Why you're unable to carry pregnancy to full term

It is every pregnant woman's desire to carry their pregnancy to full term and give birth to a healthy baby.

But this is not always the case. Some women experience complications such as recurring pregnancy loss from around week 13 onwards due to a condition called cervical incompetence or cervical insufficiency.

Dr Lorraine Muluka, an obstetrician and gynaecologist, explains more about this condition and if it can be managed.

What is cervical insufficiency?

Cervical insufficiency is the inability of the cervix to retain a pregnancy. In other words a woman has a weak cervix that lacks the structural integrity to carry a pregnancy to full term. The cervix starts dilating (opening) too early during pregnancy leading to a miscarriage or a preterm birth. This happens in the second trimester. From week 13 to 28. 

What are the signs to look out for?

Most women do not know they have the condition until an event has occurred, that is the loss of a pregnancy. Some of the symptoms are a bit of spotting and abdominal cramping. We tend to make a diagnosis of insufficiency most of the time after someone has had second trimester loss.

They tend to have painless labour whereby they report having their water break and soon thereafter lose the baby. What women should know is that if they get pregnant and experience recurrent pregnancy loss, especially as they get into the second trimester, they need to see a gynaecologist.

Some have lost hope of carrying a pregnancy because they don’t know it's something that can be corrected or treated. They are condemned because people think that they just can't carry a pregnancy and they end up not getting help yet it's something they can be assisted with. Community education is also key.

What causes an incompetent cervix?

Some women are born with a cervix that is incompetent in terms of structural integrity. They just have a weak cervix.

Sometimes a woman undergoes surgery to treat an abnormal pap smear and because of a part of the cervix being taken out (large biopsies) then the structural integrity of the cervix is lost or reduced.

Then there are those who just tend to have a short cervix, that is, less than two centimetres. It dilates (opens) prematurely. There are no herbal remedies for this.

Sometimes it can occur after having normal childbirth when one suffers excessive trauma to the cervix to a point it loses its structural integrity.

Others are just born with what we call congenital anomalies of the cervix. This presents a range of disorders from the absence of the uterus and cervix to a duplicate uterus and cervix, among other issues.

Are there any treatments available for this condition?

Yes. It is treatable. There are treatment options whereby hormones are used. The hormones have been shown to help the woman carry the pregnancy to term. The hormone used is progesterone and it has no major side effects.

Another option is surgical treatment. This involves having a stitch. This method is however not suitable for women carrying twins or more.

One is put vaginally. The other abdominally. We usually wait for the woman to get past her first trimester. Then somewhere between week 12 and 16 we put a stitch at the level of the cervix. This one is called a McDonald stitch. The stitches are recommended when the cervix is at risk of opening before the baby is ready to be born.

The stitch is then removed at around week 37 of pregnancy. The McDonald stitch is usually put in after one has gotten pregnant because its goal is to support the cervix during pregnancy. There is a small risk of getting an infection as well as accidentally rupturing the membranes if done past 18 weeks. 

I am not aware of any herbal treatment. None that’s been scientifically shown to help prevent cervical insufficiency.

What is the cost of treatment?

It depends on the mode of treatment. For hormonal therapy a woman spends Sh3,000 per month. Usually the woman would be on the hormones all the way to around 36 weeks of pregnancy.

If one opts for surgical management, then it basically depends on whether it’s being done in a public or private hospital and whether you are having the vaginal stitch inserted, which is cheaper than the invasive surgery, which tends to be pricey.

It could be in the range of Sh20,000 to Sh30,000 to about Sh200,000 if you end up going for laparoscopy, a type of surgery where a doctor accesses the inside of the abdomen and pelvis without having to make large incisions in the skin.

I have handled a number of patients with cervical insufficiency. It's a devastating experience.

One of the worst experiences was when we had a woman who had the condition and still had issues with infertility. We had made a diagnosis of the condition based on a prior midterm trimester loss. We put  a McDonald stitch but she still lost the pregnancy.

How is it detected?

The condition is not something you can self-examine. It is also not painful like you would have period cramps. What happens is that the cervix dilates painlessly and then the next thing is pregnancy loss.

An incompetent cervix can be seen on an ultrasound scan.

A transvaginal scan is also able to show that the cervix is quite short. Especially in women who have lost pregnancy before, we tend to do a cervical surveillance through scans from week 16. Week 16 is when its advisable to look at the length of the cervix to see whether there is any signs of incompetence. The good news is that you can still get pregnant if you have the condition. It is not a hindrance.

How do you keep your cervix healthy?

Basically eating a good diet. You would want to avoid smoking. Ensure you are well hydrated. Exercise too.

Also, ensure your sexual health is on point. Have regular sexual health checkups because the things that have been shown to make the cervix unhealthy are sexually transmitted infections such as the human papillomavirus (HPV) and others, which cause inflammation of the cervix.

Women should constantly ensure their cervix is healthy by doing a pap smear. However, HPV and the abnormalities it may cause in the cervix are not linked to cervical insufficiency. 

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