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MOST women with healthy pregnancies start feeling that they are out of the woods when they complete their first trimester.
While this might be the case for some women, obstetrician-gynaecologist Dr Robyn Khemlani says a number of pregnancy-related complications, such as cervical incompetence, can increase a woman's chances of pregnancy loss in the second trimester.
“Cervical incompetence is a clinical diagnosis applied to women based on a history where it is assumed that the cervix is weak and unable to remain closed during the pregnancy. Therefore, during pregnancy, there is the inability of the cervix to retain a pregnancy in the absence of the signs and symptoms of clinical contractions or labour, or both, in the second trimester,” Dr Khemlani told All Woman.
She said that there are a number of factors that may increase a woman's risk of cervical insufficiency, including trauma to the cervix from any previous procedures, such as a conisation or loop electrosurgical excision procedure, as well as the mechanical dilation of the cervix during the termination of a pregnancy. In much rarer cases, Dr Khemlani said cervical insufficiency is seen in individuals with congenital anomalies and deficiencies in cervical collagen and elastin.
“A cervical incompetence diagnosis is based on a history of painless cervical dilation after the first trimester, which leads to the expulsion of the foetus and placenta in the second trimester, usually before 24 weeks of gestation. However, because in non-pregnant patients there are no tests that can be done to diagnose cervical insufficiency or detect a weak cervix, the condition [cannot be detected] until the pregnancy is threatened,” Dr Khemlani explained.
Even while there might not be any distinct signs and symptoms in early pregnancy, between weeks 14 and 20 the patient might experience mild symptoms that could indicate cervical incompetence. Some of these signs include a sensation of pelvic pressure, backache, mild abdominal cramps, a change in vaginal discharge, and light vaginal bleeding.
Once cervical incompetence is detected, your doctor might recommend medical prevention measures, particularly the cervical cerclage, to treat the condition.
“Placing a cervical cerclage, or a stitch, in the cervix remains a commonly performed intervention [method], used by most obstetricians, for the management of cervical insufficiency or incompetence. Once you have a history of second-trimester loss, where there was no pain felt and the cervix dilated or opened prematurely, then your doctor may offer you the placement of the cerclage at 12 to 14 weeks gestational age in a subsequent pregnancy. You can also have a cerclage placed in pregnancy, if upon presentation to your obstetrician the cervix is found to be prematurely open on speculum and vaginal examination,” Dr Khemlani advised.
She explained that a cervical cerclage can also be placed if an ultrasound shows a very short cervix, especially in a patient with a history of pre-term delivery or second-trimester loss, or if a patient had one in a previous pregnancy. However, she said that the decision to use this type of intervention in any of these situations is also dependent on whether or not the patient is having pain or bleeding, how much the cervix is dilated, the gestational age of the foetus, as well as the risks associated with the procedure.
Some risks, though rare, include uterine rupture, bladder rupture, cervical laceration, maternal haemorrhaging, pre-term labour, and premature rupture of membranes.
“This cervical cerclage should be removed before labour, usually between 36 and 37 weeks of gestation, unless delivery is by elective caesarean section, in which case its removal is delayed until the time of the C-section,” Dr Khemlani advised.
She said that in some instances the health providers of pregnant women discovered to have a “weak cervix” will recommend bed rest, however, the obstetrician-gynaecologist said there is no evidence that this method is beneficial.
“While there is no proof how much, if any at all, bed rest actually helps these patients, I generally recommend that these women avoid certain exercises during pregnancy, as well as heavy lifting. Patients may also be advised to avoid sex during pregnancy, however, like the other two methods, it has not been proven to be effective for the management of these patients,” Dr Khemlani said.