Published on January 3, 2009
Slide 1: Cervical Incompetence Jed Anay Melvin Campiceno Luke Dela Cruz Joy Tering Slide 2: This is the inability of the cervix to support a pregnancy to term due to structural and or functional weakness. It is an important cause of recurrent midtrimester abortions (miscarriages). DEFINITION Slide 3: ETIOLOGY / PDF Functional: no pathology, cause presumed to be the premature triggering of the normal mechanisms for effacement and dilatation of the cervix. Structural defect: congenital or acquired Congenital: congenital weakness of the internal Os (histologic defect- increased smooth musclce fibres, decreased collagen/elastic fibres = muscular cervix that is inherently weak). female fetal exposure to diethylstilbestrol (DES)- MOA unknown. Short, hypoplastic cervix Slide 4: Acquired: Trauma to the cervix overzealous dilatation and curettage cone biopsy cervical amputation difficult or instrumental vaginal delivery (cervical laceration) infection: bacterial vaginosis The most important cause of cervical incompetence is overzealous dilatation and curettage. Three or more first trimester induced abortions by dilatation and curettage carries a 12% risk of a spontaneous pregnancy loss, while a single second trimester induced abortion carries a 14% risk. Pathophysiology : Pathophysiology Slide 6: Prelude to parturition the collagen is degraded Cervix becomes soft and pliable Dilatation of the cervix bulging of the amniotic sac or bag of water Preterm labor Thinning of the cervix Infections and inflammations Surgery Trauma to cervix Diethylstilbestrol (DES). Hormonal imbalances Abnormal uterine and cervical structure Risk factors: Slide 7: Backache Discomfort or pressure in the lower abdomen (stomach). Gush of warm liquid from the vagina. Mucous-like vaginal discharge Pain when passing urine Sensation or feeling of a lump in the vagina Slide 8: Women with incompetent cervix typically present with "silent" cervical dilatation (i.e., with minimal uterine contractions) between 16 and 28 weeks of gestation. Slide 9: ASSESSMENT History of painless cervical dilatation with preterm delivery History of forceful cervical dilatation and evacuation History of obstetric trauma: cervical lacerations, prolonged second stage followed by cesarean Prior cervical surgery: cone, loop DES exposure in utero Cervical sonography Short cervical length Cervical funneling Cervical sonography: : Cervical sonography: Slide 12: 2 images of the same cervix, 20 seconds apart, without and with applying pressure: Slide 13: Dilators or balloons to determine cervical resistance and/or hysterosalpingograms to measure the width of the cervical canal between pregnancies are neither sensitive nor specific. Digital examination of the cervix is highly subjective. Sonography has provided a reproducible method of evaluating the cervix. Diagnosis Surgical Management : Surgical Management A cervical cerclage can be used during future pregnancies to prevent miscarriage in a woman with an incompetent cervix. A cerclage is a stitch inserted around the cervix to prevent it from opening too early. The procedure is usually done 14 to 16 weeks into the pregnancy. The woman may be put on bed rest for a short period of time. The cerclage can be removed at the time of delivery, or it can be left in place if a cesarean section is done. Medical Management : Medical Management Tocolytics: These medicines stop and prevent pre-term contractions. Nursing Diagnosis : Nursing Diagnosis Slide 18: Nursing Diagnosis : Anxiety May be related to: situational crisis, threat of death/fetal loss Nursing interventions 1. Identify client’s perception of the threat represented by this occurrence. Encourage expression of feelings. The ambiguity of the outcome can aggravate the anxiety. 2. Assess physiological indicators of anxiety: BP, pulse, RR and diaphoresis. Physiological changes in vital signs may have psychological origin. 3.. Remain with couple. Explain what is happening and what can e expected. Provide factual information about causes, implications and proposed treatment. Slide 19: Nursing Diagnosis: Injury, risk for maternal r/t surgical interventions use of tocolytic drug Nursing Interventions: 1. Note presence of vaginal bleeding, leaking amniotic fluid or uterine contractions after surgery. Vaginal bleeding other than slight spotting may be a sign of cervical dilatation. 2. Monitor vital signs closely. Changes in vital signs may indicate infection or shock. 3. Notify physician for abnormal findings or signs of labor. Prompt intervention lessens likelihood of complications. Slide 20: Nursing Diagnosis: Injury, fisk for fetal Risk factors: premature delivery, surgical procedure Nursing Interventions: 1.Auscultate and report FHTs, noting strength, regularity and rate. Note any changes in fetal movement. Note EDB and fundal height. Indicates fetal well-being. EDB provides rough estimate of fetal age to help determine chance of viability 3. Asses maternal condition and presence of uterine contractions or other signs impending delivery. If advance cervical dilatation (4cm or more) or regular uterine contractions occur, likelihood of preserving pregnancy is small. 2. Assist with ultrasounography, if indicated. Provides more accurate picture of fetal maturity and gestational age. If advance cervical dilatation (4cm or more) or regular uterine contractions occur, likelihood of preserving pregnancy is small. Slide 21: Nursing Diagnosis: Grieving, anticipatory r/t to perceived fetal loss Nursing Interventions: 1. Encourage expression of feelings. Opens lines of communication and facilitates progress toward successful resolution of feelings. 2. Discuss normalcy of individual feelings/grief reaction. Client may suffer loss of self-esteem related to her difficulty in carrying a pregnancy to term. 3. Review information about event, and discuss possibility for f future pregnancies. May lessen feelings of guilt and promote future and couple’s relationship. Slide 22: Nursing diagnosis: Knowledge deficit regarding nature of condition, self care needs Nursing Interventions: 1. Determine level of client’s knowledge. Provides opportunity to clarify what has been learned previously and to correct misconceptions. 2. Assess degree of anxiety. Anxiety can interfere with learning process. 3. Provide information about future expectations. Client may experience concern about whether difficulties may be encountered. Slide 23: Thank YOU!