THE INCOMPETENT CERVIX

Dr. K. N. Georgewill
Department of Obstetrics and Gynaecology, UPTH.
SYNOPSIS
–INTRODUCTION
–DEFINITION
–INCIDENCE
–ETIOLOGY / PDF
–CLINICAL PRESENTATION
 INTRODUCTION
The first description of cervical incompetence
appeared in the medical literature in 1658
Over 200 yrs passed b/4 it was mentioned
again by Grenin in 1865, who speculated that
division or dilatation of the cervix might
structurally weaken it, making it incapable of
supporting a pregnancy to term
Only in the past 40 years has the clinical entity
of cervical incompetence received significant
attention.
Lash and Lash, in 1950, described the
technical details of repair of the cervix between
pregnancies (wedge excision of the damaged
cervix).
Shirodkar in 1955, described a method for the
management of the incompetent cervix with
surgical repair during pregnancy. Shirodkar's
contribution, in combination with the
modifications described by Barter and
colleagues, became widely accepted among
American obstetricians.
Contributions by McDonald, Mann, Hefner and
associates, Page, Barnes, and Baden added
significantly to the options in the surgical
management of cervical incompetence.
 DEFINITION
This is the inability of the cervix to support a
pregnancy to term due to structural and or
functional weakness.
It is an important cause of recurrent
midtrimester abortions (miscarriages).
Recurrent abortion is the occurrence of 3 or
more consecutive spontaneous pregnancy
losses before the age of fetal viability
 INCIDENCE
The incidence of recurrent miscarriages in general
is difficult to determine but is thought to affect
approximately 15-20% of all pregnancies.
Once a miscarriage has occurred the risk of
further miscarriage rises to about 20% reaching
over 40% after three consecutive losses.
The incidence of cervical incompetence is also
difficult to determine because it is usually over
diagnosed but reported incidence in different
centres in Nigeria vary between 0.5 - 3.5%. This
variation is based on differences in diagnostic
criteria and the method of identification of the
incompetent cervix.
 ETIOLOGY / PDF
Functional: no pathology, cause presumed to be the
premature triggering of the normal mechanisms for
effacement and dilatation of the cervix.
Structural defect: congenital or acquired
– Congenital:
congenital weakness of the internal Os (histologic
defect- increased smooth musclce fibres,
decreased collagen/elastic fibres = muscular
cervix that is inherently weak).
female fetal exposure to diethylstilbestrol (DES)-
MOA unknown.
Short, hypoplastic cervix
– Acquired:
Trauma to the cervix
– overzealous dilatation and curettage
– cone biopsy
– cervical amputation
– difficult or instrumental vaginal delivery
(cervical laceration)
infection: bacterial vaginosis
The most important cause of cervical incompetence is
overzealous dilatation and curettage. Three or more
first trimester induced abortions by dilatation and
curettage carries a 12% risk of a spontaneous
pregnancy loss, while a single second trimester
induced abortion carries a 14% risk.
RISK FACTOR IN OUR PATIENT
Hx of bearing down/pushing against a poorly
dilated cervix in her second confinement.
CLINICAL PRESENTATION
Recurrent, painless, spontaneous midtrimester
or early third trimester pregnancy losses, or
preterm deliveries.
Rupture of the fetal membranes or protrusion of
the membranes into the vagina.