A Consideration of the Incompetent Cervix*

A CONSIDERATION OF THE INCOMPETENT CERVIX* HARRISON PICOT, M.D., H. GLENN THOMPSON, M.D., AND CHRISTOPHER

J.

MURPHY, JR., M.D .•

ALEXANDRIA, VA.

(From the Department of Obstetrics and Gynecology, Alexandria Hospital)

T HE -

documentatim~ re~ative

o.rlr.t.tTnnfr.

«'--L'--'~l.LU\JV

frL LV

.O.c1tohl,~h

~DI.JU,J_l_.J.~.LJ

.. + .1\:

..lei

UD

to rt>r,:iral inco_mpetency has been more th~n o.

U

-f,,"'YintlfYnnl iU..l..IVLlV_I__I_U,.L

n.,..,t,t"'",..

'-·.l.Ll!.l.'-;,V.

Po.lrnnv ..l.

U.L.l.lJ_\.,.J.

o-rr..-1'

U_l_.l"-t

T.nn.rni'l.TYlc.R .lJU\_VJ..lJ.l.ll'-_..

lYl

.l.L.L

1948 and Lash and Lash 5 in 1950 first called attention to this condition. Further contributions to the understanding of this entity have been made by Asplund, 1 Rubovits/ 0 and Shirorlkar, 11 and more recently by McDonalrl, 6 Barter, 2 Durfee," and Page.' Recognition and correction of the inadequacy offer perhaps the only present possibility of preventing certain late abortions or early premature labor and resultant fetal loR.<.;. Cause

Cervical incompetence has usually bren ascribed to some type of trauma or surgical procedure, and in many cases this is quite obvious. 1t may be that one traumatic experience will be of such magnitude as to render immediately a f'ervix incompetent for all future pregnancies. Classic examples of this would he provided by high amputations of the rervix or unrepaired cervical lacerations from some arrourhement forre. ·where trauma as a factor is absent, the literature regarding cause has been ambi~tuous. If we, define t1·auma as a stress &!'reater than that which is plwsiologie:> the cervices of many patients haw n;;t been rendered incompetent by trauma. Our experience points to the fact that in such instances the cause is a basic weakness of the supportive tissues of the cervix. Most of our patients presenting an incompetent ~ervix have not been subjected to trauma~ Their histories will be only that they have had their babies in a normally acceptable fashion. We believe incompetency to represent a congenital weakness of the cenix which renders it incapable. of withstanding the~ stress of one or more normal parturitions. The degree of incompetency is most apt to bt' a gradual proceRs in which each succeeding prPgnancy will bP of a shorter duration than the previom; one. Eventually a point is reached where all pregnancies terminate in late abortions. In thr series of patients wP have observed, several gave an obstetrical history of multiple pregnancies, the duration of each being shorter than the preceding one. In addition to these etiological factors we wish to suggest that cervical incompetence may occasionally he a symptom of certain pathologic systemic states. \Ve recently observed a patient whose pregnancy was complicated b;\- a lowered •Presente
stetricians and Gynecologists, Roanoke, Va., Feb. 4-7, 1959.

i86

Volume 78 Number+

CONSIDERATION OF INCOMPETENT CERVIX

787

seru~ P?tassium due to chronic and voluntary vomiting. When the condition was m~t1ally recognized there was an accompanying lack of all muscle tone producmg such weakness that the patient eould not stand. At 28 weeks of pregnancy the cervix became effaced and was 1 to ~ em. dilated. \Vith a restoration of the normal potassium level the cervix closed and attained some length. Two weeks later the patient suffered a relapse. The cervix again dilated \vith the aeutely !o,v·ered serum potassium of 1.9 mEq. The patient subsequently was delivert>d of a viable male of 3 pounds at 30 weeks of pregnancy.

Diagnosis The history of one or more late abortions characterized by an unexpected spontaneous ru.pture of the membranes follo,ved by a short, relatively painless labor should suggest the possibility of an incompetent cervix. There must, however, he an absence of any pathologic factors such as intrauterine fetal death, placental bleeding, or uterine tumors. In the nonpregnant patient the passage of an 8 mm. Hegar dilator or olivetipped sound through the internal cervical os without discomfort to the patient is judged to indicate incompetency. Asplund/ and Rubovits, Cooperman, and Lash10 have described radiographic techniques :for the demonstration of the socalled funnel cervix. Jeffcoate and Wilson 4 studied 69 women who had had premature labors and in 50 per cent they were able to demonstrate such a defc•ct. In the pregnant patient the diagnosis is made by careful obsenation of the cervix. If we suspect the possibility of cervical incompetence, it is our practice to examine the cervix each week after the fourteenth week in search for the silently dilating cervix. Diagnosis is made by observing gradual dilation of thr internal os and near complete effacement of the cervix. We feel that inrreasf'd experience with the behiwior of the cervix during this period, plus careful observation of its changes, \vill enablE' one to determine the optimal timE' fol" reinforcing the cervix. Incidence 'l'lw irwinPnPe of ·PPrviP.al inPomnetence has not been accuratelv determined. Its t~~; f~;q~;;~~y -~a~- b;,-~~p~~;sed only when the number of eorrected eases plus the number of unrecognized or uncorrected cases terminating in uncomplicated late abortion are related to the number of concurrent live births. The reported series of patients, with one exception, comes from our own praetirr. On this basis we estimate its :frequency to be 3 per 1,000 delivrries.

Correction of Cervical Incompetence There are three types of corrective procedure that may be done prior to pregnancy. The Palmer-IJash technique involves the excision of a wedge of tissue from the lower uterine segment. Shirodkar reported performing his fascial transplant to the nonpregnant cervix. Page 7 most recently reported circular wrapping of the eervix with talc-impregnated oxycel gauze held in place with ribbon sutures. There are two general types of techniques which may be used during the pregnant state. The Shirodkar11 procedure is done ·with homologous fascia. With this same technique, preserved fascia, Dacron mesh, and protein sutures 6 ha.vr. been emnloved. Another a.pnroach is that advocated by McDonald, in Nylon used. is string purse a as cervix the about placed silk black ,~hi~h heavy and other ~ynthetic fibers and tubing have been used as purse-string sutures also.

PJCO~',

788

THOMPSON, AND MURPHY

i\m. ). Oh>t. ·

& Gyner. Ortoher, 1959

Operative Techniques Our own efforts to correct this cervical defect have evolved through three phases. Initially we performed the Lash procedure and found it completely satisfactory. In using this technique there are certain matters to consider. A vertical scar is created in the lower uterine segment and cervix. The possibility of rupture of this scar in the latter weeks of pregnancy causes definite anxiety in the mind of the obstetrician. These patients must usually be delivered by cesarean section. A higher than usual incidence of infrrtility among patients so operated upon is recorded. In 1957 Lash, as quoted by Page, 7 reported that he had done 68 wedge resections. Forty-one of these patients became pregnant and 34 were delivered of viable babies. From the Lash procedure we turned to that of Shirodkar, using homologous fascia as he advocated. Here no scar is created in the lower uterine segment and cervix. In contrast, the cervix is tremendously strengthened by the fascial collar. When this procedure is used we believe it unnecessary and undesirable to wait until the cervix is dilated and the membranes visible. A corrective procedure done under these circumstances is technically more difficult. There is greater chance of rupture of the membranes, infection, amnionitis, uterine irritability, and abortion. We feel this procedure is best done between the sixteenth and the twentieth week. Among the patients on whom the Shirodkar procedure was done there seemed no tendency for labor to occur prematurely. It is our belief that the Shirodkar proeedure provides the firmest support to the cervix of any advocated. However, all of these patients must be delivered hy cesarean section since the fascial collar will not. t1ilate. In our search for a procedure that would both support the ct'rvix to term and permit delivery from below, we employed a modification of the technique of McDonald, suggested by Smith. 12 T~vo. purse-string sutures of autoclavable polyethylene tubing, through which tantalum wire is threaded, are placed through the exocervix at the level of the internal os. The wire prevents stretching of the tubing. At the onset of labor the sutures an• cut and the patient is delivered from below. With this procedure the exocenix .<>eems to roll down'vard 'vith the suture. This technique does not support the cervix as \voll as the others. These patients were delivered one month earlier than those on whom the Shirodkar procedure was clone. This is prohahly true because the purse strings go through only the exoccnix. Results The cases shown in Tables I-IV represent all but one in which a corrective procedure was clone. The details of this case have been previously reported.') As the patient was cleliYered of a viable infant, the effort could not be called a failure; however, we did not feel that it should be included. Our results with these three procedures are shown in Tables I-IV. 'L'ABLE

I.

RESULTS

Wn•n

1'HE LASH PROCEDURE

PRIOR TO CORRECTION TOTAL LIVING _ _P_A_TI_E_N_T_---'--_P_R_E_GN_A_N_C_I_ES - - · CHILDRE_I'__

C. H. J. s.

S.H. Total

4 1

0

6

0 0

1

0

j

I

AFTER CORRECTION TOTAL PREGNANCIES

LIVING CHILDREN ---··-----·-

2

2

1 4

1 4

1

1

Volume 78 Number 4

CONSIDERATION OF INCOMPETENT CERVIX TABLE

II.

RESULTS WITH THE SHIRODKAR PROCEDURE

PRIOR TO CORRECTION TOTAL PREGNANCIES

PATIENT

M.J.K. M.D.K.

5 7 3 3 4 8 4 34

M.A.L.

M.S.K. M.M..T. E.W.M. B.Q. U.* Total

789

AFTER COltRECTION

LIVING CHILDREN

TOTAL PREGNANCIES

LIVING CHILDREN

2

1

1 1

1

0

1

1

3

3 1 1 1 9

1 2

3

1 1

0

1

9

9

l

•courtesy Drs. George Speck and Paul E. Halter. TABLE

III.

RESULTS WITH THE DOUBLE POLYETHYLENE PURSE STRING PR0C'ED11RE

LIVING CHILDREN

PATIENT

L.M. B.W.

Total

7 TABLE

LaAbs

IV.

6

Shirodkarr 34 McDonaldz 7 =-~--------------Total 47

3

1 1 2

1 ]

2

CoMBINED RESULTS WITH ALI, PROCEDURES

0 9 3

4 9 2

4 9 2

··- --· --:;-;:-~=~------=--::-----~-~--12 (2fi%) lfi ]fj Comment

Cervical incompetence as a cause of late abortions is now accepted. It is probable that a lesser degree of incompetence is responsible for the fact that certain patients repeatedly deliver prematurely. It is conceivable that such operations might justifiably be indicated on occasional patients who hahitnall,v go into premature labor. However, one would have to evaluate most carefully the history and results of all previous pregnancies in arriving at such a. decision. In this connection we wish to emphasize this point. Reinforcement of the cervix is technically very difficult after the twenty-fourth week because the cervix is so high in the pelvis. If changes in the cervix prior to premature labor are waited for, the reinforcing procedure will probably be impossible. Therefore corrective measures to prevent repeated premature labors must be done either prior to pregnancy or before the twenty-fourth week of pregnancy. We do not feel that there is yet available an ideal procedure for reinforcing the cervix. Such a procedure should physiologically and adequately strengthen the cervix during pregnancy and at the time of labor permit its dilatation. The search for such a means will he an interesting and exciting one and its attainment a truly satisfying reward.

7HO

PICO'r, THOMPSON, AND MCHP!IY

Summary l. The diathesis, e1mse, diag·nosis, of !•ervieal ineompetene<' arc discusse(L :.!. Correetin~ proeedures proposed fo1· (•orreetion of this eondition prior to and during pregnane~· are n'\'iew<:>d. 3. Om· eom>ideration of and om· <:>XJH'riellN' and l'esults with thl•se proeedm·ps m·e prl'fwntrd.

References 1. As!Jlund, J.: Acta radiol. (Suppl.) 91: 3, 1952.

2. Barter, R. H., Du~babek, .T. A., Riva, H. L., :ttl(l Park~, .J.:

a. 4. i5.

6.

7. 8. 9.

10. 11.

1''

AM . .J. OBS'r. & OYxF:<'.

75: 511, 1958. Durfee, R. B.: Obst. & Gynec. 12: 91, 195!-l. Jeffcoate, 1'. N. A., and Wilson, ,T. K.: Nt•W York J. l\lt>d. 56: 680, Hl56. Lash, A. F., anrl Lash, S. R.: A~I. ,J. 0BS'l'. & GYNEC. 59: 68, 1950. McDonald, l. A.: J. Oh~t. & Gynaee. Brit. Emp. 64: 346, 1957. Page, E. ,r.: Obst.. & Gynee. 12: 509, 1958. Palmer, R. and La<>.omme, M.: Gynec. et ob8t. 47: 905, 1948. Picot, H., Thompson, II. G., and Murphy, G. J .. ,Tr.: Obst. & Gyn<•c. 12: 269, 1958. Rubovits, }'. E., Cooperman, K. R., and Lash, A. F.: A:>L J. 0BST. & GYNEC. 66: 269, 1953. Shirodkar, V. N.: 'l'em1anerR aduellrs en gyni'r·nlogie c>t ohstetrique, Geneva, 1954, G
Discussion lJR. HUGH J. BICKERS'I'AFF, Columbus. Ga.-W<• ha.ve eHeounterPd incompetenN> of the •·ervix in 16 women, of whom 3 wt;re refen.•d and 2 Wl\IP R(Wn in eonsultation. The remaining l i wPre found owr a 6 year period in the ordinary flow of a private obstetrical practiee. The :frequency is e·sthnated H.R nPar1y !) per 1,000 pn)gnanciesj a little lrss frf•quent than tht• oe<'tnr<'nrn of P<·topic prPgnan<'y in tlw Ranw lJl'a«t.i<'·''• alld somewhat more fn•quent than reported h.v t1u• essayist. The compo~ite past reproduetive reeord uf tho~e 15 patients is even more di~mal than in Pieot 'R ~aRe~. Thrre wt>re only l ~uccessful e.ompletions out of :l7 pregnancieR prior to operation. If krrninations short of 16 WPPks lw ex<~luded, thi~ would adjust the survival rate to 4 out of 3+. Fifteen of our patients were treated ~urgi<'ally, 11 h,v interval Lash operations and + by the Shirodkar metl10d with use of ox fascia. The outcome of pregnancies followed hy us after surgieal <'orreetion is quite gratifying but falls Rhort of the enviable record of the author. Existing and enming pregnancies total 17, of which 5 are in progress and 12 have terminated. Tlw 12 completed !'regnancies wen' sue<•essful delivE>ries of surviving infants i11 fl and failure in :l. The failure rate of on<>·fourth i~ the samP for both procndures. All 12 pregnancif'S t>ndNl in spontaneou~ re eonfirmest prPoperative earry. The Lash procedure also sePmP
78

4

CONSIDERATION OF INCOMPETENT CERVIX

791

\Ve assumed that a fascial collar, leaving an inelastic purse string, would necessitate eesarean section, or else severance for vaginal delivery. One patient with previous losses at 28, 20, and 16 weeks, was operated upon by the Shirodkar procedure at 11 weeks. At 38 W(•eks the area was explored surgically for the purpose of release but no fascia remained. The internal os area had a circular constriction, tight to a finger tip, which was partially severed leaving a 3 finger ealiber. After 2 days with no labor the patient went home. Labor >'tarted 2 weeks later, one day past the estimated date of confinement, and, after 15 hcurs of normal progres;;, delivery was uneventful. Somewhat over a year later we 1·emoved hpr utems and found the gross and microseopie appearance of the isthmus 'luit.e normal PXeept for moderate circumferential fibrosis. Our last Shirodkar operation \vas performed at about the twenty-fourth week. Labor occurred at 36 weeks of gestation .and progressed in 6 hours to normal delivery. Absorption of fascia has been observed by others and in some instances this absorption has appareully prevented the eorrection. Substitution of nonabsorbable mt'dia has been employed by Barter and others, hut Stromme has reacted similarly to ourselves and ha~ allowed trial labor with S'll(~(~t'8S.

'rhe average obstptrician whose interest is aroused will at first have a residual backlog of eases, following which he will encounter relatively few. It is regrettable that many of u~ are simultaneously hut separately gaining fragmentary experi..,nce. The following an' some uncertainties upon wllich others may be more enlightened than am I: J. Is the Lash procedure apt to rupture from labor, as is the tendt•nry after myomPs a fascial implant eventually always ahsorh, l<>aving dependable healing' If w. what extn•mes of timP mark the !wginning and tlw Pnd of the proePs~f DR. ROBERT A. ROSS, Chap<'l .1-Iill, N. C.-The authors have roportt•d their TosultR in a serie~ of 12 patirnt8 on whom an operation was performed in the hope of pre~!'tving pregnane.y and to better insure the delivery of a living infant. B<•fore the operation, these womt>n had had a total of 47 pregnancies with 12 living children; and, suhsequt:>nt to opPm· tion, tlwy had 15 pregnancies with 15 Jiving ehihlrPn. Most will agree on the selection of patients and will concede that the history is probably the most critical it<>m. The easy passage of a 5 rum. or largPr sound is simple and u~ually revealing, provided anatomic almonnalitiPs of the utf'rus a.nd cervix are ruled out. R-esults are generally good following any of the several procedures now in vogue and prohahly will <•ontinue acceptahle with the new variations which will eertainly he added. Our prder!Hlee i~ nonahsorbable ~ynthetic material, placed aftl'r pregnaney is accomplished, ansence of ruptured membranes, bleeding, tumors, or fetal death. There are certainly some hazards associated with this operation and, with the increasing serie8 , w<' should be alert to reports of infection, ruptured ut<•ri, resulting tPchnical difficulties, or any evidence that affects mat~>rnal and fetal health. DR. PICOT (Closing).-vVe have permitted none of our patients on whom we did a Lash procedure to deliver from below hecause of ff'ar of uterine rupture. This, in our minrvix dilated with ease. The cervices of the remaining patients on whom the fascial transplants wert' done showed no signs whatsot>ver of dilating, nor did this seem possible. Dr. Bickerstaff, using preserved ox fascia, was able to deliver his patients from below. "\Ve, using homologous fascia, were not. This certainly suggests that homologous fascia is a better reinforcing material than preserved ox fascia.