A fascinating debate at the 2017 ACOG clinical and scientific meeting delved in to the history, utility, and relevance of a longstanding obstetrical diagnosis.
The term “cervical insufficiency” describes a mysterious phenomenon, and its diagnosis is one of exclusion, using patient history, ultrasound, and the physical exam as criteria. ACOG practice bulletin #142 defines cervical insufficiency as “the inability of the uterine cervix to retain a pregnancy in the absence of the signs and symptoms of clinical contractions, or labor, or both in the second trimester.”
“Should We Abandon the Diagnosis of Cervical Insufficiency?” was the title of the Morton and Diane Stenchever lecture, held Monday at the 2017 ACOG Annual Clinical and Scientific Meeting. Arguing against doing so was Dr John Owen of the University of Alabama at Birmingham. Noting that cerclage is the primary treatment, and treatment indications, like the diagnosis, depend on history, ultrasound, and the physical exam, Dr Owen reviewed studies of effectiveness of cerclage by each indication. Noting that actual placement of a cerclage is very safe, he concluded that the diagnosis is valid “despite some problems.”
Dr Jay Iams of Ohio State University, arguing for “a paradigm shift in thinking about preterm parturition,” made it clear that he does not disagree with the treatment for cervical insufficiency, but rather with the diagnosis itself. Cervical competence is not a continuum, he pointed out, and the woman with the weakest cervix will benefit most from cerclage. He insisted, “the 20-week line between miscarriage and preterm birth is a fraud,” and “the 20-week line between cervical insufficiency and premature labor is a fraud.”
Asking the question, “Why haven’t we dumped the 20-week boundary between ‘miscarriage’ and ‘premature birth’?” he listed 4 reasons: “1) It’s historical, even biblical. Change is hard. 2) It’ll be a major headache to track births at 16–20 weeks. No one does that, do they? 3) It’s a sociopolitical nightmare. If births >16 weeks are called births and counted, then … 4) We haven’t thought of births at 16–20 weeks as the obstetrical equivalent to advanced ovarian cancer.” While epithelial ovarian cancer is aggressively documented and actively researched, he said, births at this gestational age are poorly documented and actively ignored.