Rebecca Evans, a journalist in the UK, recently wrote a moving story about the loss of her baby due to an incompetent cervix. Just six weeks into her pregnancy, Rebecca started to bleed and was told she had a large, benign fibroid tumor, and that her baby had implanted in her fallopian tube, a condition known as an ectopic pregnancy. Within weeks, Rebecca was relieved to learn that the physicians had been wrong and that she was fine. She was elated when she heard the baby’s heartbeat on the Doppler ultrasound.
During the following months, however, Rebecca continued to suffer from heavy bleeding and pain. She went to the hospital multiple times, and each time, she was sent home after a quick scan showed her baby’s heart was beating. None of the physicians seemed concerned about her pain or bleeding, even though both are signs of an incompetent cervix. Furthermore, the procedure used to determine that her tumor was benign may have put her at risk for having an incompetent cervix.
Rebecca was anxious and sought private medical advice. The private clinician told her she had a short cervix, which meant that her body was getting ready to go into labor months before her due date. She immediately had a stitch placed in her cervix, also known as a cervical cerclage, in order to prevent premature birth.
Due to diagnostic delays and dozens of ineffectual appointments, Rebecca was at week 18 of her pregnancy when she received the cerclage. The procedure came devastatingly late; Rebecca learned that she should have gotten the cerclage within the first 10 weeks of gestation for it to be most effective against premature labor. The private clinician who diagnosed her expressed horror that she hadn’t gotten the cerclage sooner.
Rebecca went into labor at 22 weeks and lost her baby.
Understanding the risks of cervical incompetence
According to the Mayo Clinic, an incompetent cervix causes as many as 20 – 25% of miscarriages in the second trimester. An incompetent (or insufficient cervix) is a medical condition that occurs when weak cervical tissue (the tissue at the lower part of the uterus) causes or contributes to a miscarriage or premature birth. Premature birth puts the baby at risk for a number of birth injuries such as cerebral palsy, intellectual and developmental delays, infection, lung problems and overventilation injuries, and intracranial hemorrhages (brain bleeds).
Before pregnancy, the cervix is normally closed and rigid. As pregnancy progresses, the cervix gradually softens. It decreases in length (effaces) and opens (dilates) in response to contractions. When a woman has an incompetent cervix, the growing pressure in the uterus causes the cervix to open too soon. This results in the membranes bulging through the opening and eventually rupturing, often before the baby can survive outside the uterus. Sadly, labor often is detected when it is far too advanced to stop the process.
Incompetent cervix treatments
If a woman has a history of early premature birth or other risk factors for cervical incompetence, the physician may use transvaginal ultrasounds to begin monitoring the length of her cervix. If her cervix begins to open or becomes shorter than a certain length, the physician may recommend a cervical cerclage.
Cerclage helps reinforce the cervical muscle in order to help the cervix remain closed under the weight of the baby. If a woman is 24 weeks or less pregnant, the cervix is stitched closed with strong sutures. Cerclages are usually performed between weeks 14 and 16 of the pregnancy and can be performed before week 14 as a prophylactic measure.
An additional treatment for an incompetent cervix is the hormone progesterone. When given vaginally, progesterone helps prevent preterm birth in women at risk of premature delivery due to a short cervix.
Incompetent cervix risk factors
Anything that can cause cervical weakness is a risk factor for cervical incompetence. Risk factors include:
- Diagnosis of cervical incompetence in a previous pregnancy
- Previous preterm premature rupture of membranes (PROM)
- A biopsy of the cervix used to remove pre-cancerous cells or for diagnostic purposes (cone biopsy/cervical conization)
- Trauma from a previous childbirth during which the cervix was torn
- Repeated or late-term abortion
- Uterine abnormalities and anomalies
- Exposure to the drug diethylstilbestrol (DES)
- D & C procedures
Causes of incompetent cervix
There are many factors that can cause an incompetent cervix. Causes of an incompetent cervix can include the following:
- Obstetric trauma. If a woman has experienced a cervical tear during a previous labor and delivery, she 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.
Signs and symptoms of cervical incompetence
If a woman has an incompetent cervix, she might not experience any signs or symptoms as the cervix begins to open during early pregnancy. When the cervix reaches 4 cm or more, active uterine contractions or rupture of membranes may occur.
Signs and symptoms of a weak or incompetent cervix include:
- A sensation of pelvic pressure
- A backache
- Mild abdominal cramps
- A change in vaginal discharge
- Light vaginal bleeding
Diagnosing an incompetent cervix
If any of the risk factors for an incompetent cervix are present, the physician should review the woman’s history and perform a physical exam and ultrasound tests to determine the length of the cervix. Methods for diagnosing an incompetent cervix include the following:
- Transvaginal ultrasound. If the fetal membranes aren’t in the woman’s cervical canal or vagina, the physician will use a transvaginal ultrasound to evaluate the length of the cervix, determine how much the cervix has dilated, and examine the fetal membranes. In a compromised cervix, the length may be shortened.
- Physical exam. A manual pelvic exam of the cervix during the second or third trimester can reveal the partial opening of the cervix (dilation) with shortening and thinning of the vaginal part of the cervix (effacement), which would indicate cervical structural weakness.
Failure to recognize and treat incompetent cervix is negligence that can have devastating consequences
Rebecca had signs of an incompetent cervix, as well as at least one risk factor. Cerclages may be performed before 14 weeks of pregnancy. Had physicians given Rebecca a cerclage weeks earlier, labor may not have occurred so early in her pregnancy, and her baby may have survived.
It is crucial for medical professionals to diagnose an incompetent cervix in a timely fashion and treat it appropriately. If there are any risk factors or signs of cervical incompetence, the physician should take all necessary steps to treat the incompetence and prevent premature birth. It is negligence when physicians fail to properly monitor and test a pregnant woman and treat her incompetent cervix. When this negligence results in death or injury to the baby, it is medical malpractice.
If your child was born prematurely and suffered an injury or injuries, a review of your medical records can determine whether negligence played a role in causing damage. The birth injury attorneys at ABC Law Centers (Reiter & Walsh, P.C.) can help.
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