Cervical weakness

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Cervical insufficiency
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Cervical weakness, also called cervical incompetence or cervical insufficiency, is a medical condition of pregnancy in which the cervix begins to dilate (widen) and efface (thin) before the pregnancy has reached term. Definitions of cervical weakness vary, but one that is frequently used is the inability of the uterine cervix to retain a pregnancy in the absence of the signs and symptoms of clinical contractions, or labor, or both in the second trimester. [1] Cervical weakness may cause miscarriage or preterm birth during the second and third trimesters. It has been estimated that cervical insufficiency complicates about 1% of pregnancies, and that it is a cause in about 8% of women with second trimester recurrent miscarriages. [2]

Contents

A sign of cervical weakness is funneling at the internal orifice of the uterus, which is a dilation of the cervical canal at this location. [3]

In cases of cervical weakness, dilation and effacement of the cervix may occur without pain or uterine contractions. In a normal pregnancy, dilation and effacement occurs in response to uterine contractions. Cervical weakness becomes a problem when the cervix is pushed to open by the growing pressure in the uterus as pregnancy progresses. If the responses are not halted, rupture of the membranes and birth of a premature baby can result.

The older terminology is perceived as blaming the woman for the miscarriage, as if she were an incompetent or insufficient person. Consequently, cervical weakness is the recommended term. [4]

Risk factors

Risk factors for premature birth or stillbirth due to cervical weakness include: [5]

Diagnosis

Diagnosis of cervical weakness can be challenging and is based on a history of painless cervical dilation usually after the first trimester without contractions or labor and in the absence of other clear pathology. In addition to history, some providers use assessment of cervical length in second trimester to identify cervical shortening using ultrasound. [6] However, short cervical length has actually been shown to be a marker of preterm birth rather than cervical weakness. Other diagnostic tests that have been suggested which have not been validated include hysterosalpingography and radiographic imaging of balloon traction on the cervix, assessment of the patulous cervix with Hegar or Pratt dilators, the use of a balloon elastance test, and use of graduated cervical dilators to calculate a cervical resistance index. [1]

Normally, the cervix should be at least 30 mm in length. Cervical weakness is variably defined. However, a common definition is a cervical length of less than 25 mm at or before 24 weeks of gestational age. The risk of preterm birth is inversely proportional to cervical length: [7]

Treatment

Cervical weakness is not generally treated except when it appears to threaten a pregnancy. Cervical weakness can be treated using cervical cerclage, a surgical technique that reinforces the cervical muscle by placing sutures above the opening of the cervix to narrow the cervical canal. [8]

Cerclage procedures usually entail closing the cervix through the vagina with the aid of a speculum. Another approach involves performing the cerclage through an abdominal incision. Transabdominal cerclage of the cervix makes it possible to place the stitch exactly at the level that is needed. It can be carried out when the cervix is very short, effaced or totally distorted. Cerclages are usually performed between weeks 12 to 14 of the pregnancy. [8] The sutures are removed between weeks 36 and 38 to avoid problems during labor. The complications described in the literature have been rare: hemorrhage from damage to the veins at the time of the procedure; and fetal death due to uterine vessels occlusion.

No significant differences in pregnancy outcomes were found in a study evaluating pregnancy outcomes after cervical conization. This study suggests for women with cervical insufficiency due to prior cone biopsy, cerclage is not superior to no intervention. [9] As cerclage can induce preterm contractions without preventing premature delivery, [10] makes the recommendation that it be used sparingly in women with a history of conization.

A cervical pessary is being studied as an alternative to cervical cerclage since there are fewer potential complications. A silicone ring is placed at the opening to the cervix early in the pregnancy, and removed later in the pregnancy prior to the time of expected delivery. Further study is needed to determine whether a cervical pessary is equal or superiour to current management. [11]

Notes

  1. 1 2 American College of Obstetricians and, Gynecologists (Feb 2014). "ACOG Practice Bulletin No.142: Cerclage for the management of cervical insufficiency". Obstetrics and Gynecology. 123 (2 Pt 1): 372–9. doi:10.1097/01.AOG.0000443276.68274.cc. PMID   24451674. S2CID   205384229.
  2. ↑ Alfirevic, Zarko; Stampalija, Tamara; Medley, Nancy (2017). "Cervical stitch (cerclage) for preventing preterm birth in singleton pregnancy". Cochrane Database of Systematic Reviews. 2017 (6): CD008991. doi:10.1002/14651858.CD008991.pub3. ISSN   1465-1858. PMC   6481522 . PMID   28586127.
  3. ↑ Cervical assessment from Fetal Medicine Foundation. Retrieved Feb 2014.
  4. ↑ Christiansen, Ole (2014). Recurrent pregnancy loss. Chichester, West Sussex, UK: John Wiley & Sons. pp. 98–99. ISBN   9780470672945. It is important to bear in mind that some clinical terms can cause great distress and even anger. The terms "blighted ovum" and "cervical incompetence" both imply blame. Cervical incompetence is better described as cervical weakness.
  5. ↑ Althuisius SM; Dekker GA; Hummel P; Bekedam DJ; van Geijn HP (Nov 2001). "Final results of the Cervical Incompetence Prevention Randomized Cerclage Trial (CIPRACT): therapeutic cerclage with bed rest versus bed rest alone". American Journal of Obstetrics & Gynecology. Academic Press. 185 (5): 1106–1112. doi:10.1067/mob.2001.118655. PMID   11717642.
  6. ↑ Macdonald, R; Smith, P; Vyas, S (Sep 2001). "Cervical incompetence: the use of transvaginal sonography to provide an objective diagnosis". Ultrasound in Obstetrics & Gynecology. 18 (3): 211–6. doi: 10.1046/j.1469-0705.2001.00459.x . PMID   11555448.
  7. ↑ Cervical incompetence at Radiopedia. By Dr Praveen Jha and Dr Laughlin Dawes et al. Retrieved June 2014
  8. 1 2 Brown R, Gagnon R, Delisle MF (February 2019). "No. 373-Cervical Insufficiency and Cervical Cerclage". Journal of Obstetrics and Gynaecology Canada. 41 (2): 233–247. doi:10.1016/j.jogc.2018.08.009. PMID   30638557. S2CID   58617759.
  9. ↑ Armarnik, S; Sheiner, E; Piura, B; Meirovitz, M; Zlotnik, A; Levy, A (April 2011). "Obstetric outcome following cervical conization". Archives of Gynecology and Obstetrics. 283 (4): 765–9. doi:10.1007/s00404-011-1848-3. PMID   21327802. S2CID   21944658.
  10. ↑ Zeisler, H; Joura, EA; Bancher-Todesca, D; Hanzal, E; Gitsch, G (July 1997). "Prophylactic cerclage in pregnancy. Effect in women with a history of conization". The Journal of Reproductive Medicine. 42 (7): 390–2. PMID   9252928.
  11. ↑ Abdel-Aleem, H; Shaaban, OM; Abdel-Aleem, MA (May 31, 2013). "Cervical pessary for preventing preterm birth". The Cochrane Database of Systematic Reviews. 5 (5): CD007873. doi:10.1002/14651858.CD007873.pub3. PMC   6491132 . PMID   23728668.

Related Research Articles

<span class="mw-page-title-main">Cervix</span> Lower part of the uterus in the human female reproductive system

The cervix or cervix uteri is the lower part of the uterus (womb) in the human female reproductive system. The cervix is usually 2 to 3 cm long and roughly cylindrical in shape, which changes during pregnancy. The narrow, central cervical canal runs along its entire length, connecting the uterine cavity and the lumen of the vagina. The opening into the uterus is called the internal os, and the opening into the vagina is called the external os. The lower part of the cervix, known as the vaginal portion of the cervix, bulges into the top of the vagina. The cervix has been documented anatomically since at least the time of Hippocrates, over 2,000 years ago.

Dilationand curettage (D&C) refers to the dilation (widening/opening) of the cervix and surgical removal of part of the lining of the uterus and/or contents of the uterus by scraping and scooping (curettage). It is a gynecologic procedure used for diagnostic and therapeutic purposes, and is the most commonly used method for first-trimester miscarriage or abortion.

<span class="mw-page-title-main">Preterm birth</span> Birth at less than a specified gestational age

Preterm birth, also known as premature birth, is the birth of a baby at fewer than 37 weeks gestational age, as opposed to full-term delivery at approximately 40 weeks. Extreme preterm is less than 28 weeks, very early preterm birth is between 28 and 32 weeks, early preterm birth occurs between 32 and 36 weeks, late preterm birth is between 34 and 36 weeks' gestation. These babies are also known as premature babies or colloquially preemies or premmies. Symptoms of preterm labor include uterine contractions which occur more often than every ten minutes and/or the leaking of fluid from the vagina before 37 weeks. Premature infants are at greater risk for cerebral palsy, delays in development, hearing problems and problems with their vision. The earlier a baby is born, the greater these risks will be.

A pessary is a prosthetic device inserted into the vagina for structural and pharmaceutical purposes. It is most commonly used to treat stress urinary incontinence to stop urinary leakage and to treat pelvic organ prolapse to maintain the location of organs in the pelvic region. It can also be used to administer medications locally in the vagina or as a method of contraception.

<span class="mw-page-title-main">Obstetric ultrasonography</span> Use of medical ultrasonography in pregnancy

Obstetric ultrasonography, or prenatal ultrasound, is the use of medical ultrasonography in pregnancy, in which sound waves are used to create real-time visual images of the developing embryo or fetus in the uterus (womb). The procedure is a standard part of prenatal care in many countries, as it can provide a variety of information about the health of the mother, the timing and progress of the pregnancy, and the health and development of the embryo or fetus.

A hysterotomy is an incision made in the uterus. This surgical incision is used in several medical procedures, including during termination of pregnancy in the second trimester and delivering the fetus during caesarean section. It is also used to gain access and perform surgery on a fetus during pregnancy to correct birth defects, and it is an option to achieve resuscitation if cardiac arrest occurs during pregnancy and it is necessary to remove the fetus from the uterus.

<span class="mw-page-title-main">Atosiban</span>

Atosiban, sold under the brand name Tractocile among others, is an inhibitor of the hormones oxytocin and vasopressin. It is used as an intravenous medication as a labour repressant (tocolytic) to halt premature labor. It was developed by Ferring Pharmaceuticals in Sweden and first reported in the literature in 1985. Originally marketed by Ferring Pharmaceuticals, it is licensed in proprietary and generic forms for the delay of imminent preterm birth in pregnant adult women.

<span class="mw-page-title-main">Asherman's syndrome</span> Medical condition

Asherman's syndrome (AS) is an acquired uterine condition that occurs when scar tissue (adhesions) forms inside the uterus and/or the cervix. It is characterized by variable scarring inside the uterine cavity, where in many cases the front and back walls of the uterus stick to one another. AS can be the cause of menstrual disturbances, infertility, and placental abnormalities. Although the first case of intrauterine adhesion was published in 1894 by Heinrich Fritsch, it was only after 54 years that a full description of Asherman syndrome was carried out by Joseph Asherman. A number of other terms have been used to describe the condition and related conditions including: uterine/cervical atresia, traumatic uterine atrophy, sclerotic endometrium, and endometrial sclerosis.

Antepartum bleeding, also known as antepartum haemorrhage (APH) or prepartum hemorrhage, is genital bleeding during pregnancy after the 28th week of pregnancy up to delivery.

Cervical dilation is the opening of the cervix, the entrance to the uterus, during childbirth, miscarriage, induced abortion, or gynecological surgery. Cervical dilation may occur naturally, or may be induced surgically or medically.

<span class="mw-page-title-main">Vacuum aspiration</span> Gynaecological procedure

Vacuum or suction aspiration is a procedure that uses a vacuum source to remove an embryo or fetus through the cervix. The procedure is performed to induce abortion, as a treatment for incomplete spontaneous abortion or retained fetal and placental tissue, or to obtain a sample of uterine lining. It is generally safe, and serious complications rarely occur.

Dilation and evacuation (D&E) is the dilation of the cervix and surgical evacuation of the uterus after the first trimester of pregnancy. It is a method of abortion as well as a common procedure used after miscarriage to remove all pregnancy tissue.

<span class="mw-page-title-main">Prelabor rupture of membranes</span> Medical condition

Prelabor rupture of membranes (PROM), previously known as premature rupture of membranes, is breakage of the amniotic sac before the onset of labor. Women usually experience a painless gush or a steady leakage of fluid from the vagina. Complications in the baby may include premature birth, cord compression, and infection. Complications in the mother may include placental abruption and postpartum endometritis.

Cervical effacement or cervical ripening refers to a thinning of the cervix.

<span class="mw-page-title-main">Cervical cerclage</span> Obstetrics medical procedure

Cervical cerclage, also known as a cervical stitch, is a treatment for cervical weakness, when the cervix starts to shorten and open too early during a pregnancy causing either a late miscarriage or preterm birth. In women with a prior spontaneous preterm birth and who are pregnant with one baby, and have shortening of the cervical length less than 25 mm, a cerclage prevents a preterm birth and reduces death and illness in the baby.

Cervical conization refers to an excision of a cone-shaped sample of tissue from the mucous membrane of the cervix. Conization may be used for either diagnostic purposes as part of a biopsy or therapeutic purposes to remove pre-cancerous cells.

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<span class="mw-page-title-main">Osmotic dilator</span> Medical device to dilate the uterine cervix

Osmotic dilators are medical implements used to dilate the uterine cervix by swelling as they absorb fluid from surrounding tissue. They may be composed of natural or synthetic materials. A laminaria stick or tent is a thin rod made of the stems of dried Laminaria, a genus of kelp. Laminaria sticks can be generated from Laminaria japonica and Laminaria digitata. Synthetic osmotic dilators are commonly referred to by their brand names, such as Dilapan. Dilapan-S are composed of polyacrylonitrile, a plastic polymer. The hygroscopic nature of the polymer causes the dilator to absorb fluid and expand.

The following outline is provided as an overview of and topical guide to obstetrics:

Cervical pessary is a medical device used to treat an incompetent cervix. Early in the pregnancy a round silicone pessary is placed at the opening to the cervix to close it, and then it's removed later in the pregnancy when the risk of a preterm birth has passed.

References

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