62

CERVICAL INCOMPETENCE

CRITERIA OF CERVICAL DILATATION

1.Fluid or fetal parts within cervical canal.

2.Shortened cervix.(Closed portion)— Cervical length<2.5 cm.(Normal cervical length=2.5-4.5 cm)
3.Increased width of cervical canal.--- >12 mm is abnormal.(Normal width =7-8 mm or less.)
4.Increased width of Cervix. >2cm is abnormal.

Incompetent cervix –Widening of Int. Os(arrow) Widening of Int. Os

AF-Amniotic fluid FH-Fetal head B-Bladder CX-Cervix.B-Bladder

HOW TO ASSESS EARLY CERVICAL DILATATION ?

Early cervical dilataion can be made with transvaginal or translabial scan by applting
transfundal pressure & looking for any exaggeration of funneling of internal os.

DYNAMIC NATURE OF CERVICAL DILATATION

Cervical dilatation may develop rapidly.Also it may come & go.Thus serial scanning is
essential whenever there is suspicion of cervical dilatation.When evaluating for cervical
incompetence scanning should be repeated at weekly intervals from 15 th week till 24th
week.If fluid is not seen in endocervical canal by 24 th week incompetency is unlikely.

RELATIONSHIP OF CERVICAL EFFACEMENT TO CERVICAL LENGTH.

With cervical dilatation there is gradual effacement that is cervical portion gradually merges
into the lower uterine segment. Cervical effacement is a clinical diagnosis.However by assessing
cervical length on ultrasound percentage of cervical effacement can be known by correlation.
It has been found that cervical length of 1.5 cm corresponds to 50% effacement while a length
of 1 cm corresponds to 75% effacement.

Patients with effacement 50% or less & dilatation of internal os 3 cm or less are usually
asymptomatic clinically.If on u/s diagnosis can be made at this stage the patients
can be successfully managed with uterine relaxants while where effacement is upto 75%
impending delivery cannot be prevented.Thus U/S is requested to detect cervical dilatation in

Institute Of Ultrasound Training,New Delhi,India

 63

these asymptomatic patients based on suspicion whenever the predisposing causes are present.

.PRECAUTIONS IN ASSESSING CERVICAL DILATATION

(A)False Negative(i.e.cervical dilatation is present but missed on u/s)

1.Overdisteded bladder:Overdistention leads to collapse of incompetent cervix from

increased pressure in urinary bladder.Many believe that bladder should be emptied & patient
scanned for dilatation by translabial or transvaginal method.

Overdistended Bladder leading to collapse Partial emptying of the bladder clearly shows
of incompetent cervix(arrow).H-Fetal Head incompetent cervix.EC-Endocervical canal

2.Dynamic nature of cervical dilatation:As mentioned before cervical dilatation may be

transient.(it may come & go).Thus serial scanning is essential whenever there is clinical
suspicion of cervical dilatation.

3.Cervical dilatation obscured by fetal parts:

In such cases cervical length assessment is invaluable.

Institute Of Ultrasound Training,New Delhi,India

 64

----------------
(B)False positive(i.e.there is false impression of cervical dilatation on u/s)

Contractions of lower uterine segment may mimic cervical dialatation.However in such cases of pseudodialatation ,
the cervical length is more than 5 cm & normal appearing cervical tissue is seen (between callipers) distal to the
apparently dialated segment

Pseudodilatation due to uterine contraction

To confirm this false positive dilatation of cervical canal a repeat scan after 30 minutes may be
done to see normal appearing cervix after the contraction passes off.

TRANSLABIAL SCANNING

Advantages:
1.Best done with Transvaginal probe but can also be done with normal 3.5 MHz Transabdominal
probe.
2.Does not require bladder distention.
3.Does not require much expertise unlike transvaginal sonography.
4.It is extremely useful in assessing cervical region & its relations.This feature is specially useful
in III trimester when overlying fetal parts prevent assessment of cervical region.

Institute Of Ultrasound Training,New Delhi,India

 65

Saggital scans with measurement of cervical length.Straight arrow shows cervical canal.Curved arrow-Inner
fibromuscular stroma of cervix.Cervical length shown between calipers

(A)Transabdominal scan showing fetal extremity obscuring (B)Translabial scan outlining cervix
cervix (cervical length=1.5 cm)

Fig A –Translabial scan showing cervix 2.3 cm in length Fig.B shows practically 0 cervical length.Only after
1 ½ hrs of previous scan suggesting rapid onset
of cervical dilatation.

Institute Of Ultrasound Training,New Delhi,India

 66

ARTEFACTS
External os at times is obscured by shadowing from rectal gas .In such cases scanning may be
done in lateral decubitus positions or rescanning with patient in supine position after rotating
the patient into decubitus positions.

Fig A shows shadowing (arrow)due to rectal gas.

Cervical length was erroneously measured as 1.8 cm Fig B.After the patient was put in decubitus position
Shows actual cervical length which was 2.8 cm.

TRANSVAGINAL SCAN-Best to assess the cervical length.Normal cervix appears slightly curved
on TVS. Straightening of cervix gives suspicion for dialted cervix however confirmation is made by
measurement only.

TVS in a case of placenta previa showing normally

curved (arrow) cervix.

Institute Of Ultrasound Training,New Delhi,India