Past history of bad outcomes in pregnancy


These histories could include that of:

a) previous miscarriages

b) previous spontaneous preterm labour

c) previous indicated preterm delivery

d) previous low birth weight baby (<2.5 kg) or intrauterine growth restriction

e) previous pre-eclampsia

f) previous stillbirth

g) previous fetal abnormality - fetal abnormality may be due to chromosomal abnormality, structural abnormality, genetic syndrome, or infection.


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Cervical Insufficiency


Cervical insufficiency (previously known as cervical incompetence) is defined as the inability of the cervix to retain the pregnancy, which then result in painless cervical dilatation or pregnancy loss in the absence of uterine contractions. This occurs in 1% of all pregnancies, and in as many as 20% of mid second trimester spontaneous pregnancy losses.


There are some conditions that predispose to cervical insufficiency. These include:

1. Trauma or injury to the cervix associated with a prior delivery, miscarriage or previous surgery to the cervix or uterus

2. Congenital uterine anomalies

3. Intrinsic deficiencies in cervical collagen and elastin.


The cervix is usually firm and composed of collagen that plays an important role in protecting the pregnancy. Therefore, any condition that degrades collagen may enhance the softening of the cervix and later lead to cervical dilation.


The diagnosis of cervical insufficiency is usually made in one of a few different ways:

1. A history of pregnancy losses between 12-23 weeks gestation that are characterized by painless cervical dilatation

2. Transvaginal ultrasonography showing a very short cervical length at 20 weeks pregnancy

3. Painless dilatation of the cervix and / or prolapse amniotic membrane at the vagina or out of the vagina in this current pregnancy


Treatment

1. Bed rest and activity restriction

2. Vaginal progesterone for cervix length less than or equal to 25 mm reduces the risks of preterm birth.

3. Cervical Cerclage before 24-26 weeks may prolong pregnancy with a diagnosis of cervical insufficiency. This is a stitch on the cervix performed usually under regional anaesthesia by an obstetrician experienced in such procedures.


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