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DESCRIPTION
An incompetent cervix is also called cervical insufficiency. The cervix is the neck of the womb that connects the vagina with the uterus. Normally, the cervix remains closed during pregnancy until your baby is ready to be born (usually after 37 weeks of pregnancy) and until labor begins. A normal pregnancy lasts for about 9 months.
Women who are diagnosed with an incompetent cervix experience premature opening (dilation) of the cervix usually in mid-pregnancy (18 to 22 weeks or 4 to 6 months of pregnancy). The condition occurs in about 1 out of every 100 pregnancies and may be responsible for 20 to 25 percent of second trimester miscarriages. The miscarriage occurs after the uterus has enlarged somewhat and the developing fetus becomes heavy enough to press the cervix open.
FREQUENT SIGNS & SYMPTOMS
No signs and symptoms are usually apparent. In a pregnant woman, there is a gradual thinning out (effacement) and widening (dilation) of the cervix usually without vaginal bleeding or uterine contractions. The amniotic sac, also called the bag of water, may bulge down into the opening of the cervix until it breaks. This may cause the baby to be born prematurely (early).
In some cases, a woman may experience pressure in the lower abdomen or vaginal pressure, unusual urinary frequency, vaginal discharge (with or without bloody discharge), a sudden change in discharge, especially if it is a thick mucus (loss of cervical mucus plug), or a sensation of a lump in the vagina (may be protruding membranes) or a sudden gush of warm water (amniotic fluid if the bag breaks).
If you feel that something is not right (or a hunch that makes you think anything is at all wrong), go get it checked out by your midwife or health care provider. If you have any of the above symptoms, insist on a cervical ultrasound. Keep in mind that a manual vaginal exam often misses an incompetent cervix. The earlier an incompetent cervix is caught, the better the odds of a successful rescue cerclage being performed.
CAUSES
There is no one cause of an incompetent cervix.
The cervix may be weakened by injury (trauma), previous childbirth, induced abortion, forced D & C (dilation and curettage) surgery, cervical surgery or laser therapy. There are rare conditions in which the substance of the cervix is not strong enough to support a pregnancy. Hormonal influences, uterine abnormalities, or congenitally short cervix may cause cervix incompetency problems.
PRETERM LABOR RISK INCREASES IN/WITH
Multiple gestation (e.g., twins, triplets).
A woman who was exposed to DES (diethystilbestrol; a drug once used to prevent miscarriage) when she was in her mother's womb.
An abnormally developed uterus.
Uterine fibroids.
High blood pressure (hypertension), kidney disease, diabetes, or heart disease.
A previous history of preterm labor.
Younger than 18 or older than 40.
Stress or depression.
Lack of proper nutrition and do not follow a healthy dietary plan.
Smoking, drug use, drinking excessive amounts of alcohol.
Vaginal or uterine infections.
PREVENTIVE MEASURES
If a woman experiences a miscarriage that is diagnosed as being caused by cervical incompetence, there are preventive measures that can be taken with a subsequent pregnancy to reduce the risk of another miscarriage.
If you fall into any of the following categories, insist on extra cervical ultrasounds:
- Your mother took DES while pregnant with you.
- You have a prior history of second-trimester loss.
- You have a prior history of traumatic birth (and your cervix was damaged).
- You have had any traumatic procedure performed on your cervix (cerclage, biopsy, LEEP).
- You have a history of repeated abortions, or prior late-term abortion.
- You have an abnormally developed cervix and/or uterus.
EXPECTED OUTCOME
If diagnosed with a previous miscarriage and with proper treatment in the subsequent pregnancy, chances of carrying to term are good.
POSSIBLE COMPLICATIONS
Repeated miscarriages and fetal death.
Premature delivery of prematurely developed infant with all the problems that often accompany prematurity.
TREATMENT
GENERAL MEASURES
DIAGNOSIS
Diagnosis is determined by a history of repeated miscarriages, an internal pelvic examination, and by ultrasound scanning. The use of ultrasonography has been very helpful with the diagnosis, and is made when the cervical os (opening) is greater than 2.5 cm, or the length has shortened to less than 20 mm. A vaginal ultrasound can be very helpful in diagnosing and incompetent cervix. Sometimes funneling is also seen, this is where the internal portion of the cervix, internal os (portion of the cervix closer to the baby) has begun to efface. The external os will be unaffected if diagnosed in time. An incompetent cervix may also be corrected in a non-pregnant woman.
TREATMENT
Treatment involves the placing of a stitch or suture (cerclage) into the wall of the cervix and drawing it up (similar to a purse string). This helps hold the fetus in the womb. The procedure is normally performed under regional anesthetic or sometimes local anesthetic at about the 12th to 14th week of pregnancy. The stitch is removed shortly before the baby is due or at the time of delivery (depending upon the midwife's or health care provider's preference) so a normal delivery can take place. Stitch removal is simple and does not require anesthesia.
A pessary may be placed inside your vagina to support your cervix. A pessary is a rubber or plastic device.
For diagnosis made during pregnancy, you must meet certain criteria before a cerclage can be performed. You are not eligible for the cerclage if you have:
- Hyper-irritability of the cervix.
- Your baby has already died.
- You are more than 4 cm dilated.
- Your water (amniotic bag) has broken.
CERCLAGE
There are five different techniques for performing the cerclage. The two most common are the McDonald and Shirodkar.
The McDonald procedure is done with a 5 mm band of permanent suture is placed high on the cervix. This is indicated when there is significant effacement of the lower portion of the cervix. It is generally removed at 37 weeks, unless there is a reason to remove it earlier, like infection, preterm labor, premature rupture of the membranes, etc. It is also shown that this has very little impact of the chance for vaginal delivery.
The Shirodkar is also used a frequently used technique. However, this was previously a permanent purse string suture that would remain intact for life. When this type of cerclage is done, a cesarean section will always be performed.
There are health care providers performing modified techniques, where the delivery does not necessarily have to be by cesarean, nor the suture left intact. Ask your practitioner which procedure they perform.
The Hefner cerclage, also know as the Wurm procedure, is used for later diagnosis of the incompetent cervix. It is usually done with a U or mattress suture, and is of benefit when there is minimal amounts of cervix left.
Uterosacral cardinal ligament cerclage is generally done after the McDonald and Shirodkar procedures have failed, or where there is a congenital shortened cervix, or subacute cervicitis. It can be done vaginally, but is frequently done abdominally. Again, cesarean delivery is mandated for birth.
The last procedure, the Lash, is performed in the non-pregnant state. It is typically done after cervical trauma that has caused an anatomical defect. There is the possible, though rare, side effect of infertility.
While these procedures are life-saving, they also have potential risks:
- Premature rupture of membranes (1-9 percent).
- Chorioamnionitis (Infection of the amniotic sac, 1-7 percent) (This risk increases as the pregnancy progresses and is at 30 percent for a cervix that is dilated more than 3 cms.)
- Preterm Labor.
- Cervical laceration or amputation (This can be at the procedure or at the delivery, from scar tissue that forms on the cervix.)
- Bladder Injury (rare).
- Maternal hemorrhage.
- Cervical dystocia.
- Uterine rupture.
The procedure is generally to observe the woman for 24 hours before performing the cerclage. During this time she will be observed for preterm labor and screened for infection. Generally this is done with the woman in the Trendelenburg position, feet above your head. Spinal anesthesia is used to prevent pain and maternal straining during the cerclage. Your bladder will be filled to try and move your membranes away from the os. You will be given antibiotics to help stave off infection, and Indocin to help your body ignore the prostaglandins released during the procedure.
Post-operatively you will be on bed rest for the next 24 hours, possibly in the Trendelenburg position. And monitored for uterine activity.
Once released from the hospital you will be on pelvic rest (no sex) for the remainder of the pregnancy. You will need to have periods of rest each day and decreased physical activity. You will be seen in the office at least once weekly until the birth. You will also be monitored for preterm labor. If you have any contractions you should contact your health care provider or midwife.
Cerclage seems to be a very effective treatment for incompetent cervix. The success rates can be very high (80-90 percent), particularly when done earlier in a pregnancy. If you have concerns about your prenatal history or suspect an incompetent cervix ask your practitioner to examine you.
OTHER OPTIONS
Bed rest and use of a uterine support (pessary) for the duration of the pregnancy may be recommended instead of or in addition to the surgical procedure.
AFTERCARE INSTRUCTIONS:
Ask your midwife or health care provider when to return for a follow-up visit. Keep all appointments. Write down any questions you may have. This way you will remember to ask these questions during your next visit.
Rest: You may need to rest in bed, lying on your left side most of the time. Avoid heavy work such as lifting to prevent premature labor or delivery.
Quit smoking: It is never too late to quit smoking. Smoking harms the heart, lungs, and the blood. You are more likely to have a heart attack, lung disease, and cancer if you smoke. You will help yourself and those around you by not smoking. Ask your health care provider or midwife for more information about how to stop smoking if you are having trouble quitting.
CONTACT A HEALTH CARE PROVIDER IF:
You have a fever (increased body temperature).
You have chills, cough, or feel weak and achy.
Your skin is itchy, swollen, or has a rash.
You have lower abdominal (stomach) or back pain that comes and goes. You have questions or concerns about your condition, medicine, or care.
SEEK CARE IMMEDIATELY IF:
You have fluid coming from your vagina.
You have foul smelling discharge coming from your vagina.
You have regular contractions.
You have vaginal bleeding.
ONLINE INCOMPETENT CERVIX SUPPORT GROUPS
Prevention.com: Online Incompetent Cervix Support Group
MEDICATION
Medication is not necessary for this disorder.
ACTIVITY
Bed rest for 24 hours following the cerclage procedure. Bed rest may be recommended for the rest of your pregnancy under some circumstances. Additional restrictions may be recommended by the midwife or health care provider. See Bedrest Checklist, Bedrest - Coping Techniques, Bedrest Exercise, Bedrest Family Tips for more information about dealing with required bedrest during pregnancy.
For some women, sexual intercourse may be restricted for the duration of the pregnancy.
DIET
No diet restrictions; continue with your recommended pregnancy diet.
BENEFICIAL DIETARY SUPPLEMENTS FOR MISCARRIAGE:
- Raspberry helps strengthen the uterus and may be taken as a tea.
Herbal Remedies: Red Raspberry Tincture Supplement, 100% Organic, 2 fl. oz.
Herbal Remedies: Red Raspberry Leaf, Yogi Tea, Woman's Female Support, 16 Tea Bags
Herbal Remedies: Red Raspberry Leaf, Traditional Medicinals, Caffeine Free, Kosher, 16 Tea Bags
Herbal Remedies: Red Raspberry Leaves, Nature's Way, 480 mg, 100 Caps
Herbal Remedies: Red Raspberry Leaf Supplements & Products
- False Unicorn helps strengthen the uterus.
Herbal Remedies: False Unicorn Root Extract Herb Tincture, 2 fl. oz.
Herbal Remedies: False Unicorn Supplements & Products
- Wild Yam helps improve hormonal balance for maintaining pregnancy.
Herbal Remedies: Wild Yam Extract Tincture, Herbal Remedies USA, 2 fl. oz.
Herbal Remedies: Wild Yam Root, Certified, 425 mg 180 Caps
Herbal Remedies: Wild Yam Supplements & Products
- Prenatal Vitamin Supplements provide general nutrition, which is very important for fetal development and to support pregnancy.
Herbal Remedies: Prenatal Multi-Vitamin & Mineral, 100% Natural Complete, Nature's Way, 180 Caps
Herbal Remedies: Prenatal Vitamins, Albion Iron, NOW Foods, 120 Caps
Herbal Remedies: Completia Prenatal Multi-Vitamin With DHA, Folic Acid & Iron, Nature's Way, 180 Tabs
- Folic Acid helps prevent birth defects and supports pregnancy.
Herbal Remedies: Folic Acid (Vitamin B-9), 100% Natural, Nature's Way, 800 mcg, 100 Caps
- Vitamin C with Bioflavonoids strengthens blood vessels.
Herbal Remedies: Vitamin C Liquid w/ Rose Hips & Bioflavonoids, Kosher, Natural Citrus Flavor, Dynamic Health, 1000 mg, 16 fl. oz.
Herbal Remedies: Ester C With Bioflavonoids, Nature's Way, 1000 mg, 90 Tabs
Herbal Remedies: Vitamin C 1000 With Bioflavonoids, Nature's Way, 100% Natural, 1000 mg, 250 VCaps
Herbal Remedies: The Right C, Nature's Way, 1000 mg, 120 Tabs
Herbal Remedies: Meta C Vitamin C Supplement, 1000 mg, 100 Tabs
Herbal Remedies: Effer-C Instant Fizzy Vitamin C Drink Mix Powder, Orange, NOW Foods, 1000 mg, 36 Packets
Herbal Remedies: Vitamin C Complex Powder, vegetarian Formula, NOW Foods, 8 oz.
- Vitamin E helps balance hormones.
Herbal Remedies: Ester E Natural Vitamin E, California Natural, 400 IU, 60 Softgels
Herbal Remedies: Vitamin E, 400 IU, 100% Natural, NOW Foods, 100 Gels
Herbal Remedies: Vitamin E-1000, NOW Foods, 1000 IU, 100 Gels
Herbal Remedies: Vitamin E, D-Alpha-Tocopherol, 400 IU, 100 Softgels
MISCARRIAGE SUPPLEMENTAL PRODUCTS
Information, supplements and products for miscarriage, the loss of a pregnancy during the first 20 weeks. Always consult with your midwife before using any herbal therapy or supplement during pregnancy.
Blue Cohosh (Caulophyllum thalictroides) Powder, 4 oz. Bulk
Blue Cohosh is used to regulate the menstrual flow and for treating suppressed menstruation. This herb eases muscle spasms and stimulates uterine contractions for childbirth and has been used in folk medicine to prevent miscarriage.Blue Cohosh (Caulophyllum thalictroides) Tincture, 100% Organic, 2 fl. oz.
Blue Cohosh is used to regulate the menstrual flow and for treating suppressed menstruation. This herb eases muscle spasms and stimulates uterine contractions for childbirth and has been used in folk medicine to prevent miscarriage.CapsiCool, Cayenne Formula, Nature's Way, 390 mg, 100 Caps
Cayenne has been one of the world's most popular herbal supplements since the time of the early Peruvians. CapsiCool is a special cayenne supplement formulation that provides the benefits of Cayenne without the burning feeling and discomfort in the stomach that otherwise may be experienced.False Unicorn Tincture, 100% Organic, 2 fl. oz.
Many herbalists recommend False Unicorn for reducing menopausal symptoms, and treating ovarian cysts. It has also been used to normalize hormone levels following oral contraceptive use. Native American women reportedly chewed the root to prevent miscarriages.Fertility Pregnancy Tincture, 2 fl. oz.
The Fertility Pregnancy Supplement helps tone the female organs to support fertility. This also helps to prevent miscarriage and create a strong pregnancy. Fertility Pregnancy Supplement can ejuvenative after miscarriage or abortion.Folic Acid (Vitamin B-9), 100% Natural, Nature's Way, 800 mcg, 100 Caps
Folic acid (Vitamin B-9) is necessary precursor for the manufacture of genetic material like RNA and DNA. It also assists in the growth and repair of tissues and in the conversion of fats and amino acids into other useful products in the body.Healthy Pregnancy, TCM Formula, Duzhong Yutai, 100% Natural, 60 Caps
Healthy Pregnancy, TCM Formula, Duzhong Yutai is made of cuscuta seed, amomum fruit, prepared rehmannia root, ginseng, mistletoe, donkey hide gelatin, Chinese cornbind (shou wu), mugwort leaf, morinda, atractylodes, codonopsis, deglued antler powder, wolfberry, dipsacus and eucommia bark.Manganese Ionic Mineral Supplement, Fully Absorbable, 30 +/- ppm, 16 fl. oz.
WaterOz Ionic Manganese is a pure liquid Manganese supplement. Manganese, also called the "brain mineral," is important in the utilization of all mental facilities/functions.Miscarriage Tincture (Helps Prevent), 100% Organic, 2 fl. oz.
The Miscarriage Tincture was created to help prevent miscarriage.Natural Progesterone Cream: A Safe Alternative To Conventional Hormone Replacement Therapy, By C. Norman Shealy, M.D., Ph.D.
In this Keat's Good Health Guide, Dr. Norman Shealy answers all your questions about natural progesterone cream, a viable and safe alternative to synthetic hormone replacement therapy.Prenatal Multi-Vitamin & Mineral with Folic Acid, 100% Natural & Complete, Nature's Way, 180 Caps
Nature's Way Prenatal Vitamin with Folic Acid is a complete vitamin formulated to support the health of the mother and child. Nature's Way Woman's Prenatal Multivitamin and mineral supplement provides specially balanced prenatal vitamin and mineral potencies for pregnant women or postnatal lactating women.Red Raspberry Tincture Supplement, 100% Organic, 2 fl. oz.
Red Raspberry supplement is said to be good for common female problems, but it's healing properties for other uses are sometimes overlooked. Red Raspberry Supplement is beneficial for pregnant women as it tones the uterine and pelvic muscles, preparing for an easier labor, as well as for the prevention of miscarriage. Red Raspberry Supplement relieves morning sickness. It also helps to increase the flow of the mother's milk, brings balance into the menstrual cycle, and will help alleviate excessive bleeding and cramps. Red Raspberry Supplement is safe and effective for children to use for diarrhea and stomach complaints.St. John's Wort Herb Tincture, 100% Organic, 2 fl. oz.
St. John's Wort is mainly used for the treatment of mild to moderate depression.U O Clear, Ovarian Cyst & Fibroid Support, 500 mg, 60 Caps
The herbs work synergistically to strengthen the body's natural capability of female systems self-cleaning functions, especially for uterus and ovary.Vitamin C 1000 with Bioflavonoids, Nature's Way, 100% Natural, 1000 mg, 250 VCaps
Nature's Way Vitamin C with Bioflavonoids provides antioxidant protection for many of the body's important enzyme systems.Wild Yam Extract Tincture, Herbal Remedies USA, 2 fl. oz.
Wild Yam has been used to treat indigestion, coughs, morning sickness, gall bladder pain, menstrual cramps, joint pain, and nerve pain. Wild Yam was used for centuries as a medicinal herb by the Aztec and Mayan peoples for a wide range of ailments including many female problems and to relieve the pain of child birth.Wise Woman Herbal For The Childbearing Year, By Susun S. Weed, Janice Novet
This is a complete herbal pharmacopoeia for dealing with every problem that might arise before, during and after pregnancy and childbirth. Simple, safe, remedies for pregnancy, childbirth, lactation, newborns. Includes herbs for fertility and birth control.
Herbal Remedies: Miscarriage Information
Herbal Remedies: Miscarriage Supplements & Products
NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER IF...
You or a family member is pregnant and experience any new or unusual symptoms such as cramps or spotting.
SYMPTOMS OF PRETERM LABOR (APPEARS BEFORE 37 WEEKS)
- More than four contractions per hour, or contractions are becoming stronger or more regular.
- Abdominal pain or pressure (may be crampy).
- Lower back pain, especially rhythmic.
- Sudden change in discharge (may become watery, mucousy or bloody).
- A rush of fluid, or regular seeping fluid from your vagina (signifies broken water).
Note: If you think anything at all is wrong, please go get checked out. Again, the earlier preterm labor is caught, the better the odds of it being stopped before a preterm birth.
Signs of infection: pain on urination, frequent urination, or a general ill feeling and fever.
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Prescription for Nutritional Healing: The A-To-Z Guide To Supplements
-- by Phyllis A. Balch, James F. Balch - 2nd Edition
Prescription for Nutritional Healing: The A-To-Z Guide To Supplements
-- by Phyllis A. Balch, James F. Balch - 4th Edition
Prescription for Herbal Healing: The A-To-Z Reference To Common Disorders
-- by Phyllis A. Balch
The Complete Guide to Natural Healing
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