Incompetent cervix -- caring for it during pregnancy

by Tristine Miller and Julie Snyder

Tristine recalls her experience with IC

Incompetent CervixWhat causes an incompetent cervix? How is it treated? Are there risks to a cerclage?

A week before we lost our son, I had gone into the doctor's office for our 19-week ultrasound. We were anticipating finding out if we were having a boy or girl. We were also excited to see real baby features aside from the blobs we had seen at earlier ultrasounds. We left the office full of pride and excitement.

A couple days later, I felt something different. I knew the baby's movements were going to be felt soon. In fact, I thought I had felt a little twinge of a foot or an arm before our ultrasound. I had never carried a pregnancy this far before so wasn't sure what I was feeling. It felt as if the baby had moved somehow, the weight of the baby causing more pressure on my intestines and bladder. Since it did not seem painful or 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 or unbearable. I drank some prune juice and went back to bed. I woke up an hour later to more pain. I kept feeling like I had to go to the bathroom but nothing would happen. Finally, I realized something wasn't right and I woke 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. 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 and put me on a stretcher. 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 had was no control. My son was born one minute before we reached the hospital. It was one week since our ultrasound and the day before my 23rd birthday. Gabriel passed an hour later.

Since the loss of our son, I have been diagnosed with IC. I know this means we'll 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.

What causes an incompetent cervix?

An IC accounts for 20-25 percent of all second trimester losses. Many women aren't aware they have one until after they've experienced two or more losses in the second trimester.

The causes can range from trauma to the cervix including extensive cervical conization (cervical biopsy), uterine abnormalities and anomalies, exposure to the drug DES. Even previous childbirth can weaken the cervix. For some women, there's no definitive cause.

Diagnosing an incompetent cervix

It can be diagnosed via manual examination. Vaginal ultrasounds can help monitor the cervical length and check 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 IC. Also, funneling of the cervix can be a sign that the cervix has begun to efface. You might experience increased discharge and feeling heaviness in the pelvis. This can be caused by a dilated cervix 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 far into the birth canal in effect, bulging from the cervix. Tragically, many cases are not detected until premature delivery occurs.

Treatment Options

Once it's been diagnosed, a woman undergoes treatment for future pregnancies, which involves a surgical procedure called a cerclage. The cerclage is a purse-string stitch that acts as an cinch to keep the cervix from dilating. It's placed between 12-15 weeks gestation. The stitch is inserted surgically while the patient is under spinal, epidural, or general anesthesia. The procedure can be considered outpatient surgery, although there's a chance that you might need to spend the night in the hospital if you experience cramping or extensive bleeding.

Five types of cerclages

The McDonald stitch is the most common. It's the easiest to use and allows vaginal delivery. The stitch is woven in and out of the cervix and pulled tightly and tied to keep the cervix closed.

The Shirodkar stitch can be permanent (requiring a cesarean section) or be removed near term. The stitch starts at a 12 o'clock position, worked through the cervix to the 6 o'clock position, ending back in the 12 o'clock position on the other side of the cervix. It's pulled tightly and tied to keep the cervix closed.

An abdominal stitch is used when there is too little cervix to work with. The upper and lower part of the cervix are stitched together. A cesarean section is required for delivery.

The Hefner cerclage is commonly used when IC 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's placed prior to pregnancy. This stitch is used in cases of extensive cervical trauma or an anatomical defect. It's permanent and requires a cesarean delivery.

What happens after the cerclage?

Once the cerclage has been placed, you'll be put on bedrest for a period of 24-72 hours. You could have your regular and sexual activity restricted or have bedrest continue if complications occur. Look for signs of increased discharge with odor, spotting, heavy bleeding, burning, itching or a fever over 101. If you notice any of these symptoms, contact your physician immediately.

Photo courtesy iStockphoto.