Cervical incompetence occurring after caesarean section: a case report

A case of cervical incompetence as a result of caesarean section is presented. The role of caesarean section as an aetiological factor in cervical incompetence is discussed.

Incompetent cervix: pathogenesis, diagnosis and treatment

The incompetent cervix is a diagnostic dilemma. There are no well-defined or strict criteria to diagnose cervical incompetence, and therefore the indications for treatment are not always clear. Forty years ago, when the basic methods of treatment were first described, the diagnosis seemed relatively simple and the treatment acceptable. There have been very few large, prospective, randomized, well-controlled studies to determine the efficacy of the various surgical methods. Liberal use of cerclage procedures in situations of moderate risk for premature delivery or as prophylactic measures in multiple pregnancy does not appear to improve outcome as judged by prematurity or fetal survival. At the present, fetal survival cannot be a measure of the success of a surgical procedure because so many other factors play a role in outcome, such as the quality of obstetrical and neonatal care. Therefore, outcome of surgical procedures should be judged by more objective criteria, such as prolongation of pregnancy (in weeks) and birth weight. The methods that would allow making an unequivocal and objective diagnosis of incompetent cervix are not yet available. Until we reach this goal, the subject of cervical incompetence and effectiveness of its treatment will remain challenging and elusive.

[Clinical trends in 520 twin pregnancies in 22 years]

In the last 22 years 520 twin pregnancies were seen at the Department of Obstetrics and Gynecology, University of Ulm. The material was analyzed retrospectively according to the 4 time periods 1965-1974, 1975-1980, 1981-1983, and 1984-1987. An equal-size group of singleton pregnancies was used as control. 1. By the 20th week the diagnosis had been established in 67% between 1984 and 1987 and 29% between 1975 and 1980. 2. A cervical cerclage was most commonly done between 1981 and 1983 (75%). The frequency decreased afterwards and a cerclage was only done in 18% in 1987. 3. Tocolytic agents were used in 7% between 1965 and 1974 and in two thirds of cases in the last years. 4. Hospital admission before delivery was most common between 1975 and 1980 (33%). In the last 7 years it was only half as common (15%). 5. There was no difference in the frequency of preeclampsia and eclampsia between singleton and twin pregnancies in the last years. 6. Maternal hemoglobin levels below 10% were more common in twin pregnancies than in the control group: Before delivery 11%, after delivery 22% in the twin pregnancies, compared with 6% and 4% in the singleton pregnancies. 7. There was no increase in the duration of pregnancy in the last 22 years. The difference between actual birth date and estimated date of delivery remained about the same in the 4 examined time periods: 21 days, 20 days, 21 days, 27 days. There was a slight increase in the frequency of delivery before the 37th week in twin pregnancies: 38%, 41%, 43%, 47%.

Cervical incompetence in a pregnancy following a cervical ectopic pregnancy

A case of cervical incompetence is reported which occurred in a pregnancy which followed soon after treatment of a cervical ectopic pregnancy using a Foley catheter. Very few pregnancies following cervical pregnancy have been reported. Although this isolated case is clouded by other risk factors, cervical incompetence should be considered as a potential complication of such pregnancies.

Transabdominal cervicoisthmic cerclage: a review

A successful case of transabdominal cervicoisthmic cerclage is presented. The indications and surgical technique for this rarely reported treatment of incompetent cervix are described, and the pathophysiology of the condition is reviewed. The currently accepted treatment alternatives for incompetent cervix are presented and compared with the transabdominal approach. The existing reports on transabdominal cervicoisthmic cerclage are reviewed, and the morbidity of all reported cases is discussed. A scheme to assist in patient selection is suggested.

Cervical incompetence and preterm labor

The ability of the cervix to function as a competent sphincter to retain the fetoplacental unit in utero until term is dependent on a complex set of biochemical, biophysical, and environmental events. The understanding of these interactions is limited at present and requires that cervical incompetence be a diagnosis of exclusion. Currently, differentiation of cervical incompetence from preterm labor is a major problem. Advances in ultrasonography, ambulatory uterine activity monitoring, cervical histomorphology, and biochemistry should improve the understanding of both normal and abnormal cervical and uterine function and may provide new techniques to distinguish between true cervical incompetence and preterm labor. Well-designed and strictly executed randomized clinical trials of cervical cerclage should answer the question of therapeutic efficacy for this popular technique when the diagnosis of cervical incompetence is made.

Pregnancy and delivery after cone biopsy of the cervix

Seventy-seven women had 98 pregnancies after a cone biopsy of the cervix. There were 62 deliveries, 26 legal abortions, 9 spontaneous abortions and 1 ectopic pregnancy. Cervical cerclage was done for 22 out of 62 conized parturients (35.4%) and for none in the matched control group. There were 4 (6.4%) preterm deliveries in the cone biopsy group and 1 in the control group. The perinatal mortalities were 3.2% and 0% respectively. The mean duration of labour was 2.4 h shorter in the conized parturients than in the controls (P less than 0.05) but there were no difference in the mode of delivery in the two groups.

Cervicovaginal fistulas: management of subsequent pregnancy

Cervicovaginal fistulas that develop after midtrimester abortion represent a significant risk to subsequent pregnancies. Since patients with this condition appear to be at increased risk for preterm labor and cervical incompetence, I recommend a cerclage procedure. The probability of complications during labor in such cases makes elective cesarean delivery the method of choice.

The incompetent cervix

All methods for the management of CI have been described as producing a significant improvement in fetal salvage. The Lash procedure and the pessary have been deemed the most effective. However, the methods of patient selection in many of the older studies are not described, and their statistical validity is suspect. CI is thus a disease of uncertain etiology. Its pathophysiology is poorly understood, and methods of treatment vary greatly both as to technique and efficacy.

Can a low-lying placenta be the risk factor of cervical incompetence? A preliminary study on the relationship between placenta insertion and anatomical status of uterine cervix

An attempt was made to verify the hypothesis that a low-lying placenta may be a factor leading to the dynamic form of cervical incompetence. A vaginal evaluation of the cervix was made in 143 pregnant women who by means of ultrasonographic method were found to have low-lying placentas. In as many as 68 out of the 143 studied cases (47.5%), the low-lying placenta coincided with a shortening of the cervix about half its normal length or in both shortening and patency of the uterocervical canal, measuring up to 2 cm in diameter (39 cases). The statistical calculations indicate that a low-lying placenta can influence cervical behaviour and that it appears to be a risk factor of cervical incompetence.

Outcome of third trimester pregnancies after cryotherapy of the uterine cervix

A retrospective study was undertaken to assess the effect of cryotherapy of the uterine cervix on the outcome of third trimester pregnancies. It was concluded that cryosurgery of the cervix had no effect on the onset or progress of labour, or on the infant, an important advantage compared with cold-knife conization as a therapy for young women with cervical intraepithelial neoplasia.

Does cervix conization increase the risk of complications in subsequent pregnancies?

In a series of 414 patients who underwent cervix conization because of cancer in situ, the risk of complications in subsequent pregnancies was analyzed by studying the outcome of their 923 pregnancies before and after cone biopsy. After conization the incidence of late spontaneous abortion was seven times higher than before. Moreover, 20.5% of pregnancies following cone biopsy required cervix cerclage because of suspected cervical insufficiency, or cesarean section because of a scarred cervix stenosis.