THE SOLE CRITERIA RESIDUAL CERVICAL LENGTH IS MORE IMPORTANT THAN THE OTHER MEASUREMENTS

  33. RR OF PTD AS CX LENGTH SHORTENED

  34. ACOG PRACTICE BULLETIN NUMBER 48,NOVEMBER 2004 • ROUTINE USE OF CX LENGTH IS NOT RECOMMENDED BECAUSE IT LACKS ENOUGH DISCRIMINATORY POWER

  35. FUNNELING OF THE CERVIX INTRINSIC WEAK CERVICOISTHMIC JUNCTION SOME STUDIES HAVE FOUND THIS TO BE AN INDEPENDENT RISK FACTOR FOR PTB ( INDEPENDENT OF CX LENGTH ) CERVICAL STRESS TEST

  36. Transvaginal Cervical Sonography Illustration by James Cooper MD Found in Callen, 4th edition

  37. 20 years ago Zilianti described the continuum from a “T “ to a “ Y” to a “V “ and finally to a “U” shaped lower segment. Moderate funneling defined as 25- 50% cervical shortening had a increased preterm birth of 50 %

  38. Cervical Effacement = T Y V U T Y V U Zilanti M, et al: JUM 1995

  39. One or Two Measurements?

  40. If the cervical length is deviated (defined as greater than 5mm from straight) then 2 straight lines should be used. Usually a short Cx not deviated If the cx canal is closed then the only measurement that is necessary is the cervical length .

  41. Don’t Trace to Measure the Cervical Length If the is > 3 mm, use two measures

  42. ABNORMAL CX FINDINGS SHOULD BE REPORTED TO THE PATIENT REPEAT IN 1 – 2 WEEKS OPTION OF CERCLAGE BED REST / RESTRICTED ACTIVITY DISCUSSED DIFFERENT FOR MULTIPLE GESTATION ?

  43. CX LENGTH AND PTD CERVICAL LENGTH IS LINKED TO : PTD IN CURRENT PREGNANCY HISTORY OF PTD INDEPENDENT OF OTHER RISK FACTORS: RACE , Ffn , BLEEDING , BACTERIAL VAGINOSIS ,BMI ,CONTRACTIONS

More Related