Management of Recurrent Pregnancy Loss From Cervical Insufficiency: An Overview

Introduction:

The loss of a desired pregnancy has the potential to cause significant physical and mental health challenges to women. While there are several causes of pregnancy loss, a major cause of pregnancy loss, especially after three months of pregnancy, is cervical insufficiency, also called cervical incompetence. Cervical insufficiency is the inability of the cervix to remain closed and support pregnancy to term, resulting in either a miscarriage (loss of a pregnancy before 20 weeks of gestation) or preterm labor (labor that begins before 37 weeks of pregnancy). It is a common cause of recurrent second-trimester miscarriage and presents with painless cervical dilation, leading to rupture of fetal membranes and subsequent expulsion of the fetus. The timely insertion of cervical cerclage (a stitch placed through the vagina to tie the cervix and prevent it from opening prematurely during pregnancy) significantly increases the chances of pregnancy progressing to term and therefore increases the chances of the child surviving.

What Are the Causes of Cervical Insufficiency?

The cause of this weakness in the cervix may be congenital as in the cases of women with collagen vascular disease (conditions that cause long-term inflammation). Other causes include forceful dilation of the cervix during dilatation and curettage, uterine instrumentation procedures, and some diagnostic or therapeutic procedures on the cervix, such as cone biopsy (a procedure that involves removing a sample of cervical tissue for analysis). Also, a previous history of miscarriage, especially after the second trimester, and a cervical tear that was poorly repaired increase the risk of cervical insufficiency.

What Are the Symptoms of Cervical Insufficiency?

People with cervical insufficiency have a miscarriage of their pregnancy after three months due to weakness of the cervix, which is the mouth of the uterus. It could occur at four, five, six, seven, or eight months. The classical presentation involves a history of standing or walking and suddenly noticing a gush of water from the vagina, followed by pain, which leads to a miscarriage. This is a classical presentation of cervical incompetence, as cervical insufficiency presents with painless dilatation of the cervix.

How Is Cervical Insufficiency Diagnosed?

A single classical history, as above, or a history of significant trauma to the cervix is an indication for the client to be monitored in subsequent pregnancies using a transvaginal ultrasound scan (an imaging test that produces images of the cervix and other pelvic structures using sound waves) to measure the length of the cervix. If the length of the cervix is less than 25 millimeters (0.984 inches), then a diagnosis of cervical insufficiency can be made. However, if there are two instances of classical history, it is enough to make a diagnosis of cervical insufficiency and the client should be managed accordingly.

What Are the Management Options for Cervical Insufficiency?

Cervical insufficiency is a manageable condition, and it is possible to carry a pregnancy to term and have the number of babies one desires. For individuals with a history of cervical insufficiency, care for the pregnancy should be scheduled as early as pregnancy is discovered or at least before ten weeks of pregnancy. Measures would be instituted to reduce the risk of miscarriage, like administering antibiotics to reduce the risk of local cervicitis (inflammation of the cervix) and vaginitis (inflammation of the vagina) that can cause miscarriage and increasing fluid intake to 101.44 to 135.25 fluid ounces a day depending on the individual's condition. Additionally, some investigations are done to confirm the viability of the pregnancy and rule out the presence of congenital anomalies before the placement of a cervical cerclage.

Thereafter, plan for a cervical cerclage, a stitch applied through the vagina to tie the mouth of the uterus (the cervix). This is usually done between 14 to 16 weeks of pregnancy or two weeks earlier than the age of the last miscarriage. This would prevent the premature opening of the cervix and, therefore, prevent miscarriage. With this intervention, there is a high likelihood of carrying the pregnancy to term, at which point the stitch would be removed to allow for delivery.

Sometimes cervical stitch is combined with vaginal progesterone support and bed rest, especially for people that have had a previous failed cervical cerclage. Most of the time, this results in them carrying their pregnancy to term.

The commonly done cervical cerclage is the McDonald cervical cerclage (a suture wrapped around the cervix in a purse-string pattern and knotted anteriorly.) which is placed through the vagina. Occasionally, modified Shirodkar cerclage is inserted, especially in women with very short cervical lengths. For women who have had a failed cervical cerclage of a severely short cervix, a transabdominal cerclage is used in such cases. This transabdominal cerclage is inserted either before pregnancy or during pregnancy before 12 weeks gestational age. Usually, it increases the chances of carrying the pregnancy to term. Clients with transabdominal cerclage are usually delivered via an elective cesarean section.

What Are the Post-Cervical Cerclage Insertion Care Instructions?

Patients with cervical cerclage in situ should:

1. Avoid Heavy Lifting: Refrain from heavy lifting or strenuous physical activities that could strain the abdomen or potentially impact the cervix.

2. Avoid Sexual Intercourse: Typically, sexual intercourse is restricted after cervical cerclage to reduce the risk of infection or inadvertently causing trauma to the cervix. This restriction should be for at least six weeks, after which the client can gradually resume sexual intercourse provided there are no other contraindications.

3. Watch Out for Unusual Symptoms: If experiencing any unusual symptoms such as increased vaginal discharge, pelvic pressures, or contractions, do not ignore them. Contact the healthcare provider immediately.

4. Keep to Follow-up Appointments: Regular monitoring is essential after cervical cerclage. Missing appointments could mean missing early signs of complications.

5. Avoid Stress: Minimize stress as much as possible. Stress can have physical effects on the body and potentially impact pregnancy outcomes.

6. Keep Self Well Hydrated: Dehydration affects the function of the body and could induce contractions. So, the clients are advised to keep themselves well hydrated, to minimize the risk of having a miscarriage or failed cerclage.

When Should a Cervical Cerclage Be Removed?

The aim of placing a cervical cerclage is to increase the chances of pregnancy reaching term. Therefore, cervical cerclage is traditionally removed at 37 weeks of pregnancy, so that the client can go into spontaneous labor provided there are no contraindications to pregnancy. Some other indications to remove cervical cerclage earlier than term include:

1. Preterm Labor: If preterm labor begins despite the cerclage, the cerclage may need to be removed to allow for cervical dilation and facilitate appropriate management of labor. If this is not done, it could cause a significant tear in the cervix and further worsen the prognosis of subsequent cerclage insertion.

2. Premature Rupture of Membranes (PROM): If there is premature rupture of membranes and the pregnancy is viable, the cerclage may need to be removed to avoid complications related to infection or to allow for appropriate management of labor.

3. Cervical Shortening or Dilation: If there are signs of cervical shortening or dilation that indicate the cerclage is no longer effective in supporting the cervix, it may need to be removed.

4. Fetal Compromise: In cases where there is fetal compromise or signs of intrauterine growth restriction (IUGR), the cerclage may be removed to facilitate better monitoring and management of the pregnancy.

5. Infection: If there is evidence of infection around the cerclage site or if there is concern about infection risk, removal may be necessary to prevent further complications.

6. Other Maternal or Fetal Complications: Occasionally, other maternal or fetal complications may necessitate removal of the cerclage to allow for appropriate management of the pregnancy.

Conclusion

Recurrent miscarriage from cervical incompetence is treatable. So, do not lose hope; it is still possible to carry a pregnancy to term and deliver a live baby with appropriate and timely placement of a cervical cerclage. With proper medical care and monitoring, many individuals successfully navigate this challenge. Furthermore, ongoing advances in treatment options and techniques continue to improve outcomes for those affected by cervical insufficiency.