The Silent Killer: Cervical Insufficiency
I am the face of cervical insufficiency. After years of infertility, my husband and I successfully conceived twin boys with IVF/icsi. One Sunday afternoon after intercourse, I noticed a very strange, thick discharge but thought I’d ask the doctor on Wednesday. On Monday all day, I noticed that I was extremely wet (later learned that I was leaking amniotic fluid). Monday night, I began spotting. Early Tuesday morning, I woke to a gush of fluid. While the ER and my ob both felt I had possibly just had a bladder accident, the high-tech equipment at the MFM’s office proved otherwise: Baby A’s fluid was completely gone.
They sent me home on bed rest telling me there was really nothing to do but to monitor my temperature and if it got above 100, then to return to the hospital. The MFM did mention the possibility of incompetent cervix, but I was only focused on the horror of the impending loss.
On Wednesday, I began cramping something awful. This turned into full blown contractions and I had to go to L&D. They gave me iv pain medicine, though this really didn’t help. After a couple of hours, I got up to use the bathroom and it was there that Isaac simply fell out of me.
After a trip to the OR, my OB said there was possibly infection inside of me, so she could not sew me up (cerclage). She put in a catheter so I could stay in bed the rest of the night.
Again, later that night, I awoke to a gush. I called the nurse because I thought the catheter had fallen out. Sadly, it was Baby B’s water going. I was taken into the OR again, but before we arrived the short roll down the hallway, Samuel had already fallen out of me, as well.
My doctors all said that my pprom was a “fluke” due to carrying twins. They said that I should not carry twins again. My pathology report showed infection, but my boys were perfect. My doctor said that asking which came first, pprom or infection, was a chicken/egg question. One offered to put in a vaginal cerclage in the future, the other thought a “wait-and-see” approach would be best. Even in the discussion of a future vaginal cerclage, nobody mentioned IC.
This document is not meant to serve as any sort of medical advice. I AM NOT A DOCTOR. (Read Dr. Haney’s (a medical doctor) responses to FAQs on IC on his page at the University of Chicago.) Nor is this blog entry a document exhausting all the knowledge available on the subject of IC. I simply mean for this document to offer you some very basic information on cervical insufficiency/incompetent cervix so that you can further explore this in the given resources and with your medical caretakers.
What is IC?
An incompetent cervix is when the cervix opens prematurely without labor or contractions (but just because you had contractions, don’t cross this off your list yet…more on that below). This can cause major problems including, but not limited to, pprom and fetal demise. This usually presents in the second trimester, though can also happen at the beginning of the third trimester. The cervix opens and closes at will (can change even within five minutes) under the increasing weight of baby, often allowing infection in or the amniotic sac out.
What about infection?
During pregnancy, the cervix has a very thick column of mucus called the mucus or cervical plug. This is a closed tight barrier that does not allow infection up. Many of the bacterium that we’ve found in our postmortem are not problematic in the vagina, but play havoc in the uterus. You must demand an answer from your doctor, though, on how infection got past your cervical plug. Many doctors like to shrug or say they don’t know which came first: infection or pprom. Either way, bacterium somehow got past the cervical plug OR the amniotic sac bulged through the cervix and picked up vaginal bacteria. Both of these scenarios demonstrate that the cervix was NOT tight and closed – it did not do its job.
How is IC diagnosed?
Sadly, there is no test for IC. Currently, the standard of care in the United States is for doctors to not consider IC until after two or more second trimester losses.
It seems there are three possible responses for future pregnancies after a pprom loss or premature baby:
a) the “wait-and-see” approach: doctors are not willing to blame the cervix and will offer more frequent cervical scans during the next pregnancy. If they note cervical change, then they may intervene with a vaginal cerclage,
b) the “I don’t think it was IC, but I will put in a vaginal cerclage at 12-14 weeks just in case” approach, or
c) the “it is definitely IC and let’s put in a cerclage” approach – and doctors discuss with you the various types of cerclages available so you can make an informed decision.
See treatment options/opinions for further information.
But, wait, if there is no test for IC, who could say it’s definitely IC after one loss? There is a handful (or two handsful) of doctors around the world who are experts in IC. They understand the nuances of what the pregnancy, labor, and delivery look like for an IC patient. In the United States, the top three doctors are Dr. Arthur Haney (University of Chicago), Dr. James Sumners (St. Vincent’s Hospital, Indianapolis, IN), and Dr. George Davis (New Jersey/Philadelphia). [There ARE others! Check the Abbyloopers Database and post in the FB groups to find more!]
All three of the aforementioned doctors currently offer free email and consultations with patients to discuss their history and potential IC diagnosis.
But, I had contractions or I held my baby for x weeks after pprom
If you read my story above, you know that I also had contractions. The way Dr. Haney explained it to me was that yes, my uterus was working, but it was trying to push out infection, not babies. He said that at 16 weeks (my pprom date), the something-or-other receptor sites were not developed and it would be impossible to even induce labor. What I did NOT have to do was actually labor to push out my babies like I see on television. They simply slipped out because my cervix opened up…and not for the first time. My cervix initially opened up and I lost part of my mucus plug – then infection went up. Whether infection or funneling caused my pprom, I don’t know. But both infection and funneling are caused by IC. (Funneling is when the top of the cervix starts to open up and the baby slips further down into the cervix. This causes pressure on the amniotic sac, as well as puts the sac in closer proximity to the vagina and bacteria.)
Some women or doctors discount IC as the culprit because there was a significant time period between pprom and delivery. The later the pprom occurs, the greater the latency period usually is. The cervix is still demonstrating its inability to stay tightly closed and immovable, regardless of the time frame between pprom and delivery.
Causes of IC
Previous surgical surgeries (such as a LEEP or CONE) or traumatic births can damage the cervix. However, in some cases, there is no known cause. It is interesting to note, though, that a high correlation exists between women with IC and uterine abnormalities (uterine septum, bicorniate uterus, etc.). Also, an exposure to DES is linked with IC.
Dr. Sumners has also written about acquired IC on his FB page. Perhaps you had previous successful pregnancies and then experienced a 2nd tri loss. You would think that since your cervix was fine previously, it is fine now, and you discounted IC as the problem. You should reconsider.
Treatment for IC
Since the cervix will not stay closed, treatment is to close it via intervention. This is referred to as a cerclage. There are many types of cerclages, all varying by method and height of placement. Please follow the menu to read further about cerclages.