Cervical insufficiency refers to presumed weakness of cervical tissue that contributes to or causes premature delivery not explained by another abnormality. Estimated incidence varies greatly (1/100 to 1/2000).
Etiology of Cervical Insufficiency
The cause of cervical insufficiency is not well-understood but seems to involve some combination of structural abnormalities and biochemical factors (eg, inflammation, infection); these factors may be acquired or genetic.
Most women with cervical insufficiency do not have risk factors; however, the following risk factors have been identified:
Congenital disorders of collagen synthesis (eg, Ehlers-Danlos syndrome Ehlers-Danlos Syndrome Ehlers-Danlos syndrome is a hereditary collagen disorder characterized by articular hypermobility, dermal hyperelasticity, and widespread tissue fragility. Diagnosis is clinical. Treatment is... read more )
Prior cone biopsies (particularly when ≥ 1.7 to 2.0 cm of the cervix was removed)
Prior deep cervical lacerations (usually secondary to vaginal or cesarean delivery)
Prior excessive or rapid dilation with instruments (now uncommon)
Müllerian duct defects (eg, bicornuate or septate uterus)
≥ 2 prior fetal losses during the 2nd trimester
Overall risk of recurrence of fetal loss due to cervical insufficiency is probably ≤ 30%, leading to the question of how large a role fixed structural abnormalities have. Risk is greatest for women with ≥ 2 prior 2nd-trimester fetal losses.
Symptoms and Signs of Cervical Insufficiency
Cervical insufficiency is often asymptomatic until premature delivery occurs. Some women have earlier symptoms, such as vaginal pressure, vaginal bleeding or spotting, nonspecific abdominal or lower back pain, or vaginal discharge.
The cervix may be soft, effaced, or dilated.
Diagnosis of Cervical Insufficiency
Transvaginal ultrasonography at ≥ 15 to 16 weeks for women with symptoms or risk factors
Usually, cervical insufficiency is not identified until after preterm delivery occurs for the first time.
The diagnosis of cervical insufficiency is suspected in women with risk factors or characteristic symptoms or signs. Then, transvaginal ultrasonography is done. Results are most accurate after 16 weeks gestation. Suggestive ultrasonographic findings include
Cervical shortening to < 2.5 cm
Protrusion of fetal membranes into the cervical canal
Treatment of Cervical Insufficiency
Cerclage (reinforcement of the cervical ring with nonabsorbable suture material) may be indicated based on history alone (history-indicated cerclage) or based on ultrasonographic findings plus history (ultrasound-indicated cerclage [ 1 Treatment references Cervical insufficiency (formerly called cervical incompetence) is painless cervical dilation resulting in delivery of a live fetus during the 2nd trimester. Transvaginal cervical ultrasonography... read more ]). Cerclage appears to prevent preterm delivery in patients with ≥ 2 prior 2nd-trimester fetal losses. In these patients and other patients at high risk of cervical insufficiency, cerclage is done during the 1st trimester. Cerclage may be done before 24 weeks if the patient's obstetric history is unknown but problems are suspected and the patient has a short cervix.
For other patients, the procedure should probably be done only if all of the following are present:
Patients have a history that strongly suggests cervical insufficiency.
Cervical shortening is detected by ultrasonography before 22 to 24 weeks gestation.
Patients have a history of preterm deliveries.
Restricting cerclage to such patients does not appear to increase risk of preterm delivery and reduces the number of cerclages currently being done by two thirds. Evidence suggests that cerclage may help prevent preterm delivery in women who have a history of idiopathic preterm delivery and whose cervix is < 2.0 cm long.
If preterm labor is suspected after 22 to 23 weeks, corticosteroids (to accelerate fetal lung maturation) and modified activity (modified rest) may also be indicated (2 Treatment references Cervical insufficiency (formerly called cervical incompetence) is painless cervical dilation resulting in delivery of a live fetus during the 2nd trimester. Transvaginal cervical ultrasonography... read more ).
1. American College of Obstetricians and Gynecologists: ACOG Practice Bulletin No.142: Cerclage for the management of cervical insufficiency. Obstet Gynecol 123 (2 Pt 1):372–379, 2014. doi: 10.1097/01.AOG.0000443276.68274.cc
2. Raju TN, Mercer BM, Burchfield DJ, Joseph GF Jr: Periviable birth: Executive summary of a joint workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists. Obstet Gynecol 123 (5):1083-1096, 2014. doi: 10.1097/AOG.0000000000000243
Usually, risk of cervical insufficiency cannot be predicted before premature delivery occurs for the first time.
Do transvaginal ultrasonography after 15 to 16 weeks if women have risk factors or symptoms.
Treat at-risk women with cerclage.