Cervical Insufficiency

Risk of premature birth is one of the most important issues that worries expectant mothers who plans every moment. The risks of preterm birth can affect the baby's health, even if the idea of holding your baby earlier in your arms is pleasant to you. Although the idea of holding your baby earlier in your arms is pleasant, preterm birth carries many risks that may affect the baby's health. If there is a risk of preterm birth during pregnancy, it should be treated accordingly.



 

How is it diagnosed?

One of the major causes of preterm labor is cervical insufficiency. Cervical insufficiency diagnosis is based on history and ultrasonography. Recurrent second trimester loss and miscarriages as a result of painless opening of the cervix are history-based diagnosis. It should be taken into consideration that there should be at least 2 losses occurred before the 28th gestational week. The other diagnosis is based on ultrasound cervical measurement. It his group, the cervix should be below 25 mm before the 24th gestational week or a progressive change in the cervix should be observed during the examination. There should be 1 or more losses between the 14th and 36th gestational week. If the cervix is less than 25 mm and there is no history of loss, but if there is another risk factor for cervical insufficiency, these patients can still be included in the diagnosis.

Incidence is increasing

It is more realistic to see cervical insufficiency as a process that develops in the time as part of and a union of premature birth and premature rupture of membranes. The number of patients diagnosed with cervical insufficiency has increased thanks to vaginal ultrasound measurement of cervical length and the incidence in the community has increased to 2-5%.

There could be many reasons

Cervical layer weakness, various gynecological interventions (abortion, biopsy, cold conization, LEEP and cervical cancer surgery, etc.), trauma, infection, contraction due to uterine contraction may cause cervical shortening. 

A measurement should be between the 14th and 36th week

When ultrasonography is used for the diagnosis of cervical insufficiency, it is important to remember that the cervix is a dynamic organ. Cervical measurement may vary within minutes and with contractions. Therefore, there should be sufficient time for measurement. Measurements made from the abdomen with full bladder are quite deceptive. Measurement and evaluation should be vaginal. Measurement should be made between the 14th-24th gestational week. Before the 14th week measurements are not sufficient to determine treatment.

Recent studies support cervical death for the group of patients without any risk and history of preterm birth. Bu çalışmalarda sağlıklı hastalarda rahim uzunluğu ölçümü yapılması önerisi, bu grupta şayet rahim ağzı kısalmış çıkarsa vajinal yoldan uygulanacak progesterone tedavisi ile erken doğum oranının azaltılması bilimsel kanıtı sonrası ortaya çıkmıştır.

Correct treatment is important

Implementing progesterone treatment for patients who experience preterm labor in their previous pregnancies, making successive transvaginal cervical length measurements, applying cervical cerclage suture in the shortened cervix may increase high success rates in appropriate patients. Thus our patients have a better chance of giving birth a healthy baby.

Pay attention to infection

Circlage can be applied based on identification, history, ultrasonography or the dilatation identified in physical examination. Patients should be monitorized before the procedure to determine the presence of pain, and cervical cultures should be taken before the procedure to rule out the possibility of cervical infection. Furthermore, if the mother has obvious or hidden findings of infection (increased leukocyte count, fever, increased CRP, tachycardia, uterine sensitivity, malodorous vaginal discharge) cervical circlage shouldn't be applied. If patients with cervical dilatation have active labor pains, bleeding or water breaking, sutures are not recommended. Although some joyful results were reported in twin pregnancies, allowing the second twin a chance to live after the first baby is born, in general these applications are not currently recommended due to the severe risk of infection in the mother and baby.

Abdominal suture increases the chance of treatment

In cases where previously cervical circlage was applied vaginally and failed, where the cervix is deformed, damaged due to scar tissue and where vaginal circlage is technically impossible, and for patients whose cervixes are removed due to cervical cancer precursors or cancers, abdominal sutures increase the chance of successful treatment.

Should be applied by experienced physicians

Abdominal circlage through closed methods, that is, laparoscopically is a very technically difficult operation that requires experience. Additionally, advantages of closed surgery such as short hospital stay period, minimal postoperative pain and rapid return to normal life may be the reasons for preferring this method. This operation can be carried out before or at the beginning of pregnancy, depending on patient characteristics. However, as pregnancy progresses the technically very risky operation requires a high amount of experience. Patients have to be evaluated and selected for treatment based on their detailed history of previous miscarriages, characteristics and current physical examination findings.