Incompetent Cervix

Background Diagnosis Causes Treatment Bibliography

Background:

A week before we lost our son, I had gone into the doctor s office for our 19-week ultrasound. My husband and I were so excited to know if we were having a boy or a girl. We were also excited to see real baby features aside from the blobs we had seen at earlier ultrasounds. We had left that office with such pride and we both were glowing from excitement.

A couple days later, I had felt something different. I knew the baby was going to be felt soon. In fact, I thought I had felt a little twinge of a foot or an arm before our ultrasound. But this feeling was something very different. I never had carried a pregnancy this far before so I was not sure what I was feeling. I felt as if the baby had moved somehow, as if the weight of the baby was causing more pressure on my intestines and bladder. Since it did not seem painful nor was it accompanied by other symptoms, I wrote it off as the baby just doing battle with my insides.

Tragedy hit us three days later. I started feeling as if I was constipated. I woke up early Monday morning with pain but it wasn t regular nor was it unbearable. I drank some prune juice and went back to bed. I awoke only an hour later to more pain. It still was not intense but it did start causing me some more concern. I kept feeling like I had to go to the bathroom but nothing would happen. Finally, I knew something wasn t right and I went to wake up my husband to take me to the emergency room.

I felt that sensation of having to go to the bathroom again. On my way from the bedroom to the bathroom, I felt this huge gush of fluid. Panic set in. I knew my water broke. I screamed for my husband to hurry and get dressed. He helped me lay down on the couch while he gathered his thoughts. I felt down between my legs and could feel something protruding from my vagina. Was it the sac? Was it my son s head? The pain became more intense. I knew I could not sit up in the car so we called for an ambulance.

The paramedics arrived quickly and put me on a stretcher. They were trying to assess what was happening. I heard them mention placenta previa. They thought they were looking at the bag of waters. I could feel my body push. The paramedic told me not to push if I could help it. I tried to stop my body from pushing but there was no control over the pushing. My son was born one minute before we reached the hospital. It was exactly one week since our ultrasound and the day before my 23rd birthday. Gabriel passed on from this earth an hour later.

Causes:
Incompetent cervix accounts for 20-25% of all second trimester losses. Many women do not even know they have an incompetent cervix until after they have experienced 2 or more losses in the second trimester.

The causes of an incompetent cervix can range from trauma to the cervix including extensive cervical conization (cervical biopsy), uterine abnormalities and anomalies, exposure to the drug DES (diethylstilbestrol) and undergoing a forced D & C with a late pregnancy termination. Even previous childbirth can weaken the cervix. For some women, there is no definitive cause for an incompetent cervix. There are also claims that an incompetent cervix is over-diagnosed because often the indications for treatment are not always clear.

Diagnosis:
An incompetent cervix can be diagnosed through the use of manual examination. Vaginal ultrasounds are also helpful in monitoring the cervical length and checking to see if the cervix is opening. When the cervical opening is greater than 2.5 cm, or the cervical length has shortened to less than 20mm, a diagnosis can be made for incompetent cervix. Also, funneling of the cervix can be a sign that the cervix has begun to efface.

There are some symptoms you might experience due to incompetent cervix. The most common complaint is increased discharge and feeling some heaviness in the pelvis. This can be due to a dilated cervix that is feeling the pressure of the bag of waters. When the cervix is dilated, there is no pain until the membrane rupture and labor is triggered, or the bag of water moves so far into the birth canal in effect, bulging from the cervix. Tragically, many cases are not detected until premature delivery occurs.

Treatment:
Once incompetent cervix has been diagnosed, a woman undergoes treatment for future pregnancies, which involves a surgical procedure called a cerclage. The cerclage is a purse-string stitch (suture) that acts as an cinch to keep the cervix from dilating. It is often placed between 12-15 weeks in pregnancy. The stitch is inserted surgically while the patient is under spinal, epidural, or general anesthesia. Often times the procedure is an outpatient surgery, although there is a chance that the woman may still need to spend the night in the hospital if she begins to experience cramping or extensive bleeding.

There are 5 types of cerclages that can be used; the McDonald, Shirodkar, Hefner, abdominal stitch, and Lash.

 The McDonald stitch is the most common for it is the easiest to use and can allow for vaginal delivery. The stitch is weaved in and out of the cervix and pulled tightly and tied to keep the cervix closed.

 The Shirodkar can be both permanent (requiring a cesarean section) or it can be removed near term. This stitch is started at a 12 o clock position, worked through the cervix to a 6 o clock position, ending back in the 12 o clock position on the other side of the cervix. It is also pulled tightly and tied to keep the cervix closed. How the stitch is tied off determines whether it will be removed or if it is permanent.

 An abdominal stitch is used when there is too little cervix to work with. It is used to stitch the upper and lower part of the cervix together and requires a cesarean section for delivery.

 The Hefner cerclage is commonly used when incompetent cervix is diagnosed later in pregnancy. It has an added benefit when there is little cervix to work with. This cerclage is removed closer to term as well.

 The Lash cerclage is the only type that is placed prior to pregnancy. In cases where there has been extensive cervical trauma or an anatomical defect, this stitch can be used. It is permanent and requires a cesarean delivery.

It is important to discuss all risks with your doctor prior to undergoing surgery for a cerclage. They include infection, tearing of the cervix from excessive pressure, premature rupture of the members, chorioamnionitis (infection of the membranes), pre-term labor, uterine rupture, maternal hemorrhage, and rarely, injury to the bladder

What can you expect after you ve had a cerclage placed? Once the cerclage has been placed, you will be put on bedrest from a period of 24-72 hours. There could be a restriction of activity or possibly continued bedrest if complications occur. Intercourse is also restricted once the stitch is in place due to increase risk of infection and trauma to the cervix. Spotting can occur after a stitch is placed as well as cramping. It is important to look for signs of increased discharge with odor, heavy bleeding, burning, itching, fever over 101, or heavy cramping. If you notice any of these symptoms, it is urgent you contact your physician.

The McDonald or Shirodkar stitch is often removed around weeks 37 and 38. Depending on the type of stitch, it can be removed in the office or in Labor and Delivery. Infection, pre-term labor, or premature rupture of the membranes might facilitate an earlier removal. Often, labor comes within a couple weeks of the removal of the stitch. For those who have a permanent stitch, the doctor, according to the patient s needs, schedules a cesarean section.

While it s frightening to be pregnant again once you have been diagnosed with IC, the outlook is very good. With treatment there is a success rate of 80-90%. There is every reason to feel optimistic, especially when the cerclage is done early in pregnancy. Emergency cerclages have a lower success rate due to other complications, such as a bulging membrane from the cervix, premature rupture of the membranes, or infection.

Since the loss of our son, I have been diagnosed with an incompetent cervix. I know this means we will face more challenges to starting our family. Once I make it to 12 weeks, my doctor plans on giving me a cerclage. I am hopeful that this will help us carry to term. While it may include risks and changes in lifestyle, all I can focus on is how much it will be worth enduring if I can come home from the hospital with my next baby in my arms.

Bibliography:

Hon Mother & Child Glossary

Incompetent Cervix & Pregnancy Support

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