OBSTETRICS FEATURE Cervical Incompetence Update Kara Beth Thompson, MD; Jennifer Keehbauch, MD In the face of diagnostic challenges and questions regarding treatment risks versus benefits for the neonate, what is the current consensus on the criteria and management for incompetent cervix? H istorically, cervical incompetence was defined as passive, painless cervical dilatation in the second trimester with no rupture of membranes, preterm labor, bleeding, or chorioamnionitis. Today, the cervix is viewed more as a dynamic organ, with incompetence occurring along a continuum as a result of multiple factors. Estimates of prevalence are derived from the ratio FOCUSPOINT of cerclage procedures to deliveries, which is as high as 1% of US pregnancies, or 40,000 cerToday, the cervix clages performed annually.1 Risk factors for cervical is viewed more as incompetence are listed in a dynamic organ, Table 1. However, insufficiency with incompetence may also occur in the absence of these risk factors. Thereoccurring along fore, the continuum of cervia continuum as a cal incompetence may also be result of multiple related to additional, yet-undefactors. fined processes such as infection, bacterial colonization, hormonal changes, inflammation, or genetic predisposition. in light of recent ultrasonographic fi ndings, this definition is being challenged. Transvaginal ultrasonography is a safe, reproducible method for objectively assessing cervical length, and it appears to be superior to digital vaginal examination or abdominal ultrasonography in this regard. Transvaginal ultrasonography has become the “gold standard” for cervical evaluation. The cervix in pregnancy follows a predictable pattern of effacement and dilation. Effacement begins at the internal cervical os and progresses in a “funneling” manner toward the external cervical os. On sonograms, this initially appears as a Y-shaped “beaking” of the cervical canal sidewalls that develops into a U-shaped space. The cervical length usually remains stable until the early third trimester and shortens progressively thereafter. Normal cervical lengths between 22 and 32 weeks’ gestation have been observed at 45 mm for the 90th percentile and 25 mm for the 10th percentile (Table 2).2 Serial ultrasonographic examination of cervical length can predict the risk of preterm delivery; the shorter the cervical length, the higher the likelihood ratio for preterm delivery.4 Using a value of less than 25 mm for cervical TABLE 1. Risk Factors for Cervical Insufficiency 2,3 • Gynecologic surgery LEEP Cone biopsy • Obstetric trauma DIAGNOSIS Classically, cervical incompetence was diagnosed based on clinical history—recurrent pregnancy loss in the second trimester, with each loss occurring at an earlier gestational age than the preceding one and lacking painful contractions or other inciting events. However, Cervical laceration Prolonged 2nd stage of labor Overdilation of cervix during pregnancy termination • DES exposure • Müllerian anomalies • Collagen/elastin deficiencies Kara Beth Thompson, MD, is a member of the teaching faculty, Christian Internal Medicine Specialization Program, Mbingo Baptist Hospital, Cameroon. Jennifer Keehbauch, MD, is Associate Director, Florida Hospital Family Medicine Residency Program, Orlando. 14 The Female Patient | VOL 34 NOVEMBER 2009 • Multiple gestation • History of preterm birth or second-trimester loss Abbreviations: DES, diethylstilbestrol; LEEP, loop electrical excisional procedure. All articles are available online at www.femalepatient.com. THOMPSON and KEEHBAUCH length provides a balance between sensitivity and specificity, maintaining a positive predictive value for preterm birth of 55%.5 Criteria for cervical incompetence include: • History of recurrent second-trimester losses in the absence of other inciting events • Current second-trimester presentation with acute, advanced cervical effacement and dilation without painful contractions • Ultrasonographic evidence of progressive cervical effacement (shortening to less than 25 mm or funneling). Low-risk patients are identified incidentally on transvaginal ultrasonography and have no suggestive history, no uterine malformations, no history of preterm birth or second-trimester loss, and a singleton gestation.6 Women at highest risk have 3 or more preterm births or second-trimester losses or have a history of preterm birth or second-trimester loss in the setting of a cervical length less than 25 mm.7 TREATMENT Nonsurgical Treatment Nonsurgical options may reduce the risk of preterm delivery in women with cervical incompetence. Reduction of activity or complete bed rest, avoidance of sexual inter- TABLE 2. Median Cervical Length by Gestational Age2 14−22 weeks 24−28 weeks >32 weeks 35−40 mm 35 mm 30 mm course, and cessation of tobacco use have been recommended. The use of indomethacin (100 mg once, followed by 50 mg every 6 hours for 48 hours) has been associated with a reduction in delivery before 35 weeks and decreased preterm delivery by 86% in women who presented with a shortened cervix prior to 24 weeks.8 Surgical Treatment Cerclage placement is the mainstay for preterm birth prevention in women with cervical insufficiency. Approaches and placements of the cerclage stitch differ, and no single technique has been demonstrated to be superior to others.9 The most popular transvaginal approach is the McDonald technique, which uses local or regional anesthesia to place monofi lament suture (polypropylene) or polyester fiber tape at the cervicovaginal junction. A weighted Coding for Cervical Incompetence This article discusses cervical incompetence and the diagnosis and treatment during the current pregnancy. The following codes should be used: 649.7 Cervical shortening [0,1,3] 654.4 Cervical incompetence [0–4] Presence of Shirodkar suture with or without mention of cervical incompetence Fifth Digit Required for Codes 649.7 and 654.4 0 Unspecified as to episode of care or not applicable 1 Delivered, with or without mention of antepartum condition 2 Delivered, with mention of postpartum condition 3 Antepartum condition or complication (patient still pregnant at end of episode of care) 4 Postpartum condition or complication (patient delivered during previous episode of care) The following V codes should be used when performing the transvaginal ultrasonography or surgical treatment. Codes V23.41 and/or V23.49 should be used instead of V23.4. Follow The Female Patient on and Philip N. Eskew Jr, MD V23 V23.4 Supervision of high-risk pregnancy Pregnancy with other poor obstetric history Pregnancy with history of other conditions classifiable to 630–676 V23.41 Pregnancy with history of preterm labor V23.49 Pregnancy with other poor obstetric history V89.05 Suspected cervical shortening not found The following are the Current Procedural Terminology (CPT) codes referred to in this article: 76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal (For nonobstetrical transvaginal ultrasound, use 76830) 59320 Cerclage of cervix, during pregnancy; vaginal 59325 Cerclage of cervix, during pregnancy; abdominal Philip N. Eskew Jr, MD, is past member, CPT Editorial Panel; past member, CPT Advisory Committee; past chair, ACOG Coding and Nomenclature Committee; and instructor, CPT coding and documentation courses and seminars. The Female Patient | VOL 34 NOVEMBER 2009 15 Cervical Incompetence Update Patient at risk for incompetent cervix History of 3 PTBs or 2nd-trimester losses 1 to 2 PTBs or 2nd-trimester losses with current singleton pregnancy Painless cervical dilation or bulging membranes <24 weeks Elective cerclage at 12–14 weeks Obtain TVUS at 14–24 weeks Emergent cerclage CL <25 mm CL >25 mm Therapeutic cerclage at 14–24 weeks Repeat ultrasonography at 1–2 week intervals FIGURE. Treatment algorithm for incompetent cervix.1 Abbreviations: CL, cervical length; PTB, preterm birth; TVUS, transvaginal ultrasonography. speculum is inserted into the vagina, and Sims retractors are used anteriorly for vaginal retraction. The cervix is grasped gently with an Allis clamp or Approaches and ring forceps for traction. Startplacements of ing at the 12 o’clock position, 4 the cerclage stitch or 5 successive bites are taken in a “purse-string” manner. differ, and no single The suture is tied anteriorly technique has been and trimmed. The Shirodkar demonstrated to be procedure involves placement superior to others. of the suture as close to the internal os as possible after dissection of the rectum and bladder from the cervix. After the suture is inserted, the mucosa is replaced over the knot. The McDonald procedure is generally favored over the Shirodkar procedure because of the former’s ease of suture placement.9 In transabdominal approaches via laparotomy or laparoscopy, the suture is placed in the cervicoisthmic region after dissection of the bladder away from the lower uterine segment. This invasive procedure carries a higher risk of complications (eg, hemorrhage), and it is generally reserved for patients who fail transvaginal placement, have congenital cervical hypopla- FOCUSPOINT 16 The Female Patient | VOL 34 NOVEMBER 2009 sia, or have substantial scar tissue from prior surgery or trauma. One study has shown favorable outcomes from transvaginal placement of cervicoisthmic cerclages.10 Some studies have demonstrated an overall increase in cervical length, while others have been able to show an increase in the distal cervix only. However, choice of method or placement of the cerclage closer to the internal os does not appear to significantly affect outcomes.9,11 Indications and Contraindications—The figure on this page outlines the decision tree for cerclage. Elective (prophylactic) cerclage is generally placed at 13 to 16 weeks’ gestation based on historical factors alone. This is usually reserved for patients with a history of 3 or more unexplained second-trimester losses. The presence of a live fetus without anomalies is confi rmed prior to stitch placement (Table 3).1,12-14 Urgent (therapeutic) cerclage is recommended for patients who present with ultrasonographic evidence of cervical shortening (less than 25 mm) or funneling. Ultrasonographic evaluation is usually performed due to risk factors for preterm delivery or symptoms (eg, contractions, pelvic pressure, vaginal spotting). Randomized trials for this All articles are available online at www.femalepatient.com. Cervical Incompetence Update TABLE 3. Results of Trials for Elective Cerclage Type of Trial Patient Population Findings Reference RCT 67 women with history of delivery <34 weeks No difference in preterm births <35 weeks 12 Meta-analysis 2,190 women in 6 trials No difference in preterm births <34 weeks or neonatal survival 13 Cohort 225 women at 14−26 weeks with ≥1 cm of dilation Fewer preterm deliveries <28 weeks Increased neonatal survival 14 Abbreviation: RCT, randomized controlled trial. subset of patients have demonstrated variable outcomes Until data demon(Table 4).7,14-17 Emergent cerclage is perstrate a reduction formed in women who present in preterm births and with symptoms of cervical improved neonatal incompetence, eg, pelvic pressure, clear vaginal discharge, outcomes, discuss cervical dilation of 2 cm or options and risks to more, absence of regular uterdetermine how to ine contractions (Table 5).18-20 At this stage of cervical insuffimanage cervical ciency, the membranes are incompetence in often at or beyond the external a given case. cervical os. There are various methods for reducing the membranes back into the intrauterine cavity: A Foley catheter can be placed in the bladder or the cervical os to displace the membranes caudally, or an inflated FOCUSPOINT balloon can be inserted under epidural anesthesia with the patient in the Trendelenburg position. Amniocentesis with glucose level, Gram stain, and interleukin studies should be considered to rule out subclinical intra-amniotic infection due to the exposed membranes. Transabdominal amniocentesis can also serve to reduce the membranes via amnioreduction. Complications—The most common complications of cerclage placement are rupture of membranes, chorioamnionitis, and displacement of the suture. Incidences vary with procedure indication and timing. Rupture of membranes has been reported in 1% to 18% of elective, 3% to 65% of urgent, and 0% to 51% of emergent cerclage placements. Chorioamnionitis developed in 1% to 6%, 30% to 35%, and 9% to 37% of procedures, respectively. Displacement of the suture occurred in 3% to 13% of elective cerclage procedures.3 TABLE 4. Results of Trials for Urgent Cerclage Type of Trial Patient Population Findings Reference RCT 113 low-risk women at 16−24 weeks with cervical length <25 mm OR membrane prolapse >25% of canal length No difference in gestational age at delivery or perinatal outcome 15 RCT 35 high-risk women with cervical length <25 mm at 27 weeks Fewer preterm deliveries <34 weeks 16 RCT 253 low-risk women at 22–24 weeks with cervical length <15 mm No difference in gestational age at delivery or neonatal morbidity 17 Meta-analysis 607 women from studies in references 6, 15−17 Fewer preterm deliveries <37 weeks 7 Cohort 225 women at 14−26 weeks with ≥1 cm of dilation Fewer preterm deliveries <28 weeks Increased neonatal survival 14 Abbreviation: RCT, randomized controlled trial. 18 The Female Patient | VOL 34 NOVEMBER 2009 All articles are available online at www.femalepatient.com. THOMPSON and KEEHBAUCH TABLE 5. Results of Trials for Emergent Cerclage Type of Trial Patient Population Findings Reference Observational 35 women with >2 cm of cervical dilation and no labor at 20−22 weeks Survival of 85.7% of neonates 18 Observational 46 women at 18−26 weeks with cervical length <15 mm and >2 cm of cervical dilation Fewer preterm deliveries and increased neonatal survival 19 RCT 23 women at 27 weeks with membranes at or beyond the external os Fewer deliveries at 34 weeks No difference in neonatal survival 20 Abbreviation: RCT, randomized controlled trial. CONCLUSION Until further data demonstrate a reduction in preterm births and improved neonatal outcomes, physicians and patients must discuss options, risks, and outcomes to determine how best to manage cervical incompetence in a given case. Current evidence supports the following recommendations: (1) serial transvaginal ultrasonographic evaluation for cervical length should be considered beginning at 14 to 20 weeks’ gestation in women with risk factors for cervical incompetence; and (2) elective cerclage should be considered in patients with a history of 3 preterm births or second-trimester losses or a singleton pregnancy and short cervix in the second trimester.1,6,15,20 Dr Thompson reports no actual or potential conflicts of interest in relation to this article. Dr Keehbauch served as a consultant to Schlesinger Associates and Maximus, is a stockholder in Pfizer, and is on the speakers bureau for Novartis. 8. 9. 10. 11. 12. 13. 14. 15. REFERENCES 1. Berghella V, Seibel-Seamon J. Contemporary use of cervical cerclage. Clin Obstet Gynecol. 2007;50(2):468-477. 2. Williams M, Iams JD. Cervical length measurement and cervical cerclage to prevent preterm birth. Clin Obstet Gynecol. 2004;47(4):775-783. 3. 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