A cervix (the structure at the bottom of the uterus) that is incompetent is abnormally weak, and therefore it can gradually widen during pregnancy. Left untreated, this can result in repeated pregnancy losses or premature delivery.
Incompetent cervix is the result of an anatomical abnormality. Normally, the cervix remains closed throughout pregnancy until labor begins. An incompetent cervix gradually opens due to the pressure from the developing fetus after about the 13th week of pregnancy. The cervix begins to thin out and widen without any contractions or labor. The membranes surrounding the fetus bulge down into the opening of the cervix until they break, resulting in the loss of the baby or a very premature delivery.
Causes and symptoms
Some factors that can contribute to the chance of a woman having an incompetent cervix include trauma to the cervix, physical abnormality of the cervix, or having been exposed to the drug diethylstilbestrol (DES) in the mother's womb. Some women have cervical incompetence for no obvious reason.
Incompetent cervix is suspected when a woman has three consecutive spontaneous pregnancy losses during the second trimester (the fourth, fifth and sixth months of the pregnancy). The likelihood of this happening by random chance is less than 1%. Spontaneous losses due to incompetent cervix account for 20-25% of all second trimester losses. A spontaneous second trimester pregnancy loss is different from a miscarriage, which usually happens during the first three months of pregnancy.
The physician can check for abnormalities in the cervix by performing a manual examination or by an ultrasound test. The physician can also check to see if the cervix is prematurely widened (dilated). Because incompetent cervix is only one of several potential causes for this, the patient's past history of pregnancy losses must also be considered when making the diagnosis.
Treatment for incompetent cervix is a surgical procedure called cervical cerclage. A stitch (suture) is used to tie the cervix shut to give it more support. It is most effective if it is performed somewhere between 14-16 weeks into the pregnancy. The stitch is removed near the end of pregnancy to allow for a normal birth.
Cervical cerclage can be performed under spinal, epidural, or general anesthesia. The patient will need to stay in the hospital for one or more days. The procedure to remove the suture is done without the need for anesthesia. The vagina is held open with an instrument called a speculum and the stitch is cut and removed. This may be slightly uncomfortable, but should not be painful.
Some possible risks of cerclage are premature rupture of the amniotic membranes, infection of the amniotic sac, and preterm labor. The risk of infection of the amniotic sac increases as the pregnancy progresses. For a cervix that is dilated 3 centimeters (cm), the risk is 30%.
After cerclage, a woman will be monitored for any preterm labor. The woman needs to consult her obstetrician immediately if there are any signs of contractions.
Cervical cerclage can not be performed if a woman is more than 4 cm dilated, if the fetus has already died in her uterus, or if her amniotic membranes are torn and her water has broken.
The success rate for cerclage correction of incompetent cervix is good. About 80-90% of the time women deliver healthy infants. The success rate is higher for cerclage done early in pregnancy.
DES is a drug given to women a generation ago to prevent miscarriage. At that time it was not known that female children born of women who had been given DES would show a higher rate for cervical and other reproductive abnormalities, as well as a rare form of vaginal cancer, when they reached reproductive age.
The thinning out of the cervix that normally occurs along with dilation shortly before delivery.
Labor before the thirty-seventh week of pregnancy.