One of the things we are measuring when you have an ultrasound during pregnancy is the length of your cervix. We want it to be long and strong right up until late pregnancy and ideally past 37 weeks.
For some women, their cervix is found to be shortened or insufficient and they need surveillance and sometimes treatment to make sure their cervix doesn't open and trigger early labour.
In this ep we talk about:
How the ultrasound test is done
What happens if your cervix is shortening
What can be done to stop early labour
What can be done to help prevent an insufficient cervix for your next pregnancy
How common is insufficient cervix
Welcome back everybody. This is episode 32 of the pregnancy podcast, and we're still in kind of our shutdown.
Brigid: [00:00:47] We're still homeschooling four boys.
Dr Pat: [00:00:49] so we're here in the studio recording our podcast, we're allowed in here because it's just the two of us and we're married, so that's all right.
Brigid: [00:00:58] Yeah. That's okay and part of it is escaping the fact that we're homeschooling four boys.
Dr Pat: [00:01:03] Yeah. So that has been a challenge, hasn't it?
Brigid: [00:01:06] It's been such a challenge.
I'm learning a lot though. I know what a digraph is and I trigraph and, yeah, I know a lot more about our world even.
Dr Pat: [00:01:15] I'm not sure. I’m someone who already knows how to read. I'm not sure that I needed to know or that. It seems to help the kids.
Brigid: [00:01:21] Yeah, my hats off to teachers. I don't know. I don't know how they do it.
I honestly don't know how they do it.
Dr Pat: [00:01:27] Absolutely. I saw something the other day on the internet. It was, Adam Sandler singing a song about, about homeschooling, and he said, I'm teaching my kids maths and that can't be good for America. So I think everyone feels like that.
Brigid: [00:01:45] Thank God the older boys sort of go off and do their own thing but it's just the six and the seven year old, which are. Challenging.
Dr Pat: [00:01:51] Yeah, that is true in, in general. Now, I've got a need to hear a review.
Brigid: [00:01:59] Well, I have a good one, Pat. I, they're all good. I love them all. So this one actually came through on our DMS, on our Instagram, and I love it that people take time.
You know, you can't leave a review on Spotify. So most of our listeners are on Spotify, so they, they come over to our Instagram and leave a review. Yeah, there you go. You're learning things, aren't you? It's a bit like school where we're homeschooling.
So, hi, Dr Pat and Brigid. Just wanted to touch base and say, thanks for such a great podcast. Having a doctor, husband, and being a healthcare worker myself, I feel I can relate so much to you, but also the medical side of pregnancy and birth. But what I also love is the kindness, compassion, and understanding along with the use of everyday language.
Not only has your podcast been incredibly educational and helpful, it's also been enjoyable. Thanks again for such great information on a humanly level. Take care and stay safe in these uncertain times are wonderful with kisses.
People are so generous.
Dr Pat: [00:02:54] Well, that's what we're doing here, isn't it? Trying to help do something like that to make people feel, [00:03:00] a bit more, like they're not alone.
Brigid: [00:03:01] That's it.
So, shortened cervix. It's a very, very stressful time.
Dr Pat: [00:03:05] Yeah. People have often read a bit about this when they come into pregnancy.
It's the sort of thing that you might read as someone's pregnancy story about their problems with their shortened cervix, and it can be serious. It's often not. but it does require a great deal of surveillance and thinking about, and it's a relatively common complication of pregnancy.
Brigid: [00:03:26] Yep. And it's got one of those outdated medical terms that people might know it as.
Dr Pat: [00:03:30] Oh, yes. We've moved on from that. Yes. Yeah. So it's not, we shouldn't be calling it incompetent. Yeah. So the ‘incompetent’ is one of those awful dated medical terms that makes it sound like it's your fault. Yeah. So it's insufficient.
Brigid: [00:03:45] I don't love insufficient either. I would much prefer to hear shortened cervix.
Dr Pat: [00:03:49] Yeah, maybe. I think, I don't think they're all shortened though. That's the problem. So there are some people who could have genuinely sort of, the tissue of the cervix is weak and it might look fine on ultrasound, but doesn't work properly. So cervical insufficiency is probably the closest we've got to a correct term at the moment.
Brigid: [00:04:07] All right. So we've skirted around it. It's slightly weakened tissue, but what, what, what's the actual definition of it? What, what is a shortened cervix?
Dr Pat: [00:04:17] Yeah, so it's a shortened cervix is an ultrasound finding. Okay. So, a lot of the time if we're doing scanning in early pregnancy in particular, nice scan at the 12 to 13 week mark and again at the 20 week scan, then a good scan will measure the length of the Cervix. If it seems to be quite short on, on either of those, then it does put that woman, in a risk group where the cervix may actually come open too soon. And, the absolute textbook, labor that someone might have in it with true cervical insufficiency is a relatively painless second trimester labor where the cervix kind of springs open. Maybe the baby comes out too early to survive. And we still see that from time to time because of course, if it happens in your first pregnancy, we can't really effectively predict it.
Brigid: [00:05:14] in your second and subsequent?
Dr Pat: [00:05:16] No No, if it's your first pregnancy and you have no previous experience, then the first one might catch us off guard and we might not be able to do all our special things with extra ultrasounds and stitches in the cervix and so forth until a second and subsequent pregnancy on someone who we know is at high risk.
Brigid: [00:05:35] Oh right. But for that first pregnancy, they go in at 12 weeks and have your scan and how long should your cervix be or how should it look?
Dr Pat: [00:05:44] It should be about four centimeters long. Right.
Brigid: [00:05:46] And there's no anatomical difference between women if they're tall or short or…
Dr Pat: [00:05:49] no, not really. Not really. One of the groups of women who would be particularly interested in that, in those early phases would be someone who's had a lot of surgery on the cervix before.
In particular, we get interested in people who have had a number of those LLETZ procedures for the treatment of significantly abnormal cervical screening. So pap smear what we used to call pap smear abnormalities. So you know, if you've had one of those LLETZ procedures, it doesn't change the function of the cervix in a subsequent pregnancy very much, but if you've had two or more, it can, yeah.
So, you know. That person in particular, we might be making sure on that early scan that, yep, there's the cervix four centimeters long looking good. Yeah. Yep.
Brigid: [00:06:31] And how is it measured? You said by ultrasound, but what happens there?
Dr Pat: [00:06:36] Yeah. Well, this is the trick, right? It's, it has to be done, in, in a careful way.
And ideally the same way, every time it's looked at.
Brigid: [00:06:46] By the same practitioner?
Dr Pat: [00:06:48] That's the best. Yeah. So if you're following the length of a woman's cervix throughout the pregnancy, the ideal thing is to send them to the same ultrasound practitioner every time because that person's going to do it the same every time as their habit.
And you're comparing apples with apples, one scan to the next. The cervix is a surprisingly dynamic organ, and if you, if you push on it hard with the ultrasound probe, you can make anyone's cervix look a little bit different to how it naturally sits. And you might be able to make even a perfectly normal one look long or short. So if we use the same technique every time, a look on vaginal ultrasound and a look on abdominal ultrasound with the same amount of pressure on the probe and the probe in exactly the same position every time, then we can start saying, okay, a change from week 16 to week 18 is significant.
Brigid: [00:07:44] Yeah. Can I just ask to clarify? so this isn't the, ultrasound. transducer head or whatever it's called on the abdomen. This is the vaginal probe?
Dr Pat: Yep. Both. You do both. Okay.
Brigid: In a 12 week ultrasound, do you have both? Normally?
Dr Pat: [00:08:02] No. But you would go on to do the vaginal bit if the cervix look too short.
Brigid: [00:08:06] So if you suspect it from doing the abdominal one, that's when you'd have the transvaginal probe?
Dr Pat: [00:08:12] That's right. Yeah. Yeah. So the, the whole idea of course, is to try and pick up someone who might have an issue and then put, that person into what's called cervical surveillance. So that's a program of doing more scans to see if it's three, if it's two and a half centimeters, does it stay two and a half or, or is it progressively shorter?
Yeah, and we might also start that woman on some vaginal progesterone pessaries and these little tablets to go in the vagina that have been shown to help stabilize the cervix.
Brigid: [00:08:43] Yeah. How interesting. They're like, they used to call them the footballs or something.
Dr Pat: [00:08:47] Yeah. A little, pessaries that, are use commonly used as part of our IVF treatment and various other things, and they can help stabilize the cervix.
Brigid: [00:08:54] Yeah. Cool. All right. So, can you do anything else? Like, I know our friend was told bedrest. For a little bit. What do you think about bedrest?
Dr Pat: [00:09:02] Yeah, the jury's out on, on bed rest. there were a lot of times over, the history of obstetrics and the history of, I think medicine and surgery in general where bed rest was a lot more popular than it is now.
And once upon a time, it might've been one of the very few actual things that they had to offer. But, we know that there, that it's not a harmless thing to do to tell a pregnant woman to have bed rest because pregnancy is a, is a ‘clotty’ time and you're more likely to get a blood clot in your leg that could go to your lungs, serious stuff.
And that's more likely if you spent all day in bed. So we can't recommend bed rest to people anymore unless we're very confident that the bed rest isn't more dangerous than the condition we're trying to avoid. And so a lot of these things now, we're seriously rethinking the value of bed rest.
Brigid: [00:09:53] And if you're diagnosed at 12 weeks, who wants to spend the next 28 in bed?
Dr Pat: [00:09:59] Nobody wants to. and there are, there are fewer conditions now where it's thought to be a good idea than 30 years ago.
Brigid: [00:10:05] Yeah. And so for someone that's got that very early sort of cervical surveillance, are they, changing anything about their habits? Like, do they have to exercise less or…?
Dr Pat: [00:10:15] Yeah. So there are some sensible things that people might do.
It seems likely that, vigorous exercise might not be great. Penetrative intercourse might not be great. So people will often, you know, wind those things down while at least while they were in a phase where we're trying to work out whether the issue with the cervix is a genuine problem or not.
Brigid: [00:10:39] I'm thinking, what about constipation or something like that?
Dr Pat: [00:10:41] Yeah. Look, it's possible. So keeping a good bowel habit in pregnancy, a good idea for everybody, but it may be that if you're pushing for a long time on the toilet, that that might make, make things worse. it's also possible that that's not relevant.
And all we're dealing with is the internal strength of the cervix, which is what it is.
Brigid: [00:11:01] And can you do things like pelvic floor exercises or is there any sort of way that you can strengthen muscles around the cervix?
Dr Pat: [00:11:08] No. This is the smooth muscle. This is like your heart. It's not skeletal muscle that we can exercise. So, the problem might be just something we were born with. So the, issue is trying to work out who's got the genuine problem, and who's got an ultrasound appearance where the cervix looks a little short, but there's really very low risk of a problem.
Brigid: [00:11:35] And for the high risk group, then we talk about putting the stitch in the cervix. So is that while you're pregnant?
Dr Pat: [00:11:42] yeah. It's often done while you're pregnant. You know, there's a scenario where it can be done beforehand, but let's look at the stich that goes in while you're pregnant. So we might have somebody who on early ultrasound, has a very short cervix.
Brigid: [00:11:54] So what's very short in your opinion?
Dr Pat: [00:11:56] look, that's a little technical, probably varies between [hospital] units. but one common scenario would be that someone on about 12 or 13 weeks, has a short cervix she's put into it cervical surveillance program at that hospital, or through her obstetrician and despite progesterone supplementation, it's getting shorter.
Okay. Then that's somebody we would be very interested in, and then, so the woman's already pregnant, we're really worried about the state of the cervix. So we might do an operation to stitch the cervix closed before it gets worse, or before it starts to not only shorten, but actually come open.
And that's an operation, that's done, under a general or spinal anesthetic. And the skin around the top of the, around the cervix has opened up, stitches put around it.
Brigid: [00:12:50] like a big loop loop, you can’t see what Pat is doing but he is making a big loop with his hand.
Dr Pat: [00:12:53] Yes a big loop. then we the tie knot and then, close the skin of the cervix over the top of the knot, so
Brigid: [00:13:01] How's that not going to cut off the circulation?
Dr Pat: [00:13:04] Well, you're not supposed to put it in very tight. You're not, trying to squish the cervix closed. You're just trying to stop it open and stop it opening any more. Yeah. So, it shouldn't be done with a lot of tension.
Brigid: [00:14:30] I remember in my first pregnancy, I was diagnosed with potential ,back in those days, an incompetant cervix. Yup. and so I was on the, I must have gone into the surveillance group, and I only stayed in there for a little while because nothing changed.
So maybe the length stayed the same the whole time. But even in my first pregnancy, my cervix was a little bit dilated already.
Dr Pat: [00:14:56] Yeah. That, that's sometimes just the way the cervix is sitting. And, some people are just, it's a little tiny bit open, but it's still nice and strong. Yeah. And if you've had a few babies before just about everybody's cervix is a little bit open, right?
But that doesn't sort of represent it's strength. Yeah. when you're in cervical surveillance, you don't have to stay there forever because if you keep returning normal results, then. It's less and less likely that you've got a serious problem. Yeah. And also you're going to reach a point in the pregnancy where, let's say for argument's sake, it's 28 weeks where the risk of putting a stitch in is going to be worse than the risk of having a baby.
Brigid: [00:15:39] Right. So what are the risks of putting a stitch in?
Dr Pat: [00:15:43] Well, when we put a stitch in early, it's got some risks. Absolutely. there's the risks of any operation, the anesthetic infection, bleeding. But the worst thing that can happen is we can accidentally puncture the membranes.
Brigid: [00:15:52] Oh, right. And precipitate labor.
Dr Pat: [00:15:55] Yeah. Sort of put a hole in the wall, put a hole in the membranes that infection in or the water out. Yeah. Right. not common, but it is a risk.
Brigid: [00:16:02] So up until what time, what stage of pregnancy would you put a cervical stitch in?
Dr Pat: [00:16:09] Yeah, a little complicated again, too variable, on the case by case by case.
Brigid: [00:16:14] Okay. So then somebody goes into labor. What happens to that stitch?
Dr Pat: [00:16:20] Well, if you put the stitch in, it works really great and the woman gets right out to well into the third trimester. Everybody's happy. Then we can book a procedure in theater, take it out again.
Brigid: [00:16:29] Right. Okay. So you do that before she goes into labor?
Dr Pat: [00:16:33] Oh, yeah. Ideally. So if we're right out at about 37, 38 weeks and we've done our job, everybody's happy, and then, you can just book a procedure, take it out again. And one of two things will happen. Sometimes it'll spring open pretty fast if there was genuine cervical insufficiency and the stitch was doing all the work and you'd take that out, then she might labor very quickly.
And sometimes you take the stitch out and it all stays closed and it's hard to know what to make of that. But, that one woman will just go into labor in the usual way. If the woman was having a planned section, then you can just do the Caesar and then go around vaginally, take the stitch out.
Yep. Okay. Under the same anaesthetic.
Brigid: [00:17:11] All right, so we've talked about somebody who's gone through perhaps and, it's been detected at 12 weeks that they needed a stitch put in or whatever it might've been. Is there anything you can do, even before you get pregnant? If you have, you know, suspected to have a shortened cervix.
Dr Pat: [00:17:27] Yeah. There are some people who have a stitch put in even before they're pregnant and, it's a research area, but it's in common clinical practice at the moment, it's people who've had a stitch put in vaginally that didn't work. Right? And, those women will often have a special type of stitch put in, before another pregnancy.
So, and if you approach that, the cervix from above with a, with a laparoscope, these used to be done as open operations, but these days some of us are doing those laparoscopically. And you can put a stitch in, by approaching from above, that's much higher on the cervix. And, we're hoping to see better results from those.
So slightly more complex operation, and it puts the stitch in a difficult place to get it out again. So, if that woman is in that situation and we put in a laparoscopic cervical cerclage. Before she's pregnant. She goes on to get pregnant, but she has to have that baby by caesarean section. Yeah.
And usually we just leave that stitch in there.
Brigid: [00:18:30] Yeah. And I know you, you have been doing that for a couple of years now. And I remember the first, well not the first, but one patient, it was because she'd had a couple of, 20 week losses,
Dr Pat: [00:18:42] In particular, it's someone who's had, some, some second trimester losses that including one that where the vaginal stitch didn't work.
Okay. And rather than just do the same thing again, it's well worth looking , at a laparoscopic, stitch and, it's more complicated, but, certainly there's been some terrific successes
Brigid: [00:19:04] and there's really not that many people that do. The laparoscopics cervical stitches.
Dr Pat: [00:19:08] You have to find someone who's got those.
Those skills aren't that many, that there aren't that many patients that need it. Yes and so, there aren't that many people skilled in it but people would be able to find somebody who could do that.
Brigid: [00:19:18] Yeah. Yeah. Well, it's, I mean, gosh, that's the thing, isn't it? It's the pressure. So someone's been diagnosed with, a shortened cervix or insufficient cervix that whole pregnancy.
Has that as the big black umbrella above, doesn't it?
Dr Pat: [00:19:36] That's absolutely right. Yeah. And there's that feeling that something might go wrong at any moment that people find it tough to deal with.
Brigid: [00:19:43] Yeah. So, Paddy, is there anything else somebody could be doing if they've maybe started going into labor or something because of an insufficient cervix?
Dr Pat: [00:19:51] Well, yes, it's an, it's an unusual situation, but occasionally we'll see somebody with, in the early stages of a second trimester labor, where they've come to the hospital, the cervix is clearly opening and when we do a speculum examination, we can see the cervix partially open with some membranes bulging through and maybe a fetal foot or something, trying to stick through the cervix.
And there is a sort of a hail Mary procedure that can be done in that situation where we operate, poke the membranes back in. And stitch that try and stitch the cervix closed.
Brigid: [00:20:26] Oh, how successful is that?
Dr Pat: [00:20:27] Not often successful. Yeah. Once the mechanism of labor is underway, it's hard to stop it, but that's called a rescue cerclage and it's possible. An attempt at that is considered a lot better than nothing. And sometimes, sometimes it works.
Brigid: [00:20:44] Yeah. And that's, say somebody is 30 weeks. It's, for sort of like that 20 to 30 week
Dr Pat: [00:20:51] no it's very specific. It's for before 24, 25 weeks.
So if you were 30 weeks , you wouldn't be bothered, be much better off having that baby rather than trying to stitch it in. Yep. Give that woman some antenatal steroids to improve the baby's lungs. Have the baby and manage the prematurity. Yes for the pediatricians to do their magic and deal with the prematurity.
No this is for a baby that's trying to come out pre viable. So, so before 24, when the only alternative is a loss of that pregnancy, then we. Give it a go.
Brigid: [00:21:21] Yeah. Didn't mention at the start, but you know, another reason why we decided to do a shortened cervix podcast is because we did have somebody ask us on DM saying that, you know, she's very early on in her pregnancy, but it's as something that is just keeping her awake at night.
It's just something that she's very fearful of. And I suppose what we've talked about is that at 12 weeks. You'll get assessed and the biggest key is to have that cervical surveillance and be that part of a unit.
Dr Pat: [00:21:48] Yeah. I can't remember whether the person who contacted about us about that had any special risk factors herself.
Yeah. But let's say she didn't then, then this is actually one of the lesser likely things to happen in your pregnancy. So today we've talked about the sort of cold, hard facts about how, how that's managed. but, you know, mostly the cervix is fine. It does its job perfectly well. Yeah.
And, and doesn't come open until it's supposed to at the end.
Brigid: [00:22:11] Yep. Yep. That's right. We are amazing beings aren't we, you know, that's it. We're set up anatomically to support pregnancy.
Dr Pat: [00:22:19] That's right.
Brigid: [00:22:20] All right, everyone. Well, I hope that's been helpful. we will see you next week. thank you so much for listening.
We are very grateful for all the listeners, for all our reviews. If you like you can pop over and give us a five star review on iTunes, or just send us a DM, tell us what you like hearing about.
Dr Pat: [00:22:38] Thanks for listening everybody.