What is cervical inefficiency – how to diagnose and treat?

What is cervical inefficiency – how to diagnose and treat?

1)  -When the term cervical insufficiency came first time appeared in the literature? The term was first observed in Lancet in 1865.

2)   Insufficiency”-means “Incompetency “-However, for us the clinician’s pejorative connotations”Insufficincy”-means Incompetency. And by the term insufficiency , we understand that some form active Tr is warranted .But to implement appropriate Tr implies that we must know the exact etiologic background of Insuffiency so as to select the most appropriate therapy so that preg is safely carried to term/near term. Not that in all cases thee is organic or structural changes in Cx is present prior to pregnancy. Some new factors (infns in genital tract, UTI, altered commensales & immunity) also can lead to such changes in midtrimester or at early third trimester leading to initiation of labour almost painlessly with intact healthy Cx at the onset of preg.

3)  What happens in cervix? There is a process called “premature progressive cervical ripening (earlier called Preterm Birth Syndrome) –in absence of any clinical symptom or signs of labour say chorio ammonites.

4)  What are the causes of such premature Cx changes? It is not true that fault lies with c itself always. Flowing may be the factors to give rise to premature changes in Cx eventually culminating in PTL. To name such etiology are::- 1) Subclinical genital Tr infections( That is why ART spl ,quite often prescribes Probiotics    and some local antiseptics on vulva as vulval wash, occasionally Azithromycin if excess whites suggestive of opening up  I Os. 2) Local inflammations at Cx –cause unknown-?? Altered immune response to hormones or Bacterial  Vaginosis, 3) Exagerated - excessive hormonal effect –local progesterone suppository-hopefully counteracts premature changes in Cx --in this way. UTI may, to initiate such silent Cx changes prematurely.

5)  History of “Interval Cx stitches”-In the middle part of last century two famous persons stared putting stitches(that too at interval period)-namely Shirodkars & McDonald ). Their cases were selected based on history of rec midtrimester abortions—their aim was to correct the inherent defects of Int os –so as to prevent painless dilatation of Int os. At thay evidence or guidelines were lacking. As understandable, we must by this time understand indications of surgical interference uptick that time was history bases and no randomization was de,

6)    No fight on sonological indices please i.e. on Sonographic metrics :- Time  has come when we should  sit together and stop arguing about TAS/TVS-1) Full bladder or empty U bladder-2) to press gently on abd probe tip  or not to press at all 3)  not to speak of changes induced by coughing: These are all just to some extent theoretical and we have to apply our clinical knowledge too.-There are three modalities of diagnosing threatened   insufficiency or possible insufficiency in advance & therefore select cases for putting stitch?

7)   In all fairness most us select cases in presence of any of the  following three indications :- e.g. A) A History based ( basically prophylactic)  B) Physical –Examination –indicated (emergent) cerclage –often called “clinical diagnosis “–like short Cx –and progressive changes in Cx (length and int os dilatation). C) Ultrasound indicated (rescue or urgent –not preplanned) cerclage.

An experienced clinician may be able to diagnose silent Cx dilatation or by speculum exam he/ she can visualize the bulging mm.Understandably such sera exam and quite often leads to a delayed diag and often delay inn institution of Tr. Synthesis of the entire above scenario are essential to decide to stitch or not to stitch.

8)  B) Sonological Diagnosis:- Most of us as on 2017,  rely on this methodology: By serial monitoring for cervical length & funneling of Int os,

9)   

 Medical Wisdom is essential:-

1)  Tricks of the trade Smell the possibility f PTL and implement followings, as I do e.g. 1) avoidance of too much activity after 24 weeks. 2) Local hygiene 3) Avoidance of sexual; activity 4) Oral Proboscis 5) to diag a TR asymptomatic bacteruira etc.

2)   Your diagnosis is misleading. Previously a preterm delivery. Investigate for other causes. Urinary infection, reproductive tract infection and of course you have investigated for cervical incompetence. If you find no cause for the pre term labor. It is idiopathic. Give her micronized progesterone.

3)   Put her on depot injection smithy do equally well with that.

4)  I feel she has had a history ... better to do it off and b safe. Both u n the patient

 What made to label it cervical incompetence in 1st preg? Any causative factor for preterm labor. How fast was the progress whether leaking was there take detail h/o 1st preg? If it suggest cervical incompetence better to do encerclage.

We never know after 28 wks any time cervix may give way & it will be difficult situation we may lose the baby. Cerclage is a simple non invasive procedure I think no harm doing cerclage

 A big No! Just monitor the cervix for length and funneling.

 Was the cervical length measured by TVs...?

Monitor cervical length
cos we don’t know if it was cervical weakness previously

. Sterilize vagina with Clindamycin and clotrimazol
2. Replenish with Probiotics drugs
3. Add progestogen for safety 

Weekly monitoring - usg
Add tocolytics at the right time and continue till 35 weeks
Avoid strenuous activity /work

 

Progesterone in this situation?

For example sake one of my poor pt had previous 3 preterm deliveries at 6 months. In her forth on I gave only inj maintain as pt was not willing for encerclage. Delivered at full term.

 There is lot of talk about progesterone vaginal pessaries recently but I am skeptical as the 400mg we give as pessaries is a drop in the ocean compared to what the woman produces during pregnancy. But still it is worth a try, anything that could benefit patient should be tried!!

Prophylacticaly, Cx encerclage should be done.

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5)  How relevant is adjunctive therapies in case where a stitch have been put :-be it a case of - “History indicated cases”: “Ultrasound-indicated ,  “Physical examination indicated”, but relevance of  Adjunctive therapies are no less relevant as because spont preterm labour is often a complex syndrome ad quite often evidence –based guidelines are debatable and it is difficult to define which group of women will be benefitted by cerclage open . Randomization of cases is a difficult proposition..:-Such adjunctive Tr are

1)  Probiotics, 2) maintenance of Local hygiene, 3) Progesterone pessaries / Inj 17-α-OH Progesterone caproate-IM weekly, 4)?? Bed rest/ addl rest. 5) ?? Tocolytics- Nefidepine, Indomethacin after putting a stitch for couple of days if ut irritability persists. I like to hr collective opinions  of Forum members about such ?? Supportive Tr.