Definition

Cervical incompetence or cervical insufficiency occurs when the cervical tissue, or the cervix, is weak during pregnancy. Even without uterine contractions to expel the fetus, an open cervix can cause the baby to be born too early (before 37 weeks of pregnancy). Because the baby's organs are not fully developed, this can pose health risks to a premature baby.

In the female reproductive system, the cervix is the lower part of the uterus that opens into the vagina. Generally, the cervix is closed before pregnancy. In pregnant women, as the pregnancy progresses, the cervix undergoes changes as part of the preparation for childbirth. The cervix will soften, shorten, and open wider in the third trimester to allow the baby to pass through the vagina.

In cervical incompetence, the cervix opens too early before the expected time of delivery. The cervix cannot hold the fetus in the uterus, leading to premature birth. Cervical incompetence occurs in about 1 in 100 pregnancies. Almost 25% of miscarriages in the second trimester are due to cervical incompetence.

If you are at risk of cervical incompetence, your doctor may recommend preventive treatments to avoid pregnancy complications.

Causes

The exact cause of cervical incompetence is still unknown. Cervical incompetence usually occurs in the middle of the second trimester or early third trimester, depending on its severity. It can occur due to:

• Congenital abnormalities during fetal development
• Certain syndromes are due to collagen deficiency, impairing the cervix's function
• Injury to the cervix during difficult labor or from surgical procedures
• Infection or inflammation of the cervix
• A shorter than normal cervical length

Risk Factor

Although the exact cause of cervical incompetence is not known, several factors are believed to increase the risk, including:

• Black women are at a higher risk of cervical incompetence
• A history of injury or surgical procedures on the cervix
• Exposure to DES (diethylstilbestrol), a synthetic form of estrogen, before delivery
• Previous premature birth or second-trimester miscarriage
• Abnormal shape of the uterus or cervix
• Multiple pregnancy

Symptoms

Cervical incompetence may not show symptoms early in pregnancy. Due to the lack of symptoms, healthcare providers will generally review your medical history to determine if you are at risk of cervical incompetence. However, you should consult a doctor if you experience the following symptoms in the second trimester (between weeks 14-20) of pregnancy:

• Discomfort or a feeling of pressure in the pelvis
• Lower back pain that was not previously experienced
• Abdominal cramps
• Light vaginal spotting or bleeding
• Changes in the color or increase in the volume of vaginal discharge
• A history of second-trimester miscarriage

Diagnosis

Management

The goal of treating cervical incompetence is to help you remain pregnant for as long as possible. The best treatment option is determined based on your condition and medical history.

Cervical Cerclage

This procedure is one way to prevent premature delivery. The cervix will be stitched in several places around weeks 12–14 of pregnancy. The stitches are then removed around weeks 36-38 of pregnancy to allow for a normal delivery. This procedure may be recommended if you have a history of second-trimester miscarriage and have previously undergone cervical cerclage.

For women at risk of cervical incompetence, the doctor may monitor the length of your cervix with an ultrasound until the 24th week of pregnancy.

Cervical cerclage is not recommended if:

• You are currently pregnant with twins or more.
• The cervix has already dilated to 4 cm.
• The membranes have ruptured.

Progesterone Supplements

You may be given progesterone supplements at the beginning of the second trimester if you are at risk of cervical incompetence.

Total Bed Rest

You may be advised to have complete bed rest during your pregnancy. However, some studies suggest that bed rest and activity restrictions are not effective in managing cervical incompetence.

Complications

Cervical incompetence can lead to complications such as miscarriage or premature birth. In rare cases, complications may include:

• Uterine rupture or a tear in the uterus that mostly occurs during labor
• Internal bleeding in the mother
• Bladder injury
• Tearing of the cervix
• Infection

Prevention

To prevent complications from cervical incompetence, you can have regular prenatal check-ups to monitor your and your baby's health. Inform your doctor about any complaints, pregnancy history, and concerns you have.

If you are planning to become pregnant, you can increase your intake of folic acid, calcium, and iron before pregnancy. Keep your weight within a healthy range. Avoid smoking, alcohol, and drugs. Consult your doctor about the medications and supplements you should take.

When to See a Doctor?

Contact your doctor immediately if you experience symptoms of bleeding, abdominal contractions, or lower back pain in the second trimester. It is difficult for healthcare providers to diagnose this condition when a patient does not show symptoms. Therefore, make sure to discuss your medical history and any factors that may increase your risk of cervical incompetence during prenatal check-ups.

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