AbdulNasser (AN)

AN
• Personal data
H.H is 37 years old Omani lady from Al khoudh,
G3P0A2( 21-12 weeks), at 12 weeks of gestation
known to have hypothyroidism on thyroxin. Since
2007 Admitted on 7/8/2010
LMP was on 10/5/2010 and EDD 15/2/2011
• Present complain: She was admitted for cervical
cerclage.
 h/o present complaint
• She has a h/o abortion twice
• The first was on 11 week of gestation which was
incomplete abortion & D/C on 1-11-08
• The second was on 21 week of gestation which was
incomplete D/C also done for here 1-3-2010
• She present to RH with lower abdominal pain and
heaviness in the vagina with no bleeding or leaking and on
examination there was bulging of membrane
 History of current pregnancy:
• She is G3P0A2 at 12weeks of gestation.
• LMP= 10/5/ 10. EDD= 14/2/ 11.
• She was booked RH at 7th wks of gestation.
Wt:97 kg , Ht:165cm
BP: 106/61 mmHg Hb: 13.2g/dl RBS: 6.7 mmol/L
Urine: no glucose, no protein, no ketones
Blood group: +ve
Sickling test: -ve
Hepatitis test: -ve
VDRL: -ve
HVS : show yeast infection
 1st ultrasound done at 7th weeks gestation : single viable
fetus CRL corresponding to gestational age

2nd ultrasound done before admission on 3/8/10:

• EDD:14/02/11
• BPD:12wk
• One fetus,fetal heart activity present, no gross fetal
abnormality seen at this stage
• Placenta :anterior
• Cervical length: 30.8mm
• No sign of incompetency :
Past obstetric history

Mention before
Menstrual history:
• Menarche at 14 years of age.
• regular cycles every 28 days for 5
days of moderate amount.
• no h/o dysmenorrhea.
Contraceptive history:
• None.
Past medical/ surgical history
• hypothyroidism(5yrs ago) due loboectomy
• h/o 2x D/C
• Allergies history:
• No h/o known allergies to any food or drug.
medication history
• Thyroxine(75 mg once daily)
• Folic acid
Family history
• no h/o similar problem in the family
• No h/o recurent abortion,preterm in the family
• No h/o thyroid diseases,HTN
• h/o diabetes in her father
Social history
• She is house wife
• no consanguinity
• Lives in a separate house with her husband.
• Good socioeconomic state
• No h/o smoking or alcohol drinking.
• No animals at home (cats)
 summary
• 37yrs old lady G3P0 A2 12wks gestation known to
have hypothyroidism on thyroxin with a h/o missed
abortion and admitted for cervical cerclage.
 Physical examination
General:
 Looks well, comfortable ,alert and not in distress
 No pallor ,no edema ,no calf muscle tenderness
No thyroid enlargement
Chest: clear
Heart : Normal S1 & S2 no murmurs or added sounds
Vital signs
 BP : 110/70 mmHg
 Pulse rate: 80/min
 Respiratory rate: 18/min
 Temperature: 36.9 C
 Abdominal examination
• Inspection:
• Umbilical is inverted.
• No scars.
• No visible veins.
• Palpation:
• No tenderness
• Auscultation:
• FHR=140bpm
Investigations
• CBC
– Hb 11g/dL
– WBC 7.26X109 /L
– Plt 281X109 / L
• LFT and RFT are normal
• HVS: normal vaginal flora
• Urine C/S: no bacterial growth
• TFT : normal ….. HVS : result is not shown yet.
The plan
• for vaginal cervical cerclage.
Operation
• Done for her cervical cerclage on 8/8/10
• McDonald’s technique: purse string sutures ,knot tied to left
& posteriorly.
• Post-op:
 DDx
• cervical incompetence
• parental chromosomal anomalies
• autoimmune disorders
– antiphospholipid syndrome
– systemic lupus erythematosus
• structural uterine anomalies
– bicornuate uterus
– uterine septum
– Fibroids
– intrauterine adhesions
• endocrine disorders
– polycystic ovarian disease
– uteal phase defect
– thyroid disease
• prothrombotic states
– antithrombin III deficiency, protein C or protein S deficiency/resistance, thrombocythaemia,
factor V Leiden
• infectious diseases
• embryotoxicity
Cervical incompetence
Definition:
• Condition in which the cervix fails to retain the conceptus during pregnancy.
• Cervix length less than 25 mm.
• responsible for approximately 15% of habitual immature deliveries between 16
and 28 weeks of gestation.
• prevalence:
• affects around1-2% of pregnant patients
• Embryologically, body & cervix derived from fusion and recanalization of
Mullerian ducts
• Histologically:
cervix
1. fibrous connective tissue collagen mostally
2. muscle 15%
3. blood vessels

The cervical competence is an active, not passive, phenomenon, and it is a specific

entity involving not just an abnormality or defect of cervical collagen, but is also due
to either:
1. Absence of the usual cervical musculature in cases of congenital cervical
incompetence, or
2. Injury or damage to the cervical musculature caused by previous trauma.
1. Idiopathic
2. Congenital disorders (congenital mullerian duct abnormalities eg. Septate uterus,
Bicornuate uterus).
3. DES exposure in utero.
4. Connective tissue disorder (Ehlers- Danlos syndrome).
5. Surgical trauma :
1. Conization
2. D/C
 Symptoms:

• "silent" cervical dilatation

• Mucus vaginal discharge, lower abdominal discomfort, bearing-
down sensation (S/E: visualisation of membranes bulging through
the cervix)
• When the cervix reaches 4 cm or more, active uterine contractions
or rupture of membranes may occur.
 Diagnosis
Historical factors:
1. History of painless cervical dilatation with preterm delivery
2. History of forceful cervical dilatation and evacuation
3. History of obstetric trauma: cervical lacerations, prolonged second
stage followed by cesarean
4. Prior cervical surgery: cone, loop
5. DES exposure in utero
Cervical sonography:
6. Short cervical length
7. Cervical funneling
• Digital examination of the cervix is highly subjective

• Dilators (hegar 8) or balloons to determine cervical resistance.

 Transvaginal ultrasound
• funneling of the internal cervical os (at rest or in response to transabdominal
pressure on the uterine fundus ) is the ultrasonographic appearance of cervical
incompetence.
• Provide a significant advance in the diagnosis of cervical incompetence
2 images of the same cervix without and with applying
pressure:

 
u/s findings:
1. Funneling of the cervix with the changes in forms T, Y, V, U
(correlation between the length of the cervix and the changes in the
cervical internal os).
2. Cervix length < 25 mm
3. Protrusion of the membranes.
4. Presence of fetal parts in the cervix or vagina
 Treatment
• Surgical repair of the cervix using a vaginal or abdominal approach.
• Other alternatives :Bed rest, use of vaginal pessaries to elevate and close the
cervix.
 cervical cerclage:

• Cervical cerclage: is a surgical procedure used to keep the cervix closed during
pregnancy.
 Indications
1. History compatible with incompetent cervix + U/S demonstrating funneling OR
Clinical evidence of extensive obstetric trauma to cervix
Contraindications
[Link] contractions.
[Link] bleeding
[Link]
[Link] rupture of membranes
[Link] anomaly incompatible with life
Cerclage:
1. Emergency
2. prophylactic
 Emergency cerclage
• Care of the patient with newly detected reduced cervical competence in
the second trimester is both difficult and controversial.
• When the diagnosis is made before cervical dilatation has occurred
and when there is still 10 to 15 mm or more of cervical length, admit
the patient for 24 hours of treatment with perioperative indomethacin
and broad-spectrum antibiotics before placing the cerclage sutures,
and observe the patient for 48 to 96 hours postoperatively.
• The prognosis for these patients is better than generally expected
• The prognosis is influenced by the gestational age at the time when the
suture is placed
 Prophylactic cerclage

• Prophylactic cerclage sutures (Shirodkar, McDonald )may be placed

at 12 to 16 weeks' gestation.
• Do not use tocolytics at the time of prophylactic cerclage, but give
perioperative antibiotics.
• Follow these patients with periodic vaginal sonography to assess
stitch location and funneling.
Cont.
• No additional restrictions are recommended as long as the stitches
remain within the middle or upper third of the cervix without the
development of a funnel, and the length of the cervix is greater than 25
mm.
• For patients who have not been successful with a vaginal suture
despite aggressive care and sonographic surveillance, a
transabdominal cerclage may be appropriate.
 Cerclage procedures
There are five different techniques for performing the cerclage:
• McDonald procedure
• Shirodkar operation
• Transabdominal cerclage
• Wurm procedure (Hefner cerclage)
• Lash procedure
• The two most common are the McDonald and Shirodkar.
 McDonald procedure
• is the most common
• a purse string stitch, the cervix stitching involves a 5 mm
band of suture at the upper part of the cervix while the
lower part has already started to efface.
• This cerclage is usually placed between 12 weeks and 16
weeks of gestation.
• It is generally removed at 37 weeks, unless there is a
reason to remove it earlier, like infection, preterm labor,
premature rupture of the membranes.
McDonald procedure
• Shirodkar cerclage
• is very similar, but the sutures pass through the
walls of the cervix so they're not exposed.
• This type of cerclage is less common and
technically more difficult than a McDonald, and is
thought to reduce the risk of infection.
• The Shirodkar procedure involves a permanent
stitch around the cervix because it will not be
removed and therefore a Caesarean section will be
necessary to deliver the baby.
Shirodkar cerclage
• transabdominal cerclage,
• the least common type, is permanent
and involves stitching inside the
abdomen.
• This is usually only done if the cervix
is too short to attempt a standard
cerclage, or if a vaginal cerclage has
failed or is not possible.
 Preoperative evaluation
1. Ultrasound for anomaly and viability
2. MS-AFP( Alpha Fetoprotein).
3. HVS: for vaginal infections
4. Beta Streptococci, Gonococci, and Chlamydia cultures.
Treat appropriately for infection.
• Admit for cerclage
• NPO after midnight
• Bed rest.
• 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
Post operative:
• Transfer to postpartum for observation
• Regular diet
• Bed rest 12-24 hours
• observed for any risk of cercelage (premature labor,infection)
• receive medication to prevent infection or preterm labor.
• For 2-3 days after the procedure, plan to relax at home; avoid any
unnecessary physical activity.
• Abstinence from sexual intercourse is often recommended for one
week before and at least one week after the procedure.
• May discharge if no uterine contractions, vaginal bleeding, or rupture
of membranes during observation.
 Risks of cercelage
 Premature rupture of membranes.
 Chorioamnionitis (This risk increases if cx dilated more than 3 cms.)
 Preterm Labor
 Cervical laceration.
 Maternal hemorrhage
 Cervical dystocia (inability of the cervix to dilate normally in the course
of labor)
 Uterine rupture
 Bladder Injury (rare)
 Efficacy of cerclage
• Cerclage seems to be a very effective treatment for incompetent
cervix.
• The success rate for cervical cerclage is approximately 80-90% for
elective cerclages, and 40-60% for emergent cerclages. A cerclage is
considered successful if labor and delivery is delayed to at least 37
weeks (full term).
• Approximately 1-9% of women will experience premature labor after
cerclage. The risk of chorioamnionitis is 1-7%,
 References

• [Link]
• Gynecology & obstetric surgery,David [Link],USA;1993.