J Obstet Gynecol Ind Vol. 54, No. 1 : January/February 2004 Editorial INCOMPETENT CERVIX - CURRENT STATUS The incompetent cervix classically defined, as the inability to support a full term pregnancy because of a functional or structural defect of the cervix, is the commonest cause of midtrimester pregnancy loss. The cervix is made of two main elements viz; fibrous tissue (70%) and smooth muscle (30%). The internal 0s represents a functional transition from the fibrous cervix to the muscular uterus and is responsible for retaining the growing conceptus within the uterus till term. Any etiological factors leading to a weakening of the internal os tissue like intrauterine DES exposure causing congenital weakening of the 8 or traumatic procedures on the internal os can cause cervical incompetence. Preterm birth following cervical incompetence threatens multiple gestation, Pregnancies complicated by higher order multiple births like twins, triplets, quadruplets or more are rare but are at high risk for premature cervical dilatation, premature delivery and increased perinatal morality. With ever increasing use of ovulation inducing agents, the incidence of higher order multiple births is now rising more than ever before, thus making it necessary for clinicians to divert attention to tackling problems frequently associated with these patients, cervical incompetence being one of the commonest among them. Embryo reduction is advocated and practiced freely. Cervical insufficiency is a frequent complication in these patients and is often considered to be an indication for cerclage operation. The diagnosis of cervical incompetence during pregnancy is predominantly dependent on the patient’s history of painless dilatation of the cervix resulting in midtrimester pregnancy loss. Digital examination of the cervix has been traditionally recommended. Recently, the addition of transvaginal ultrasonography has led to accurate assessment of cervical measurements with an. empty bladder to avoid distortion. The average cervical length is approximately 38 to 42 mms. Various studies indicate that a cervical length of less than 25 mm is associated with increased risk of preterm delivery’ Another parameter of marked importance on transvaginal ultrasonography is the appearance of funneling or beaking of the internal os. This may occur at rest or as a result of transabdominal pressure applied at the fundus of the uterus®. Transvaginal sonography may also be utilized to measure cervical dilatation for prediction of preterm delivery’. Attempts have been made to correlate cervical length evaluated by transvaginal sonography in non-gravid women with history of preterm delivery to gestational age at delivery by Pardo et alt. However, they concluded that in nongravid women with history of unexplained preterm delivery there is no difference in cervical length compared to that in those who delivered at term. Shortening of the cervix is most probably a reversible phenomenon that occurs during pregnancy and represents a failure of the competence mechanism to adapt to pregnancy. Various important cervical parameters like cervical length, width, thickness and cervical volume have been studied in patients of multiple gestation to establish a diagnosis of cervical insufficiency as a major cause of second trimester pregnancy loss and premature labor. Eppel et al’ compared 97 uncomplicated twin pregnancies with 113 uncomplicated primiparous pregnancies. Their analysis revealed that in general the cervical length in a multipara with multiple pregnancy is longer than that in a primipara with multiple pregnancy’. Michaels et al® conducted a comparative study of 51 consective twin pregnancies studied prospectively versus 153 consecutive twin gestation that were currently delivered but chosen retrospectively as controls. Women, in the study group were managed by a protocol that used weekly ultrasound surveillance combined with clinical assessment, Controls were not managed by the protocol or ultrasound surveillance. The results showed that all, study twins survived while nine controls delivered at a mean gestational age of 22.7 weeks, with a loss of 17 infants. A significantly greater proportion of controls delivered very low birth weight premature infants. The use of ultrasound and clinical criteria for cerclage placement helped prevent birth of youngestand smallest twins and significantly decreased perinatal mortality in the study group. Routine cerclage placement is not, recommended for twin gestations, but multifetal gestations may benefit from ultrasound surveillance for cervical incompetency’. Sonographic cervical volumetry is another useful parameter for evaluation of cervical incompetence in multifetal gestations as shown by Strauss et al”. Their results showed that volumetry using 3D ultrasound was superior for the assessment of cervical biometry and confirmation when the transabdominal 2D plane was obstructed. When the cervical length was obtainable by a conventional scan, the technically more comple 3D-imaging did not provide further information’. Many conservative therapies have been advocated for cervical incompetence. These include bed rest, vaginal pessaries, progesterone supplements like 17 - alpha 19Editorial hydroxy progesterone caproate, administration of tocolytics etc.; none of these have been widely accepted. ‘The therapy that has achieved greatest recognition for management of cervical incompetence is surgical cervical encirclage. Introduced in the year 1951, treatment with cervical circlage has undergone rigorous trials to prove its efficacy. Cervical cerclage procedures have been used liberally in patients with multifetal gestation to lengthen the gestational age at delivery. However, this does not seem to improve outcome as judged by prematurity or fetal survival. At present, fetal survival cannot be used as the measure of success of a surgical procedure because so many other factors play a role in the outcome, such as the quality of obstetrical and neonatal care‘, Strauss et al’ also showed similar results stating that prophylactic cerclage did not prolong pregnancies compared to controls. With respect to need for hospitalization or intravenous tocolysis or perinatal outcome parameters, no benefit was achieved. In case of very short, scarred or amputed cervices, transabdominal approach for placement of a cervical suture is recommended. It involves placement of a suture at the level of the internal os after lateral displacement of the uterine vessels. However, it requires laparotomy for placing the suture and cesarean section for delivery. Alternatively, transvaginal cerclage under USG guidance may be a better option for short cervices™, Rescue cerclage refers to cervical encirclage in patients with unavoidable delivery of the first twin combined with tocolysis to prevent delivery of the second twin. Zhang et al” carried out retrospective analysis of 66 such patients and concluded that cerclage after delivery of first twin was associated with longer inter-delivery interval without increasing the risk of intrauterine infection in well controlled conditions. Emergency cerclage refers to the procedure of cerclage performed in a situation with prolapsed membranes. It is technically a more difficult procedure requiring replacement of the bulging membranes by an inflated Foley's catheter followed by placement of stay suturesat the dilated cervix and then applying gentle pressure with gauze on the ring forceps along with overiilling of the bladder at the same time. The success of the procedure is limited due to intraoperative complications like infection, chorioamnionitis, rupture of membranes, preterm labor and premature delivery. Alfaro etal conducted a 10 year long retrospective study of emergency cerclage and concluded that the emergency cerclage procedure remains a heroic attempt to continue pregnancy and prolongation of the pregnancy following this procedure is highly variable with neonatal survival rate between 12 to37% only. 20 References 1. lamsJD, Goldenberg RL, Meis PJ et al. The length of the cervix and the risk of spontaneous preterm delivery. N Engl | Med 1996; 334: 567-72 2. Gunzman ER, Pisatouski DM, Vintzileos AM et al A comparison of ultrasonographically detected cervical changes in response to transabdominal pressure, coughing and standing in predicting cervical incompetence. Am J Obstet Gynecol 1997; 177: 660-5. 3. IamsJD. Cervical ultrasonography. Ultrasound Obstet Gynecol 1997;10:156-60. 4, Pardo J, Yogev Y, Ben-Haroush A et al. Cervical length evaluation by transvaginal sonography in non gravid women with history of preterm labor. Ultrasound Obstet Gynecol 2003;21:464-6. 5. EppelW, Schurz B, FrigoP etal. Vaginal sonography of the cervix in twin pregnancies. Geburtshilfe Frauenheilkd 1994;54:20-6, 6. Michaels WH, Schreiber FR, Padgett RJ et al. Ultrasound surveillance of the cervix in twin gestations: management of cervical incompetency. Obstet Gynecol 1991;78:739-44. 7. Strauss A, Heer IM, Fuchshuber S et al. Sonographic cervical volumetry in higher order multiple gestation. Fetal Diagn Ther 2001;16:346-53. 8. Jewelewicz R. Incompetent cervix: pathogenesis, diagnosis and treatment. Semin perinatol 1991;15:156-61. 9. Strauss A, Muller-Egloff 8, Heer IM et al. Cervical incompetence in multifetal gestation. Gynakol Geburtshilfiche Rundsch 2003; 43:91-7. 10. Ludmir], Jackson GM, Samuels P et al. Transvaginal cerclage under ultrasound guidance in cases of severe cervical hypoplasia. Obstet Gynecol 1991;78: 1067-72. 11, Zhang J, Johnson CD, Hoffman N et al. Cervical cerclage in delayed interval delivery in a multifetal pregnancy: a review of seven case series. Eur] Obstet Gynecol Reprod Biol 2003;108:126-30. 12. Alfaro JA, Velasquez MM, Cuervo HR et al Emergency cerclage: 10 years experience at the ABC hospital. Girfecol Obstet Mex 2003;71:131-6. C.N. Purandare