Cervical insufficiency is defined as the inability of the uterine cervix to retain a pregnancy in the second trimester in the absence of clinical contractions, labor, or both.[1] The diagnosis can present very unexpectedly and have implications for the current pregnancy, as well as future pregnancies. Placement of cervical cerclage in select patients is associated with decreased rates of preterm birth and improved neonatal outcomes.[1] OB/GYN hospitalists are often the evaluating practitioners for patients presenting to the emergency department or labor and delivery unit and have the opportunity to impact pregnancy outcomes by making an accurate diagnosis and providing timely and appropriate management of cervical insufficiency.

Knowledge

OB/GYN hospitalists should be able to:

• Define cervical insufficiency.
• Describe the pathophysiology of cervical insufficiency and preterm labor.
• Distinguish cervical insufficiency from preterm labor.
• Explain the criteria for adequate transvaginal cervical length measurement.
• List the ultrasonography criteria for the diagnosis of short cervix.
• Describe the indications for vaginal progesterone therapy and the recommended regimen(s).
• Describe treatment options for cervical insufficiency.
• Compare the effectiveness of pessary use with that of cerclage.
• Explain the criteria for history-indicated, examination-indicated, and ultrasonography-indicated cerclage.
• Discuss contraindications for cerclage and the patient populations for whom cerclage should not be considered.
• Describe the risks and benefits of cerclage for the mother and fetus.
• Describe the different cervical cerclage techniques and their specific indications.
• Discuss the evidence for antibiotics and tocolytic agents in patients with cerclage.
• Explain the role of amniocentesis in the evaluation of patients with cervical insufficiency.
• Describe the surveillance for patients with short cervix and for patients with cervical insufficiency managed with and without cerclage.
• Explain the indications and technique for cerclage removal.

Skills

OB/GYN hospitalists should be able to:

• Elicit a thorough and relevant medical history with emphasis on presenting symptoms and details of previous births.
• Predict a patient’s risk for cervical insufficiency on the basis of medical, obstetric, and gynecologic history.
• Perform an appropriate physical examination with emphasis on cervical length, location of the bladder, and any evidence of scarring from previous surgery.
• Perform or order transabdominal and/or transvaginal ultrasonography to measure cervical length.
• Interpret transvaginal cervical length images using appropriate landmarks to determine whether an image is adequate for cervical length measurement.
• Synthesize history, physical examination findings, and imaging findings to diagnose cervical insufficiency, identify appropriate candidates for cerclage, and formulate an evidence-based treatment plan and determine the level of care required.
• Engage consultants and coordinate a multidisciplinary approach, including the patient, those who support the patient, nursing staff, maternal-fetal medicine specialists, neonatologists, anesthesiologists, and primary OB/GYN provider, when indicated.
• Counsel a patient with cervical insufficiency regarding management options, including the risks and benefits of each option, and obtain informed consent for any procedure.
• Assess patient understanding of risks and benefits of cerclage, including the potential for extreme preterm birth and decisions that arise before and after fetal viability, and document accordingly.
• Perform, assist, or obtain consultation for the placement of a cervical cerclage.
• Communicate with patients regarding postoperative care and discharge instructions after cerclage placement.
• Assess patients with a cerclage in place who are in suspected preterm labor and manage or comanage with their primary OB/GYN provider and/or maternal-fetal medicine specialist.
• Manage labor and delivery in the second trimester for patients with cervical insufficiency in whom cerclage fails, is contraindicated, or is declined.
• Demonstrate proper technique, including adequate anesthesia, for removal of cerclage.
• Counsel patients regarding recurrence risk and recommend preconception counseling before subsequent pregnancies.
• In the medical record, appropriately document the medical history, physical examination findings, relevant imaging and test results, and discussion with the patient regarding the diagnosis, care options, and management plan.

Self-Awareness and Collaborative Attitudes

OB/GYN hospitalists should be able to:

• Follow evidence-based recommendations in the diagnosis and management of cervical insufficiency.
• Respect the patient’s desires, values, and autonomy.
• Collaborate and communicate effectively within a multidisciplinary team, including the patient, those who support the patient, nursing staff, maternal-fetal medicine specialists, neonatologists, anesthesiologists, and primary OB/GYN provider to optimize outcomes and the patient experience.
• Demonstrate awareness of and ability to address emotional and physical concerns in the setting of cervical insufficiency.

System Organization and Improvement

OB/GYN hospitalists should be able to:

• Lead, coordinate, and/or participate in developing evidence-based protocols for evaluation and management of patients with cervical insufficiency, including transfer protocols for patients who require a higher level of care.
• Lead, coordinate, and/or participate in educational activities to improve the understanding and comfort of staff caring for patients with cervical insufficiency.
• Implement systems to track performance and quality of care for patients with cervical insufficiency.
• Implement outcomes research to create successful management strategies for patients with cervical insufficiency.

References