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Cervical Insufficiency: why is it important to diagnose and manage cervical insufficiency during pregnancy?

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    This blog describes cervical insufficiency; considers clinical guidelines for how it should be managed during pregnancy; and the complications that can arise when it is not properly managed.

    By Abigail Ringer

Cervical insufficiency describes the inability of the cervix of the uterus to retain an unborn baby during the second trimester of pregnancy. If left untreated, the consequences can be very serious, as the baby may be born before it is mature enough to survive.

What is cervical insufficiency?

The cervix is the lower end of the uterus (womb), where the uterus meets the vagina. During pregnancy, the cervix should remain closed until the time for the baby to be born. The term cervical insufficiency or cervical incompetence is used to describe the situation whereby the cervix begins to widen long before it is meant to and in the absence of contractions or other signs of labour.

According to the most recent guidelines for the management of cervical insufficiency, prepared by the American College of Obstetricians and Gynaecologists, cervical incompetence typically occurs before 24 weeks gestation, before the baby is mature enough to survive. Therefore mismanagement of cervical incompetence can result in the death of the baby.

How should cervical insufficiency be managed?

Both British and American guidelines for the management of cervical insufficiency make recommendations for the insertion of a cervical stitch (also known as cervical cerclage) as treatment for cervical insufficiency. A cerclage may be inserted as a preventative measure when there are strong risk factors for cervical insufficiency or as an emergency when the cervix has already started to open.

Where the insertion of a cerclage is being considered as a preventative measure, the guidelines recommend that in women who are carrying just one baby, cerclage placement may be indicated before 24 weeks gestation where the mother has a short cervix (less than 25mm long) and has suffered pregnancy loss prior to 34 weeks gestation in the past.

Where a woman has a short cervix but no history of pregnancy loss, a cerclage is not normally indicated and instead, treatment may involve vaginal progesterone.

When premature cervical dilation is discovered during a physical examination or during an ultrasound scan, a cerclage may be inserted as a salvage measure. This is often referred to as a rescue cerclage.

A review carried out by Ehsanipoor et al in 2015, studying the outcomes for women who had a cervical cerclage inserted during the second trimester of pregnancy concluded that a cerclage prolongs pregnancy by about 4-5 weeks. These 4-5 weeks may well make the difference between whether or not the baby survives.

What are the possible complications of the mismanagement of cervical insufficiency?

The mismanagement of cervical insufficiency can sadly lead to a baby being born before it is old enough to survive.  As a lawyer acting for parents who have lost a baby as a result of the mismanagement of cervical insufficiency, I appreciate just how painful this can be and parents can suffer significant psychological injuries from the trauma.

If cervical insufficiency is mismanaged then it may in turn give rise to a clinical negligence claim.  An example would be a situation where a woman with a history of early pregnancy loss and a short cervix was not considered for a cervical stitch where she should have been, and as a result her baby was born before it was old enough to survive.

In relation to the procedure itself, according to the guidelines prepared by the Royal College of Obstetricians and Gynaecologists, the insertion of a cerclage is a relatively low risk procedure but complications can occur as a result of, for example, the stitch being put in the wrong place or becoming infected if appropriate care is not taken.

My colleague previously acted for a female client, who underwent a cervical cerclage procedure during her pregnancy. The stitch became infected due to negligence during the procedure. As a result of the infection her unborn child sadly died and this would have been avoided with basic care during the procedure.

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