Dear Dr Mitchell,
I lost a baby at 30 weeks due to an incompetent cervix (IC) - I didn't get the needed steroid shots to develop the baby's lungs so he died after spending two months on the ventilator. That was seven months ago.

I'm ready to try again but I'm terribly worried that the baby will not make it to full term. I know I will need a cerclarge to be put in at 12-15 weeks the latest. What chances do I have of carrying a pregnancy to full term or have a healthy baby with well-developed lungs?

Dr Sharmaine Mitchell

I am truly sorry to learn about the loss of your baby after premature delivery. The most common cause of a premature labour is found to be an underlying infection. This infection may be a bacterial or a viral infection.

The bacterial infection may be in the bladder or kidneys, vagina or cervix. A local vaginitis or cervicitis may cause bacteria to spread up to the uterus and cause inflammation in the amniotic sac which contains the foetus and this will then lead to contractions and sometimes premature rupture of the membrane with loss of amniotic fluid.

Bacterial vaginosis is a fairly common infection which causes a frothy, greyish discharge with a pungent, fishy odour. In pregnancy, this should be treated since it may lead to premature labour. Other infections that may cause recurrent pregnancy losses include toxoplasmosis (acquired from cats), cytomegalovirus, genital herpes simplex, rubella, syphilis and infection with the Human Papilloma Virus (HPV).

Uterine abnormalities and cervical incompetence are other causes of premature labour. Uterine abnormalities include defects such as a septum in the cavity of uterus or complete division of the cavity giving rise to a bicornuate uterus. Cervical incompetence is a disorder due to weakness in the muscles of the cervix.

This may be inherited or due to repeated trauma to the cervix. Repeated dilatation and curettage, termination of pregnancy, cone biopsy, or other operations on the cervix may damage the muscles causing the cervix to dilate up in the second trimester of pregnancy (usually after 14 weeks). The treatment for this is a cervical cerclage which is inserted at the end of the first trimester.

It is important to establish the diagnosis of cervical incompetence before the next pregnancy and also rule out the causes of recurrent pregnancy losses. This is important to prevent the problem from recurring in a subsequent pregnancy.

Cervical incompetence may be diagnosed by doing a Hysterosalpingogram (HSG). This is an X-ray of the tubes, uterine cavity and cervical canal which involves the injection of a dye through the cervix. This will show widening of the cervical canal giving the classical "funnel" effect.

Cervical incompetence may be treated by the insertion of a cervical cerclage, which is usually done under anaesthesia. This is a simple operation which can be done by any obstetrician. This cerclage is removed at 38 weeks gestation, or before if the patient goes into labour. There is always the risk of recurrence of premature labour and so you will need to be managed in a hospital that has facilities for premature babies.

The University Hospital has a special care nursery which is fully equipped with special ventilators and nurses with specialised training. It would be wise to register there if you live in Kingston and be followed by a consultant attached to the hospital who will appropriately manage your pregnancy. Smoking is also a risk factor for premature labour.

If you are a smoker, it would be a good practice to avoid smoking. You should also reduce sexual activity and physical activity in your next pregnancy to reduce the chance of recurrent premature labour. Steroid injections at 28 weeks gestation will also help to mature the foetal lungs in the event premature delivery occurs.

Consult your gynaecologist who will advise you and do the necessary investigations before your next pregnancy.

Dr Sharmaine Mitchell is an Obstetrician and Gynaecologist. Send questions and comments via email to allwoman@jamaicaobserver.com or fax to 968-2025. We regret that we cannot supply personal answers.

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