Pocket ObGyn – Cervical Insufficiency / Short Cervix
See Abbreviations
Definition and Epidemiology (Obstet Gynecol 2012;120:964)
- Inability of cervix to maintain a Preg until term
- Weakened cervical tissue leading to loss of Preg, often 2nd trimester
Etiology
- Congen: Collagen dz, Müllerian fusion anomalies, h/o DES exposure in utero
- Acq: Cervical trauma, D&C, cervical manipulation (LEEP, cold knife cone)
- Abnormality in cervical remodeling (4 steps: Softening, ripening, dilation, repair)
Clinical Manifestation
- Asymptomatic/painless cervical dilation/effacement
- Often h/o painless dilation & deliv in the 2nd trimester w/ prior pregnancies
Physical Exam
- Speculum exam can show a dilated cervix
- Digital exam reveals soft, effaced, & possibly dilated cervix
Diagnostic Workup/Studies
- When performing fetal anatomy US at 18–22 w, can perform CL via transabdominal CL <25 mm on transabdominal ® transvaginal US
Treatment and Medications
- For short cervix: Vaginal progesterone 200 mg micronized or 90 mg gel daily
- For short cervix or cervical insufficiency: Cervical Cerclage (Obstet Gynecol
2014;123:372)
Surgical stitch placed circumferentially around the cervix
McDonald: “Purse-string” placed at cervicovaginal junction
Shirodkar: Requires dissection of the vesicovaginal & rectovaginal fascia to the level of the internal os
• When to treat:
Singleton Preg w/:
No prior spont preterm births ® offer vaginal progesterone suppl if CL
£20 mm at £24 w
Prior spont preterm birth (start progesterone injections weekly from 16–36 w)
® consider cerclage if CL £25 mm at £24 w
Dilated cervix <24 w ® consider rescue cerclage on individual basis Multiples show no improv w/ progesterone & worse outcomes w/ cerclage
Figure 11.2 Management of short cervix
(From Committee opinion no. 522: Incidentally detected short cervical length. Obstet Gynecol. 2012;119(4):879–882.)