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Incompetent cervixBy Mayo Clinic staff
Original Article: http://www.mayoclinic.com/health/incompetent-cervix/DS01198
An incompetent cervix, also called an insufficient cervix, is a condition that occurs when weak cervical tissue causes or contributes to premature birth or the loss of an otherwise healthy pregnancy.
Before pregnancy, your cervix — the lower part of the uterus that connects to the vagina — is normally closed and rigid. As pregnancy progresses and you prepare to give birth, the cervix gradually softens, decreases in length (effaces) and opens (dilates). If you have an incompetent cervix, your cervix might begin to open too soon — causing you to give birth too early.
An incompetent cervix can be difficult to diagnose and, as a result, treat. If your cervix begins to open early, your health care provider might recommend preventive medication during pregnancy, frequent ultrasounds or a procedure that closes the cervix with strong sutures (cervical cerclage).
If you have an incompetent cervix, you might not experience any signs or symptoms as your cervix begins to open during early pregnancy. Mild discomfort over the course of several days or weeks is possible, however, starting at week 15 to week 20 of pregnancy. Be on the lookout for:
- A sensation of pelvic pressure
- A backache
- Mild abdominal cramps
- A change in vaginal discharge
- Light vaginal bleeding
Various factors can increase your risk of an incompetent cervix. For example:
- Congenital conditions. Uterine abnormalities and genetic disorders affecting a fibrous type of protein that makes up your body's connective tissues (collagen) might cause an incompetent cervix. Exposure to diethylstilbestrol (DES), a synthetic form of the hormone estrogen, before birth also has been linked to cervical insufficiency.
- Obstetric trauma. If you experienced a cervical tear during a previous labor and delivery, you could have an incompetent cervix.
- Certain cervical procedures. Various surgical procedures — including a procedure used to take a sample of cervical tissue (cervical biopsy) and a treatment that uses an electrical current to remove diseased tissue from the cervix (loop electrosurgical excision procedure, or LEEP) — can contribute to cervical insufficiency.
- Dilation and curettage (D&C). This procedure is used to diagnose or treat various uterine conditions — such as heavy bleeding — or to clear the uterine lining after a miscarriage or abortion. It can cause structural damage to the cervix.
Limited research also suggests that black women might be at increased risk of cervical insufficiency. Further studies are needed to determine the underlying causes.
If you have an unusually short cervix, you're at increased risk of premature birth. However, many women who have a naturally short cervix deliver at term.
An incompetent cervix poses risks for your pregnancy — particularly during the second trimester — including:
- Premature birth
- Pregnancy loss
If your baby is born prematurely, he or she might have health concerns — including low birth weight, breathing difficulties and underdeveloped organs. Children who are born prematurely also have a higher risk of learning disabilities and behavioral problems. The risks are greatest for babies born before 32 weeks of pregnancy.
Preparing for your appointment
If you're pregnant and have any risk factors for an incompetent cervix or you experience any symptoms during your second trimester that indicate you might have an incompetent cervix, consult your health care provider right away. Depending on the circumstances, you might need immediate medical care.
Here's some information to help you get ready for your appointment, as well as what to expect from your health care provider.
What you can do
Before your appointment, you might want to:
- Ask about pre-appointment restrictions. In most cases you'll be seen immediately. If that's not the case, ask whether you should restrict your activities while you wait for your appointment.
- Find a loved one or friend who can join you for your appointment. Fear and anxiety might make it difficult to focus on what your health care provider says. Take someone along who can help remember all the information.
- Write down questions to ask your health care provider. That way, you won't forget anything important that you want to ask, and you can make the most of your time with your health care provider.
Below are some basic questions to ask your health care provider about an incompetent cervix. If any additional questions occur to you during your visit, don't hesitate to ask.
- Has my cervix begun to open? If so, how much?
- Is there anything I can do to help prolong my pregnancy?
- Are there any treatments that can prolong my pregnancy or help the baby?
- Do I need to be on bed rest? If so, for how long? What kinds of activities will I be able to do? Will I need to be in the hospital?
- What signs or symptoms should prompt me to call you?
- What signs or symptoms should prompt me to go to the hospital?
- What will happen to my baby if he or she is born now? What can I expect?
What to expect from your health care provider
Your health care provider is likely to ask you a number of questions, including:
- When did you first notice your signs or symptoms?
- Have you had any contractions or changes in vaginal discharge?
- Have you had any previous pregnancies, miscarriages or cervical surgeries that I'm not aware of?
- How long would it take you to get to the hospital in an emergency, including time to arrange any necessary child care, transportation and so on?
- Do you have friends or loved ones nearby who could care for you if you need bed rest?
Tests and diagnosis
An incompetent cervix can be detected only during pregnancy, and even then diagnosis can be difficult — particularly during a first pregnancy. To help diagnose an incompetent cervix, your health care provider will document any symptoms you're experiencing. Also, your health care provider will ask about your medical history. Be sure to tell your health care provider if you've experienced second trimester pregnancy losses or you had a cervical tear during a previous labor and delivery.
Your health care provider might determine you have an incompetent cervix if you have:
- A history of painless cervical dilation and second trimester deliveries
- A history of short labors and progressively earlier deliveries in previous pregnancies
- Advanced cervical dilation and effacement before week 28 of pregnancy without painful contractions, vaginal bleeding, water breaking (ruptured membranes) or infection
Tests and procedures to help diagnose an incompetent cervix during the second trimester include:
- Transvaginal ultrasound. If the fetal membranes aren't in your cervical canal or vagina, your health care provider will use transvaginal ultrasound to evaluate the length of your cervix, determine how much your cervix has dilated and examine the fetal membranes. During this type of ultrasound, a slender transducer is placed in your vagina to send out sound waves and gather the reflections of your cervix and lower uterus on a monitor.
- Pelvic exam. Your health care provider will examine your cervix to see if the amniotic sac has begun to protrude through the opening of your cervix (prolapsed fetal membranes). If the fetal membranes are in your cervical canal or vagina, you have an incompetent cervix. Your health care provider will check for evidence of any congenital conditions or cervical tears that might cause an incompetent cervix. Your health care provider will also check for contractions and, if necessary, monitor them.
- Lab tests. If the fetal membranes are visible and an ultrasound shows signs of inflammation but you don't have symptoms of an infection, your health care provider might test a sample of amniotic fluid (amniocentesis) to diagnose or rule out an infection of the amniotic sac and fluid (chorioamnionitis).
Remember, there are no tests that can be done before pregnancy to reliably predict an incompetent cervix. However, certain tests done before pregnancy can help detect uterine abnormalities that might cause an incompetent cervix. For example, your health care provider might suggest an ultrasound or magnetic resonance imaging (MRI) — a procedure that uses a magnetic field and radio waves to create detailed images of the organs and tissues within your body. In some cases, hysterosalpingography — a procedure that uses X-rays to examine the inside of the uterus, fallopian tubes and surrounding area — is recommended.
Treatments and drugs
Treatments for or approaches to managing an incompetent cervix might include:
- Progesterone supplementation. If you have a history of premature birth, your health care provider might suggest weekly shots of a form of the hormone progesterone called hydroxyprogesterone caproate (Makena) during your second trimester. However, further research is needed to determine how progesterone might specifically help women who have cervical insufficiency. Progesterone also isn't recommended for women pregnant with more than one baby.
- Serial ultrasounds. If you have a history of early premature birth, your health care provider might begin carefully monitoring the length of your cervix by giving you ultrasounds every two weeks from week 15 through weeks 24 to 26 of pregnancy. If your cervix begins to open or becomes shorter than a certain length, your health care provider might recommend cervical cerclage.
- Cervical cerclage. If you're less than 24 weeks pregnant or have a history of early premature birth and an ultrasound shows that your cervix is opening, a surgical procedure known as cervical cerclage might help prevent premature birth. During this procedure, the cervix is stitched closed with strong sutures. The sutures might be removed during the last month of pregnancy or during labor. If you have a history of premature births that's likely due to cervical insufficiency, your health care provider might also recommend cervical cerclage before your cervix begins to open (prophylactic cerclage). This procedure is typically done before week 14 of pregnancy. Cervical cerclage isn't appropriate for everyone at risk of premature birth, however. Be sure to talk to your health care provider about the risks and benefits of cervical cerclage.
Your health care provider might also recommend the use of a device that fits inside the vagina and is designed to hold the uterus in place (pessary). A pessary can be used to help lessen pressure on the cervix. However, further research is needed to determine if a pessary is an effective treatment for cervical insufficiency.
Lifestyle and home remedies
If you have an incompetent cervix, your health care provider might recommend restricting sexual activity or limiting certain physical activities. Bed rest might be prescribed in some cases, although it isn't a proven remedy for preventing premature birth.
Coping and support
If you have an incompetent cervix, you might feel anxious about your pregnancy. You might be afraid to think about the future, and prenatal visits might make you particularly nervous — for fear that you'll hear bad news.
Unfortunately, anxiety can affect your health and your baby's health. Consult your health care provider about healthy ways to stay calm. Some studies suggest that certain techniques, such as imagining pleasant objects or experiences or listening to music, can reduce anxiety during pregnancy.
If you give birth prematurely, it won't affect your physical recovery from childbirth. Depending on when you give birth, however, your baby might need intensive medical care. You might be worried about the possible long-term effects for your baby. As the parent of a premature newborn, you might also feel that you did something to cause the premature birth or that you could have done more to prevent it. If you're experiencing feelings of guilt, talk to your partner and loved ones, as well as your health care provider. Try to focus your energy on caring for and getting to know your child.
You can't prevent an incompetent cervix — but there's much you can do to promote a healthy, full-term pregnancy. For example:
- Seek regular prenatal care. Prenatal visits can help your health care provider monitor your health and your baby's health. Mention any signs or symptoms that concern you, even if they seem silly or unimportant.
- Eat a healthy diet. During pregnancy, you'll need more folic acid, calcium, iron and other essential nutrients. A daily prenatal vitamin — ideally starting a few months before conception — can help fill any dietary gaps.
- Gain weight wisely. Gaining the right amount of weight can support your baby's health — and make it easier to shed the extra pounds after delivery. A weight gain of 25 to 35 pounds (about 11 to 16 kilograms) is often recommended for women who have a healthy weight before pregnancy. If you're overweight before you conceive, you might need to gain less weight. If you're carrying twins or triplets, you might need to gain more weight. Work with your health care provider to determine what's right for you.
- Avoid risky substances. If you smoke, quit. Alcohol and illegal drugs are off-limits, too. In addition, medications of any type — even those available over-the-counter — deserve caution. Get your health care provider's OK before taking any medications or supplements.
If you have an incompetent cervix, you're at risk of premature birth or pregnancy loss in subsequent pregnancies. If you're considering getting pregnant again, work with your health care provider to understand the risks and what you can do to promote a healthy pregnancy.
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