Incompetent Cervix: Information/Advice/Experiences?
March 16, 2009 1:58 PM   Subscribe

I have an incompetent cervix, and I have lost two babies because of it. My husband and I are now trying to decide if we should try to get pregnant again. Help me find treatment options and good sources for second opinions.

I have been pregnant twice, and I lost both babies due to an incompetent cervix.

My first loss was a shock—an ultrasound during my 17th week showed that my cervix was opening. A uterine contraction monitor then showed that I was having painless contractions. A perinatologist put me on bedrest, but I delivered the baby a week later.

My OBGYN and I thought that we had a plan for the second pregnancy: she would put a transvaginal cerclage (a stitch to hold the cervix closed) in during the 12th week of the pregnancy. Once I was pregnant again, however, the perinatologists did not want to place the cerclage without proof that the cervix was the problem. During the 15th week of the pregnancy, an ultrasound showed that my cervix was opening, so the perinatologists gave my OBGYN the OK to perform the cerclage. I spent the next two weeks on bedrest. The cervix opened anyway, and I delivered at 17 weeks.

The perinatologists tell me that they they’ll know what to do during a future pregnancy to prevent another loss: place a transvaginal cerclage at 12 weeks. I am skeptical. My husband and I would like to have a healthy, living child, but I need to be sure that this is a sound plan before I risk another baby’s life.

I’d like to get a second (and maybe even a third or fourth) opinion on my doctors’ plan. U.S. News and World Report tells me that Brigham and Women’s Hospital in Boston and Johns Hopkins in Baltimore might be good places to start. If you have other recommendations, I’d be glad to hear them. We're willing to travel as necessary.

I’ve read up on transvaginal cerclage and abdominal cerclage. So far, I’ve been relying on Gabbe’s Obstetrics: Normal and Problem Pregnancies for most of my information on this topic. I could use leads on any other good sources of information about these procedures and their efficacy.

Finally, it would be extremely helpful to hear about the experiences of others who have been diagnosed with an incompetent cervix. Aside from the old posts I’ve read on My Cerclage, I don’t know how anyone else has dealt with this problem firsthand.

Thank you in advance for your help.
posted by TEA to Health & Fitness (10 answers total) 1 user marked this as a favorite
Best answer: Many obstetricians (including me) think that a 12 week prophylactic transvaginal cerclage is more effective than a 15 week transvaginal cerclage after there is already evidence of cervical funnelling. It is also likely that an abdominal cerclage is more effective than a transvaginal cerclage. My personal choice based on the current evidence would be to go for abdominal cerclage. Both these choices will probably be more clear once the results of the MAVRIC trial are available.

Your experience is fortunately quite rare, and anecdotes from internet strangers probably aren't going to help. Both elective transvaginal cerclages and abdominal cerclages can be effective for women with previous mid-trimester losses. In the absence of good current evidence from randomised trials, you need to find an OBGYN who can perform abdominal cerclage, and then discuss why and whether they feel it offers advantages over transvaginal cerclage.

Good luck!
posted by roofus at 2:29 PM on March 16, 2009 [6 favorites]

I've not gone through it myself, but my best friend, who has an incompetent cervix (due to deformities from being a DES daughter) has two lovely children who made it to full-term thanks to a transvaginal cerclage. So there is hope. Good luck with however you choose to proceed.
posted by judith at 2:32 PM on March 16, 2009

I have a friend who has a wonderful daughter, after several miscarriages, due to a 12-week cerclage and bed rest. I will point her over here and see if she's willing to write about her experience. But meanwhile, just wanted to add another point saying that it is at least in some circumstances a viable and successful plan. Whether your circumstance is one of those, of course, I don't know enough to say as I am in no way, shape, or form a medical professional.
posted by Stacey at 2:50 PM on March 16, 2009

I may sound like a broken record, but once again, I say There are a couple of threads there that you might be interested in. One on cerclage that I just checked out and though there hasn't been a whole lot of activity since last fall, there are a number of posts from people I know are still active there that you could ask about. Though there might not a huge number of people with your experience there, I've found that the women who hang out there give really great advice. The message boards on the wide range of pregnancy and infertility problems are very active. I'm sorry you're going through this and I hope you can get some good answers and have a successful pregnancy.
posted by otherwordlyglow at 3:16 PM on March 16, 2009

Best answer: IANAD, but I was tentatively diagnosed with an incompetent/shortened cervix at ~week 20 of my current pregnancy, and did a TON of reading about it thereafter on PubMed and in various medical journals. Basically, my sense of the literature was that our understanding of how the cervix works in pregnancy, and in particular what causes it to open, is in a state of flux. Although lots of doctors still adhere to the old mechanical model (=pressure from the growing fetus just sort of pushes the cervix open, so bedrest and cerclage should work to fix a weaker-than-average cervix?), new research suggests that there's a lot of biochemical signalling that goes on to direct the behavior of the cervix, and that a variety of invisible factors, like subclinical infections, inflammation, etc., may have a role in causing a normal cervix to open prematurely, regardless of its inherent structural soundness.

In practice, this seems to mean that "incompetent cervix" gets used as an umbrella term for any cervix that opens early, when there could actually be several different (physical or biochemical or environmental) causes at work in different women. Obviously, your MFM/perinatologist would know best, but based on what I've seen, you might at least look into (1) screening/treatment for persistent subclinical uterine and vaginal infections (which can set off inflammatory pathways that thin the cervix, and which often have no detectable symptoms), and (2) the use of progesterone and progesterone precursors, which has been shown to have some efficacy in prolonging pregnancy in women who've previously experienced pregnancy losses due to incompetent cervix. Anecdotally, I know one older woman who was found to have a uterine infection after several early losses due to IC, and who carried her only term pregancy while on antibiotic treatment.

At the very least, I'd make sure the docs are considering the cervix in more than simply mechanical terms, and are exploring other options besides or in addition to the standard cerclage/bedrest (the latter of which, btw, is of VERY debated efficacy). There seems to be a lot of difference in practice from doctor to doctor, and also between MFMs and OB/GYNs, so definitely consider second and third opinions, as well.

For research on the subject, PubMed is awesome as a first step (just search "incompetent cervix pregnancy" for a start), but some additional general resources that might be helpful are:
--Incompetent Cervix, at Early Path Medical Consultation Svcs (useful overview)
--Compendium on Preterm Birth, from March of Dimes (powerpoint; slightly more in-depth overview, plus check out the notes for a bunch of helpful medical references)
--The monograph Preterm Birth: Causes, Consequences and Prevention, Behrman RE, Stith Butler A, eds., The National Academies Press, 2006-- I never did get hold of this, but it looked as though it'd be super useful, and the MoD presentation cites it several times.

For more specific info, I also have a bunch of .pdfs of recent journal articles that I'd be happy to pass along; MeFimail me if you'd like any copies. Good luck! It sounds as though you've had a really difficult experience so far, and I hope you find some resolution.
posted by Bardolph at 5:02 PM on March 16, 2009 [4 favorites]

I also came in to suggest - everything otherwordlyglow says, plus it's the only place I know of to discuss fertility issues without angel tickers and babydust all over the place.
posted by DarlingBri at 5:36 PM on March 16, 2009

Because I'd had several miscarriages, I had cerclage in a third-world country in the mid 80's at about the twelfth week. I wasn't told to take bed rest so carried on normally. It was painful when the baby's weight increased, and when I delivered at 32 weeks was told that the cerclage was cutting through my cervix and if the pregnancy had gone on longer I would most likely have had a ruptured uterus. I had a wonderful daughter, however, who is now in her 20's, so it was worth it all.

But I wasn't willing to go through it again. My husband wasn't supportive and didn't like the doctor who performed the cerclage so for several months I had no doctor. So when I got pregnant again I had an abortion--and the doctor who performed it said my cervix was fully dilated at 12 weeks, so another miscarriage was a given.

If you have a properly managed pregnancy here in the US or in any country where health care is good, I believe you will have a good outcome. Just rest as much as possible and monitor the situation, as I'm sure your doctors will do.

And IANAD. I wish you the best!
posted by gg at 7:19 PM on March 16, 2009

A friend of mine had multiple miscarriages and lost one baby who came too early when her water broke (I can't remember how many weeks), because of an incompetent cervix.

She had a cerclage and bed rest for her next pregnancy. She was in the hospital on bed rest for about a month or two, then home on bed rest. Her only activity was a short swim in the pool once or twice a day. She came off bed rest at the end and felt pretty lousy, but her pregnancy was full term and her child was just fine (still is).
posted by bluedaisy at 12:58 AM on March 17, 2009

I have a friend with this problem and she got a circlage after she had amnio, and is now at 34 weeks so is practically full term. We share an obstetrician -- Dr. Esfander Nawab at Holy Cross Hospital in Maryland, and I just delivered a healthy little girl at the beginning of March. He is very well regarded and is especially good with problem pregnancies. He retakes the medical boards every year just to make sure that he is current with all new developments, and I think has been on tv for being one of the only doctors who will still deliver a breach baby vaginally (where many OBs now do not have the experience or know how to do so and would simply perform a caesarian).

Dr. Esfand Nawab
5411 W. Cedar Lane, Suite #108-A
Bethesda, MD 10814
(301) 530-4001

memail me if you have questions or could use other info. Not sure you really would want to come all the way out to MD for this, but for what it's worth our experiences with this doctor have been really wonderful. Good luck to you, and all the best.
posted by onlyconnect at 8:00 AM on March 17, 2009

Response by poster: Thank you all very, very much for this information. I have a lot of research to do, and the information and encouragement that you've given me here will help a great deal.
posted by TEA at 3:01 PM on March 23, 2009

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