INCOMPETENT CERVIX (CERCLAGE)
Cervical competence is a continuum with the rate of preterm delivery increasing as
cervical length decreases.
The diagnosis of cervical incompetence has traditionally been made on the basis of an
obstetric history consistent with passive and painless midtrimester dilation of the
cervix.
The presence of uterine contractions, bleeding, ruptured membranes, and intraamniotic
infection do not necessarily exclude the diagnosis of an incompetent cervix as it is
often difficult to ascertain whether these latter complications preceded or followed
the dilation..
Risk factors associated with an incompetent cervix
Extensive cervical conization.
Treatment:
Atlhtough a large randomized trialby the Medical Research Council/Royal College of
Obstetricians and Gynaecologists found cervical cerclage to be of benefit only in women
with a prior history of three midtrimester losses, ultrasound evaluation and the
anatomic placement of cerclage were not adequately addressed in that study.
Subsequent to the study cited above, sonographic serial evaluation ( every two weeks)
of the cervix for funneling and shortening in response to transfundal pressure has been
found to be useful in the evaluation of incompetent cervix.
Indication for cerclage:
History compatible with incompetent cervix AND
Sonogram demonstrating funneling OR
Clinical evidence of extensive obstetric trauma to cervix
Contraindications:
1.Uterine contractions.
2.Uterine bleeding
3.Chorioamnionitis
4.Premature rupture of membranes
5.Fetal anomaly incompatible with life
Preoperative evaluation:
Ultrasound for anomaly and viability
MS-AFP if appropriate
Wet mount. GBS, GC, and Chlamydia cultures.Treat appropriately for infection.
ORDERS:
Admit for cerclage
NPO after midnight
Bedrest with BRP. Trendelenberg without BRP if cervix is effaced or dilated.
Surgical consent
A 100-mg dose of indomethacin may be given per rectum during the operative period,
followed by a 50-mg oral dose every 6 hours
McDonald cerclage
Postop-Transfer to postpartum for observation
Regular diet
Bedrest 12-24 hours then ad-lib
May discharge if no uterine contractions, vaginal bleeding, or rupture of membranes
during observation.
Discharge Instructions
Return to hospital for uterine contractions, leaking of fluid, pelvic pressure, or
temperature > 100o . Nothing per vagina. Abstain from strenuous activity including
heavy lifting. HROB in one week.
