Cervical Insufficiency

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.

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31 responses to “Cervical Insufficiency

  1. Thank you for sharing ur story we me!Sorry for ur losses and this blog truly brings hope and comfort to me.My family don’t understand the pain I’m feeling with my two loss they feel why keep trying when I have one living daughter. So I just keep my feelings inside and hope that my body will repair itself. Joining the TAC site I am now able to educate myself. I live in NC and I have a consultation with a doctor at DUKE who is the only doctor that performs this surgery. I’m gonna go see what he knows and still hv conversation with doctor Haney.

    • I’m glad I could help. It’s tough for other people who haven’t been through this to understand. I hope that through sharing, we can be better advocates not just for the TAC, but for grieving mothers everywhere! Feel free to ask me any questions about any of it!

  2. I just lost my twins at 17 weeks, due to IC. I thought I was going in for a routine ultrasound, then suddenly wham – “your cervix is SIGNIFICANTLY shortened, go to the hospital now!” They said it was too late for a vaginal cerclage, and gave me progesterone and bedrest. No luck, three days later I checked at home and I could feel the sac starting to come out. All-in-all we were in labor for 14 hours and then I had an emergency D&C to top it off. It’s been several weeks and I feel like everyone else has moved on, but it’s so hard! I’m trying to rejoice for all my friends and their babies, but sometimes it’s hard not to feel bitter. I’m also really interested in getting a TAC with Dr. Haney – all this research helps me feel positive about the future, but I am also SO scared to try again.

    This is turning into a long post, sorry!!! It’s just lovely to feel like I found a kindred spirit. Are you in Chicago?
    Best wishes for you and your family!
    -Stephanie

    • Stephanie, I’m so sorry for your heartache. I know it well, and it’s excruciating. Please be sure to look at my recommended grief resources, and I can’t say enough about some of the support groups on FB. If you find me on there and friend me, then I will add you to the groups – I have some that are recommended on another page: https://beyondthisdesert.wordpress.com/what-is-pprom/exploring-tac/links-to-websites/

      Know that you are incredibly blessed in that at least they know immediately that you have IC and you do not have to fight for that diagnosis! So many of us have and sadly many women lose multiple pregnancies before getting their diagnosis. 😦

      I’m in Dallas, not Chicago, but I’d fly around the world for Dr. Haney!

      XX
      Kathryn

  3. This was very informative. Thank you so much. When I conceive again my OB/GYN said he was going to refer me to a high risk team. So I am confident I will have my Rainbow baby.

    • Candace, if you get a TAC, you won’t actually even need a high risk team! The TAC eliminates cervical issues as a problem, so you will be considered a “normal” pregnancy! That’s one of the big selling points for me on TAC!
      You will also find an attitude of condescension towards the TAC among most perinatologists. I don’t understand this, but I’d hate for you to rely solely on their opinions when I know they are biased against TAC.
      Please join TAC Sisters and Abbyloopers on FB for ongoing discussions about this and keep researching and advocating for yourself!

  4. I hope you are still doing this blog. I had pprom at 34 weeks last May 2012, my baby suffered from asphyxia and died in the NICU, 17 days after that. Do you think that my case could be a mild IC? I don´t want my doctor ignores my cervix, he told me he was going to check it until 20 weeks, but I think earlier is better.

    • Miriam, I’m so incredibly sorry to hear of your little baby. I am not as well-versed in third trimester prom.
      If you can confirm IC, then the “wait and watch” approach is morally reprehensible on your doctor’s part. The problem with IC is its unpredictability – that’s why I advocate for the most aggressive approach possible: a TAC.
      In your particular case, I’d highly suggest you consult with Dr .Haney, Dr. Davis, and Dr. Sumners. Email all of them the same email and see what they respond with. I personally feel Dr. Haney has seen the most cases and can offer the clearest insight, but that’s just my opinion.
      Additionally, have you joined Abbyloopers? (The Yahoo Group AND the FB page?) TAC Sisters may offer lots of insight, too.
      I’d also encourage you to seek out Aisha’s opinion on the TAC Sister’s page.
      Please keep me posted!

  5. Thank you very much! I will write an email to the doctors, hope they have an answer. I will look for the groups! thanks again =D

  6. Kathryn, this is so helpful. I lost my baby girl a month ago, I was almost 27 weeks. It transpired I had an infection and she developed sepsis. I am completely devastated and have not been able to understand how it happened – because although my cervix had dilated, the waters were bulging and mucus plug gone, the doctors weren’t too concerned because my WATERS WERE INTACT, and I was on antibiotics to prevent infection. I now believe that the bleed I suffered 10 days prior to her delivery may have been an indication of infection, but because I was not swabbed or examined internally I will never know if this was the case. I was hospitalised and placed on bedrest but it simply wasn’t enough. This is the 2nd time this has happened to me, although my son born at 28 weeks did survive. However, because the pregnancy that followed his went full-term with no issues [although scans did show cervix funnelling] my OB decided not to consider cerclage this time. How I wished I had pushed for this now. You have a lot of knowledge, I’d be grateful for your thoughts, I’m in the UK and there seems to be far less information available here! Lisa x

    • Oh, Lisa! I’m so sorry! I’m glad I can share information that is helpful. Please come join some of the FB groups I’ve listed because there are LOADS of UK gals there who can help guide you!!!
      XX
      Kathryn

  7. I’ve had two successful cerclages after a second trimester loss of our first child and have all of my information in detail on my blog at http://angelheartsforever.blogspot.com/

    Take care xoxo

    • Melanie, I’m so thankful for your successes, though I’m sorry to read about losing Ian. 😦

      Thank you for sharing your blog, and I hope it will offer insight into anybody in our unfortunate position.

  8. Hi

    I have a question did your doctor find infection in your placenta?.

  9. I don’t remember if it was in my sons’ tissues or my placenta, but yes. However, they just classified it as chorioamnionitis, so it wasn’t specific. Dr. Haney did tell me that if no infection is found that didn’t mean one wasn’t present – it just meant they tested a tissue sample that wasn’t infected yet. Also, he said that the infection is oftentimes in the amniotic fluid, so if waters have gone, there won’t be amniotic fluid to test.

    • I would I know my babies (twins) are infected? I’m currently 28w4d on bedrest now for 4 1/2 wks. My cervix has been at a zero since I’ve been in the hospital & is open. Im taking medication for contractions & being monitored daily. I’ve had not had any bleeding. What are the signs I can look for to know if my babies may have an infection in their sac or placenta?

      • Congrats you are doing really great!!! I don’t think you would know anything other than your waters breaking but you’re far enough along that you’d be ok!!
        I’m pleased you are being monitored in the hospital. You hang in there!! The only thing you might could add would be doing some sort of vitamin C therapy like 1500-3000mg daily. It’s pretty powerful for fighting/preventing infection. Of course, check with your doctor.
        I’m assuming you’ve already had steroids given for babies lungs, but if not then make sure you are up on that.
        You are really doing superb!
        Remember before your next pregnancy that you’ll want to definitely have a TAC placed. I wouldn’t mess around with a tvc in your case at all since your cervix is at 0 now.
        Enjoy your twins when they come!!! It will be hard but oh so joyful and then the hardness just disappears! XX

  10. Thanks for your quick response, I really appreciate it. I was given the steroid shots when I got admitted. They are given me prenatal meds prescribed but I will ask my Dr. tomorrow about an extra dose of vit C. This is my first & last pregnancy so there will be no more. I’m having a girl & a boy, what more do I need? Not to mention I’m 38 now. Thank you for the supportive words.

  11. I went in for my 19week ultrasound to see the baby and to found out the gender and then they did a cervical examples and found out that my cervix was opening and funneling. The doctors immediately took me out of work and I was out on bedrest. Being that I HAD no history of this kind of thing happening because I HAD 2 pregnancies and both I carried past 40weeks, my doctor didn’t recommend a cerclage because of my history they thought progesterone suppositories was best for me. So I was taking the suppositories, my doctor couldn’t tell me why my cervix was opening. I went into preterm labor at 22 weeks and my baby did not make it, my doctor told me that one of my sacs that busted HAD a odor in it which she was pretty sure it was an infection that formed around my sac, and this is what probably caused my cervix to open. They told me that I probably don’t have a IC cervix it was just an infection that was affecting my cervix. They treated me with antibiotics and they told me that I don’t have to worry about theb infection coming back but they couldn’t guarantee me that I dont have to worry about my cervix opening up the next time i get pregnant. BUT they said it’s safer precautions we can take early on in my next pregnancy if need to be so this won’t happen again. I don’t want to experience losing another baby next time I hope that my next one I carry full term. Should I get a cerclage soon as I find out that im pregnant again just to be on the safe side? I’m scared to just wait and see what happens I don’t want to wait till the last minute, I need to be 100percent that this won’t happen again.

    • Oh, Shamika! I’m so sorry for your loss!! It’s the most devastating thing to survive.
      Obviously I disagree with your doctors. I think you have very obvious IC. You can absolutely acquire IC in subsequent pregnancies particularly if one of the previous deliveries was rather hard on the body.
      I’d encourage you to email dr. Haney for his opinion, join Abbyloopers, and post this comment exactly in Abbyloopers for other opinions.
      My personal preference is for you to have a tac places prior to pregnancy or plan on a TVCIC from Dr. Davis next pregnancy (there is now an fb group for this though I’m not a member. But Abbyloopers gals can direct you.)
      One foot in front of the other! Just keep going, Mama!!

      • Shamika quillen

        Thank you, it’s nice talking to people who understands what I’m going through. And I appreciate the feedback I will definitely look into what you said. I suppose to meet with my doctor on the 24 and I can’t wait because I have so many questions and I need reassurance that my next pregnancy will be okay.

      • I have a list of follow up questions for your ob/mfm on the menu above. I hope they help you think through some things.
        Hang in there and be gentle on yourself!!

  12. It’s so nice to communicate with ladies who have or are going through the same thing as I. A week before Christmas I was having contractions all night long. That morning I went in to see my regular OB. At the appt. I was d2 cm dilated. He referred me to a high risk doctor about 2 hours away. When my Husband and I arrived they drew my blood. The blood test gave back that I had a raging infection that caused my white blood cell count to be very high. The doctor said I was showing an infection of Chorio. An infection the attacks the amniotic sac. I was then started on a course of antibiotics through a IV. I was not a candidate for a cerclage due to the infection as that would not be safe for me as I could become septic. After 2 days of being in the hospital my membranes fully ruptured. 3 days later we lost my baby boys’ heartbeat. I was then forced to give birth at 22 weeks and 1 day. Diagnosis was Chorio as well and incompetent cervix. Solution is at 12 weeks for future pregnancies a cerclage will be placed. It just makes me so nervous that the infection came first and that I really don’t have a IC. I guess I need to have faith in my high risk OB. It’s so so scary thinking of going through this again in the future. My Husband and I have had 2 losses. One at 11 weeks and another at 22 weeks. We want to be parents so badly. We are both very healthy and people it just doesn’t seem fair that we have to go through this.

    • Holly, I’m so sorry to read of your loss. You most definitely have IC! Your cervix opening up is what allowed the bacteria to ascend into the uterus where it became an infection. Even good vaginal bacteria is bad when it gets into the uterus. I would urge you to please please please consider a TAC instead of waiting and getting the vaginal cerclage the doctor is recommending. A vaginal cerclage could work just fine, but a lot of times it does not. I see failure after failure and more losses from those vaginal cerclages. Please join Abbyloopers.org and Abbyloopers on FB to find out more after you’ve read all of my site!

  13. Love some advice. After infertility of 18 months I found out I had a complete uterine septum, which was preventing sperm from ever reaching an egg. So had surgery to correct this and I know the septum went through my cervix, even into vagina slightly. 3 months after this surgery my husband and I instantly got pregnant, they did ultrasound scans to checkj cervix and never had any issues, carried him to 40 weeks, vaginal delivery of a 10 pound baby boy (damaged cervix with delivery???) . So 9 months after he was born I again became pregnant. I am 28 weeks today but this pregnancy has been so much more worrisome. My cervix began shortening at 20 or 22 weeks. Now I am down to less than a cm, 70% effaced, softening, and also dialated to a 1 (was dialated to 1 3 weeks ago but just at the end, whereas now my mfm Dr said its open all the way through). I have been having menstral like cramping on and off for weeks. On vaginal progesterone and modified bed rest, but I’m doing strict bedrest, why take any chances. I know the baby is past the really premature point however there is still plenty of risk involved with any preemie and I am so discouraged I may not make it much more to give her the best healthy start. So my question is, considering I haven’t ever lost a baby do you think I would qualify for a tac for future pregnancies? Frankly I hate the thought of having to risk going through this constant worry, agonizing over every week of pregnancy. I don’t even want to try the TVC because I’ve read they aren’t that high of success rates and I want to be aggressive with a high likelihood of term. Would they even consider me though since my history is much less severe at this point, with no losses and no attempts of tvc first? I don’t want to risk another preemie if I can help it and I am still terrified with where I am now. I’ve read nicu can be excruciating of course.

    • Hi, Emily. I’m so sorry for your difficulty. I’m glad you had a term pregnancy last time and have made it so far this time!
      I do think you are a fine candidate for a TAC if you go to the right doctor. They need to recognize all the things you listed as showing IC rather than isolating them and then saying preterm labor. I’m curious if you’ve had an FFN test? If that came back negative in the face of your cervical changes, then that should make even other doctors know for sure it’s IC.
      Email Dr. Haney today and get his thoughts for the future!
      Also, go on over to my newest page (Crisis – it’s at the top of the IC menu) and look at some of the things I recommend pursuing.
      XX

  14. Stephanie Appel

    I’m not sure where you are located, but I would email Dr. Haney for an online consult at the very least… my (NOT A DOCTOR) diagnosis would be yes, you do have IC, so yes, a TAC is necessary for any future pregnancies. Big hugs and good luck – 28 weeks is great compared to what it could be, but I totally feel your agony. Praying for your whole family!

  15. Thank you so much for the replies, even that gives me hope now! I am in Michigan near Detroit, off hand do you know of any good drs local to here that do tac? And yes, my last 2 or 3 FFN (losing track of how many I’ve had) have all been negative. But I just had one done yesterday, results still aren’t in today yet…argh! Anticipating maybe apositive this time since all the changes to cervix. Sensing a struggle ahead for qualifying for a tac. Its a real shame this isn’t a more mainstream treatment that more drs specialize in.

  16. Honestly the thought of having this done with a high chance of carrying to term is such a refreshing happy thought. I miss the joy of pregnancy that I had with my first healthy pregnancy compared with how filled with worry, anxiety, tears, and coping with bedrest and a likely preemie. Still thankful for the baby at 28 weeks but afraid our our road ahead. My heart goes out to all you wonderful moms who have had such difficult roads with losses, hopefully we can all push for some aggressive treatment and have positive outcomes!

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