Cervical Insufficiency: A Leading Cause Of Recurrent Pregnancy Loss - Expert

KUALA LUMPUR, Aug 8 (Bernama) -- Cervical insufficiency is a leading cause of recurrent pregnancy loss (RPL), and it is a deeply distressing experience for many women.

Consultant Obstetrician, Gynaecologist and Maternal Fetal Medicine Specialist from Sunway Medical Centre Velocity (SMCV) Dr Gayathri Mariappa explained that RPL is typically defined as experiencing three or more consecutive miscarriages. 

However, she said according to some guidelines, two or more losses are enough for diagnosis as each miscarriage carries a significant physical and emotional toll on the mother.

“In Malaysia, approximately five to eight per cent of women experience two or more pregnancy losses, while one to three per cent suffer from three or more losses. These statistics highlight the need for awareness and early intervention to improve pregnancy outcomes,” she told Bernama.

Dr Gayathri mentioned that RPL can be multifactorial and often the reason is unknown, with suggested factors including maternal age, hormonal or metabolic disturbances, genetic causes, autoimmune conditions, thrombophilia (a condition where the blood has an increased tendency to form clots) and uterine structural problems (womb) or cervix (neck of the womb) and infection.

“If a woman suffers late miscarriage or pregnancy losses (after 12 weeks of gestation), it may be due to a condition known as cervical insufficiency. Normally, the cervix, the lower part of the uterus remains closed and long.

“In preparation for childbirth, it begins to dilate (widen) and efface (shorten and thin) to allow the baby to be born. However, in cervical insufficiency, this process occurs much earlier, often before the womb is ready, potentially leading to second-trimester miscarriages or preterm births,” she said.

Dr Gayathri stated that women with cervical insufficiency usually are asymptomatic, but some women may experience symptoms such as vaginal spotting, vaginal pressure, lower back pain or lower abdominal discomfort, and upon examination, the cervix may appear short and open, with exposed fetal membranes (amniotic sac) in some cases.

She said the risk factors include a prior history of preterm birth, previous preterm prelabour rupture of membranes (breaking waters), a full-dilatation caesarean section, previous second-trimester losses and previous cervical surgery such as large loop excision of the transformation zone (LLETZ), which is a type of surgery that removes a small part of the cervix. 

“The diagnosis is confirmed by internal examination (using a speculum) and a transvaginal ultrasound assessment for the cervical length.  

“We also do screening for asymptomatic bacteriuria, which is a screening for urinary tract infection in asymptomatic mothers,” she said adding that treating any sexually transmitted vaginal infections before pregnancy can help reduce the risk of cervical insufficiency.

Dr Gayathri said treatment options for cervical insufficiency include vaginal progesterones and a cerclage procedure (that is conducted either cervically or abdominally).

According to Dr Gayathri, cervical cerclage is a surgical procedure that involves temporarily sewing the cervix closed with stitches as early as 12 weeks of pregnancy, and it is usually removed at term (37 weeks) or earlier if the woman is in labour.

“Cerclage can be history-indicated, ultrasound-indicated, or rescue (emergency setting), depending on the circumstances,” she said. 

She also emphasised that women at risk of cervical insufficiency would need close monitoring and surveillance every two to three weeks with a maternal-fetal medicine specialist to ensure early detection and intervention.

In addition, Dr Gayathri highlighted that it is important to maintain proper feminine hygiene and avoid douching as it could disrupt the vagina's natural flora and cause infections.

She said women should also avoid smoking, maintain a healthy body mass index (BMI), and avoid extreme exercise and excessive caffeine intake during pregnancy. 

“Mental health and emotional support from husband, family members and friends are crucial during pregnancy or after a loss. Early intervention, continuous monitoring and personalised treatment plans can significantly improve pregnancy outcomes.

“Through education and medical support, the journey towards motherhood can become more hopeful and manageable for many Malaysian women,” she said encouraging women experiencing RPL or cervical insufficiency to seek specialist care.

-- BERNAMA

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