Cervical incompetence

Cervical incompetence refers to a painless spontaneous dilatation of the cervix, and is a common cause of 2^nd trimester pregnancy failure.

Epidemiology

The estimated incidence can very geographically and generally thought to be around 1 - 1.5 % of all pregnancies ^1,15.

Demographics and clinical presentation

Typically cervical incompetence manifests in the second trimester. Patients at high risk for preterm delivery include those with :

• uterine anomalies ⁷
• exposure to diethylstilbestrol (DES)
• previous cervical trauma or surgery
• previous recurrent spontaneous or therapeutic abortion
• previous premature delivery
• multifetal pregnancy

Patients either present with spontaneous pregnancy failure or rupture of membranes with resultant oligohydramnios.

Clinical tests

• fetal fibronectin (fFN) test on vaginal mucus : needs to be done before trans-vaginal scanning is attempted

Radiographic features

Ultrasound

Trans-vaginal, trans-labial or trans-perineal sonography is most commonly used to assess the cervix.

Technique

It should be emphasised that the appearance of the cervix may change during the examination and therefore multiple observations are recommended. Excessive pressure with the probe and an overly distended bladder may give falsely reassurance by artificially lengthening and narrowing the cervical canal. It is also useful to measure the record the worst finding.

Sonographic findings include (requires trans-vaginal scanning)

• in a late 1^st trimester scan, opening of the cervical os at rest on in response to fundal pressure is considered an early feature ¹⁸
• bulging of the fetal membranes into a widened internal os (considered the most reliable sign ⁹) :
  • the appearence of this can worsen from a T shape to a Y shape to a V shape and finally to a U shape.
  • if there complete bulging, it can give a hourglass type appearance
• shortening of the cervical canal
• in severe cases there may be fetal parts or cord that extend through the os

The cervical length (CL) is obtained by measuring the endocervical canal from the internal cervical os to the external cervical os. 

The normal cervix should be at least 30 mm in length. Cervical incompetence is variably defined, however a cervical length of < 25 mm at or before 24 weeks is often used. The risk of preterm delivery is inversely proportional to cervical length ^ref :

• 18 % for < 25 mm 
• 25 % for < 20 mm
• 50 % for < 15 mm

In borderline cases, transfundal pressure may be used to confirm the diagnosis.

The presence of cervical funneling is also an important finding. Greater than 50% funneling before 25 weeks is associated with 80% risk of preterm delivery. 

Sonographic determination of the residual closed length of the cervix may be used as a prognostic indicator for the risk of preterm labor progressing into preterm delivery.

Trans-vaginal scanning is contrandicated if there is

• known complicating pre-term premature rupture of membranes
• known hourglass type membranes
• active vaginal bleeding

Treatment and prognosis

Management options can be controversial, with conflicting results, particularly regarding the efficacy of a cerclage placement as treatment. Bed-rest, tocolysis, cerclage (tracheloplasty), trans-abdominal suture placement, and administration of steroids to accelerate fetal lung maturity are all treatment options to be considered. A recent meta-analysis suggests that cerclage is effective in reducing preterm births by 26% in singleton pregnancies.

If the cervical length is < 30 mm ( < 3cm) , close interval follow up is recommended.