Cervical Incompetence

Cervical incompetence or cervical insufficiency is the condition in pregnant women, where the cervix becomes weak and opens up during the early stages of pregnancy. Typically, the cervix opens when the baby is about to be born and not before that. However, in women with an incompetent cervix, it opens up much earlier, posing the risk of premature birth.

What is the Cervix?

The cervix is the bottom-most part of the uterus that connects it with the birth canal called the vagina. During pregnancy, the cervix remains closed, acting as a door for retaining the baby inside the uterus. Only when the baby completes full term does the cervix efface (thins down) and dilate (opens up) to let the baby out through the birth canal in a normal vaginal delivery.

What Does It Mean to Have Cervical Insufficiency?

Cervical insufficiency is a condition in which the cervix becomes weak and opens during the early stages of pregnancy itself. As the baby grows inside the uterus, it gains weight and starts exerting its weight on the cervix. If the cervix is not strong enough, it gives in to the pressure applied by the developing baby. An incompetent cervix can lead to having a preterm baby or even a miscarriage, especially during the second trimester, if not diagnosed in time. It is not a very common condition and occurs in only one in hundred pregnant women.

Causes 

There are various causes for incompetent cervix in pregnant women. They are,

• Malformations of the cervix from birth, which could mean a deviation from the normal shape of the cervix or the uterus that the person is born with.
• Any damage to the cervical walls made during a procedure on it, like dilation and curettage (D and C), biopsy for cancer detection or LEEP treatment for cervical cancer.
• Any trauma to the cervix during a previous childbirth.
• Previous exposure to Diethylstilboestrol (DES), used to avoid miscarriages during pregnancy, is known to cause problems in the reproductive tract
• History of second-trimester miscarriages, without any known reason.

Signs and Symptoms

Pregnant women with an incompetent cervix, usually start experiencing some mild symptoms during the second trimester between the 14^th and 20^th week. Women who have not had a previous episode of miscarriage due to cervical incompetence may sometimes miss these subtle symptoms. It is very important to discuss with your doctor immediately if you experience any of the following symptoms.

• Spotting or mild bleeding from the vagina
• Feeling of pressure in the pelvic area
• Cramp-like pain in the uterus
• Back pain
• A clear white coloured discharge from the vagina that turns into pink colour over time

During a regular check-up, the doctor usually checks for the length of the cervix and also for any cervix dilation, to rule out a case of insufficiency.

Complications

When a woman with incompetent cervix is not given timely care and treatment, she may face many complications in her pregnancy such as:

• Having a pre-term baby– If the cervix opens up during the later stage of the second trimester, there are high chances of the baby being born much ahead of time. In such a case, the baby will require life support and incubator until it grows to a stage where it can function independently.
• Stillbirth – A pregnancy loss that happens after week 20 if the pregnancy is called stillbirth. When the baby is born very young it usually does not have the growth and development to survive outside the uterus.
• Miscarriage – Babies born to mothers whose cervix becomes weak between the 18^th and 22^nd week usually have a miscarriage. A fetus cannot survive if it is born before 23 weeks of pregnancy.

While these complications exist, timely remedial measures such as medications, surgical procedures and rest can help many mothers to successfully deliver their full term babies.

How Often Does It Happen?

Incompetent cervix is not a very common condition among pregnant women, and only one in hundred expecting mothers have a weak cervix.

How is the Diagnosis Done?

The doctor usually conducts certain tests during the second trimester to check for any signs of cervical incompetence in a pregnant woman. These tests are conducted based on a previous history of having a pre-term baby or miscarriage, mild symptoms of incompetence or as a general wellness check-up. The diagnosis is usually done in one of the following ways,

• Transvaginal Ultrasound: It is a cervical incompetence radiology testing method, where a thin transducer is inserted inside the vagina to capture ultrasound based images of the cervix. The ultrasound of the vaginal area gives an idea about any discrepancy in the length of the cervix (below 2.5 cm), the presence of the foetal membrane in the vagina and the dilation of the cervix. This is usually done around week 15 of the pregnancy.
• Examination Of the Pelvis: To check for any prolapsed foetal membrane, i.e. a protrusion of the foetal membrane inside the vagina, the doctor physically examines the cervix. The doctor also can assess the condition of the cervix and the presence of any physical damage in the cervix through this examination. If the doctor feels the foetal membrane in the cervix, it implies that the cervix has opened before time.
• Amniocentesis: If the above two tests suggest an incompetent cervix, the doctor generally performs an amniocentesis. It is a simple laboratory procedure, where a small portion of the amniotic sac is drawn to check for any kind of infection in the sac surrounding the foetus.

Treatment

If the doctor diagnoses the cervical incompetence at a less critical stage, he or she generally chooses to treat the expecting mother through one of the following treatment strategies.

• Supplementation with Progesterone:

  Progesterone is a natural steroid hormone that is administered during the second trimester to prevent miscarriages and premature births. It is usually given as weekly shots or as preparations that can be inserted through the vagina. This treatment option is however not successful in containing multiple pregnancies.

• Continuous Monitoring:

  For women who have had a history of incompetent cervix or those who have damages in their cervix, the doctor usually examines the length of the same every once in two weeks through an ultrasound scan. During this continuous assessment, if the cervix begins to open up, the doctor immediately conducts a surgery to stitch the cervical opening called cervical cerclage.

• Cervical Cerclage:

  This is a surgical procedure, administered by doctors on women whose cervix is likely to open up prematurely. In this procedure, the doctor stitches the mouth of the cervix together, in such a way that it withstands the pressure of the developing foetus in the uterus. This greatly helps in containing the baby inside the womb. Doctors even perform this procedure on women with a previous history of this condition, before their cervix becomes weak. This is done as a precautionary measure. However, this treatment option has some restrictions.

A Woman Would Not Be Eligible for Cervical Cerclage Under the Following Conditions:

• If she is carrying two or more foetuses in one pregnancy
• If the dilation of the cervix has reached 4 cm
• If there is irritation in the cervix
• If there is any rupture in the foetal membrane

Prevention

There is nothing much you can do to prevent having an incompetent cervix, before conceiving the baby. However, once you become pregnant, you can follow these simple steps to achieve a successful pregnancy.

• Get the nutrients right: You can eat lots of fresh fruits, vegetables, and nuts to get the required amount of nutrients during pregnancy. Calcium, iron and folic acid are very critical in ensuring good health for both the mother and the baby.
• Consult your doctor regularly: If you have a history of miscarriage or of delivering a preterm baby, you must make sure that you have a regular check-up with your doctor. The doctor will periodically monitor the condition of your cervix through ultrasound and suggest the necessary precautions for a safe delivery.
• Limit physical activity: If you are at the risk of having cervical incompetence, then try to avoid any exertive physical activity. You can opt for bed rest, especially after the second trimester.
• Avoid sexual activity: You doctor might advise you to avoid sexual activity throughout the pregnancy if you have a weak cervix.

Management of Cervix Incompetence

Learn more about this medical condition and about the precautions that you can take to overcome this problem and achieve a successful pregnancy. Those who have a history of cervical incompetence tend to feel guilty or depressed and go through a lot of emotional stress. Proper care and support from the doctor and the concerned family members can go a long way in keeping the woman stay positive through the pregnancy. Cervical cerclage is a very effective strategy for dealing with incompetent cervix and the success rate of these methods are very high in successfully delivering full-term babies.