Cervical Insufficiency: Diagnosis and Management in Pregnancy

Cervical incompetence issue?

At 21 weeks of gestation, I experienced irregular uterine contractions and went to the obstetric emergency department for four consecutive days.
I was prescribed medications to prevent premature labor and received intravenous therapy, but the effects were limited.
On the third day, I began to feel lower abdominal pain.
Urinalysis and blood tests revealed an infection, and I was treated with antibiotics and medications to prevent premature labor.
However, on the fifth day, the physician performed a cervical examination and found cervical dilation, leading to an emergency transfer to a teaching hospital.
Unfortunately, my water broke, and I experienced a preterm birth.

The physicians at the teaching hospital, as well as those at the obstetric clinic (who evaluated me for increased postpartum lochia), assessed that the preterm labor was caused by contractions due to an infection (the placental pathology showed mild choriomembranitis).
They concluded that it was not due to cervical incompetence.
However, during the follow-up visit after delivery, the attending physician at the original obstetric hospital informed me that there was a case of cervical incompetence.

I am seeking clarification on how physicians assess and diagnose this condition, as they were reluctant to provide a direct response, only stating that there are many factors contributing to preterm labor and that the success and failure rates of cervical cerclage procedures vary.
I would like to know if, given this situation, it is likely that I have cervical incompetence.
Are there any methods to test and confirm whether cervical incompetence is present? (I once saw a physician on YouTube mention that a probe could be used to assess this when not pregnant, but I am unsure of its validity.) For a second pregnancy, would you recommend undergoing a cervical cerclage procedure? Thank you for your assistance in responding to this heartbroken mother.

Niming, 30~39 year old female. Ask Date: 2022/10/03

Dr. Cao Guotao reply Obstetrics and Gynecology

Hello, based on the medical history, it appears to be more like preterm labor due to uterine contractions and cervical incompetence.
The assessment primarily relies on past medical history, while ultrasound examination serves as an auxiliary function.
Wishing you good health.

Reply Date: 2022/10/03

More Info

Cervical insufficiency, also known as cervical incompetence, is a condition where the cervix begins to dilate and efface prematurely during pregnancy, often leading to preterm birth or pregnancy loss. Understanding the diagnosis and management of cervical insufficiency is crucial for expectant mothers, especially those with a history of preterm labor or other complications.

Diagnosis of Cervical Insufficiency
Diagnosing cervical insufficiency typically involves a combination of medical history, physical examinations, and imaging studies. A healthcare provider may assess the following:
1. Medical History: A detailed history of previous pregnancies, particularly any instances of preterm birth, miscarriage, or cervical surgeries, can provide insight into the risk of cervical insufficiency.

2. Physical Examination: A pelvic exam may reveal cervical changes, such as dilation or effacement, which can indicate cervical insufficiency.

3. Ultrasound: Transvaginal ultrasound is the most effective method for measuring cervical length. A cervical length of less than 25 mm before 24 weeks of gestation is often considered a sign of cervical insufficiency.

4. Dynamic Testing: In some cases, healthcare providers may perform a cervical cerclage procedure (a stitch placed around the cervix) to provide support if cervical insufficiency is suspected. This can be both diagnostic and therapeutic.

5. History of Symptoms: Symptoms such as pelvic pressure, back pain, or changes in vaginal discharge can also be indicative of cervical insufficiency.

Management of Cervical Insufficiency
Management strategies for cervical insufficiency depend on the severity of the condition and the gestational age of the pregnancy:
1. Cervical Cerclage: If cervical insufficiency is diagnosed, a cerclage may be recommended, especially if there is a history of preterm birth. This procedure involves stitching the cervix closed to prevent premature dilation.

2. Progesterone Supplementation: For women with a history of preterm birth, progesterone supplementation may be prescribed to help maintain pregnancy.

3. Activity Modification: Reducing physical activity and avoiding heavy lifting can help minimize the risk of cervical changes.

4. Monitoring: Regular ultrasounds to monitor cervical length and signs of preterm labor are essential for managing pregnancies at risk for cervical insufficiency.

5. Emergency Care: In cases of preterm labor or rupture of membranes, immediate medical attention is required.

Considerations for Future Pregnancies
For women who have experienced cervical insufficiency in a previous pregnancy, the following considerations are important:
1. Consultation with a Specialist: It is advisable to consult with a maternal-fetal medicine specialist for a comprehensive evaluation and management plan for future pregnancies.

2. Cerclage in Future Pregnancies: If cervical insufficiency is confirmed, a cerclage may be recommended for subsequent pregnancies, particularly if there is a history of early cervical changes or preterm birth.

3. Preconception Counseling: Before attempting to conceive again, discussing the risks and management strategies with a healthcare provider can help prepare for a healthier pregnancy.

4. Monitoring During Pregnancy: Close monitoring during subsequent pregnancies, including regular ultrasounds and assessments of cervical length, is crucial.

Conclusion
Cervical insufficiency is a complex condition that requires careful evaluation and management. If you suspect that you may have cervical insufficiency or have experienced complications in previous pregnancies, it is essential to seek guidance from a qualified healthcare provider. They can provide personalized recommendations based on your medical history and current health status, ensuring the best possible outcomes for you and your future pregnancies.

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