incompetent cervix
Bedrest: What’s The Point?
October 23rd, 2009This podcast discusses the rationale for the bed rest prescription, indications for bed rest and new advances in the treatment of high risk pregnancy.
Is Complete Bed Rest Best?
October 16th, 2009Recently someone made the comment that high risk pregnant women should not engage in any sort of physical activity while on prescribed bed rest. I cannot disagree more vehemently! When a pregnant woman is placed on bed rest, not only is she at risk for the usual complications of pregnancy (in addition to the particular risks that landed her on bed rest in the first place!) she then adds an increased risk for deep venous thrombosis (DVT) and embolism, pulmonary complications an muscle atrophy (wasting and loss of strength). This is why I produced Bedrest Fitness, a series of exercises pregnant women can do while on prescribed bed rest.
Numerous research studies have documented that prolonged inactivity is detrimental to health. For this reason, when a person has heart bypass surgery, as soon as they are taken off the ventilator and are breathing on their own, nurses are instructed to get them out of bed and into a chair. This sometimes occurs within in hours of open heart surgery! But the sooner patients sit in an upright position, the sooner they will begin reusing their muscles, taking deep breaths and recovering. The same thing happens for orthopedic patients. Once a hip or knee is replaced, within hours to days, physical therapists begin moving the new joint to aid in healing, range of motion and optimum utilization. Early movemtner lowers the risk of venous blood pooling in the legs , blood clot formation, embolisms (blood clots that dislodge and travel to other areas of the body), pulmonary (lung) collapse, fluid in the lungs and the development of pneumonia. So given these examples (and there are many more such as cancer patients and other surgical patients) doesn’t it seem strange that we tell pregnant women to go sit/lie down for weeks to months at a time???
I am sure that opponents and naysayers will chide me by saying, “Well then YOU take responsibility when a woman loses her baby!” I think that we can all agree that no one wants a pregnant woman to lose her baby (or babies as the the case may be). But I think that it behooves all of us, especially in this era of health care reform, to re-examine how we manage high risk pregnant women and to really ask ourselves, is complete bed rest really best?
In some cases, bed rest really is the answer. If a woman is actively bleeding from her vagina, experiencing contractions indicative of preterm labor or has severe high blood pressure and is at risk of pre-eclampsia then yes, bed rest is indicated and I think that inpatient hospital care is best in these settings. But once the bleeding stops, the contractions stop and her blood pressure is closer to the normal range is it still necessary to completely restrict a woman’s activities? Is it best to send her home without medical supervision? Is it in her and her baby’s best interest for her to remain immobile and inactive?
Researchers are just beginning to look at how high risk pregnant women are managed and are beginning to realize that perhaps restricted activity and modified bed rest are better options. If a woman is able to be up out of bed but sitting with her feet up she can work from home and engage in family activities. But some people still argue this isn’t enough, especially in the case of the incompetent cervix. They argue that the gravitational pull downward requires that a women stay reclined in bed. Again, this may not be the case.
The September 2009 American Journal of Obstetrics and Gynecology published a study, “Prediction of spontaneous preterm birth in asymptomatic twin pregnancies with the use of combined fetal fibronectin (fFn) test and cervical length”. Now first let’s qualify their findings by saying that the mothers in this study were in fact having twins but they were not otherwise high risk, i.e. they didn’t have incompetent cervices. The researchers found that in 155 twin pregnancies examined between 22 and 32 weeks gestation,
- A positive fFN test or a cervical length of <20mm increased the risk of spontaneous preterm birth at <37,<34,<32, <30 and <28 weeks gestation.
- The combination of a positive fFN test result and cervical length <20mm had a significantly higher positive predictive value for delivery at all gestational ages than either test alone.
- A positive fFN test result was a stronger predictor of spontaneous preterm birth than a short cervical length alone.
Although this is one test and on a fairly small, very specific population, we can’t ignore the potential indications. To date many women with multiple pregnancies are placed on bed rest to prolong gestation-regardless if they are having symptoms of preterm labor or other complications. While most mothers of multiples often lower their activity levels later in pregnancy out of necessity, those who wish to remain “restricted” but not “bedridden” may now have a way to determine their risk and potentially avoid bed rest.
Likewise, incompetent cervix is one of the most common reasons women are placed on prescribed bed rest. If a pregnant woman with an incompetent cervix can have a cerclage (sugical stitch placed around the cervix) and if the cervix is not effacing (thinning and shrinking), the fFN test may be used to establish which mothers actually need to be on bed rest because preterm labor is highly probable and which mothers may be able to be on modified bed rest, “house arrest” or simple modified/restricted activity.
Truly more research must be done in this area, but it is exciting to see that people are actually doing work for us high risk mamas. Maybe one day, we’ll be better able to tell who really needs to be on bed rest and who does not.
Mamas on bed rest, if you want to keep moving, try Bedrest Fitness! It’s simple yet effective at helping maintain muscle strength and mobililty. see a clip at www.mamasonbedrest.com.
Incompetent Cervix, Now What?
October 5th, 2009One of the most common indications for the bed rest prescription is incompetent cervix. What is an incompetent cervix and what does it mean for the pregnancy if a woman has this diagnosis?
Simply put, an incompetent pregnancy is one that is unable to remain closed for a full term pregnancy. Abnormally weak, an incompetent cervix will gradually widen (dilate) and shrink (efface) typically during the second trimester of pregnancy as the uterus enlarges and becomes heavier. Undiagnosed, incompetent cervix often leads premature labor and/or miscarriage. 
There are several causes for incompetent cervix. These include:
- Congenital abnormalities
- Hormonal changes such as occur during pregnancy
- prior cervical surgery (such as conization)
- Trauma during another procedure (such as during dilation for D&C) or a prior traumatic delivery
- In Utero Exposure to DES (Diethylstilbestrol)
- No obvious reason
Unfortunately for many women, the first indication that they have an incompetent cervix is when preterm labor or a miscarriage occurs. With subsequent pregnancies these ladies may opt to have a cerclage, a surgical procedure during which the cervix is stitched closed, performed between about 14-16 weeks gestation. Depending on the woman’s situation, she may then be prescribed bed rest for the remainder of her pregnancy.
For some women, the incompetent cervix is not initially detected, but becomes suspect if a women has 3 consecutive pregnancy losses in the second trimester. Pregnancy loss due to incompetent cervix occurs in about 20-25% of all second trimester pregnancy losses. An incompetent cervix can be detected via manual examination or by ultrasound.
Once an incompetent cervix is diagnosed, what then? For those ladies in whom there is no anatomic abnormality, the cerclage will typically suffice. If the cervix is too dilated (more then 4 cm) or if there are complications with the fetus (intrauterine fetal demise, premature rupture of membranes (rupture of the amniotic sac) then a cerclage cannot be performed and the pregnancy will be lost. But of the cervix is less than 3 cm dilated and the fetus is not in any danger, then the cerclage can be placed and the mother closely monitored for the rest of her pregnancy. The success rate for cerclage is quite good, especially if done early in the pregnancy. Roughly 80-90% of pregnant women with incompetent cervices will deliver healthy babies.
The decision to put a woman with an incompetent cervix on prescribed bed rest is controversial and the decision is typically made on a case by case basis. Because some women experience significant contractions in addition to the incompetent cervix, bed rest is used in conjunction with the cerclage and medication to stop the contractions and to prolong pregnancy. For other women, the need for bed rest is not so clear. Many obstetricians fearing pregnancy loss will put women with an incompetent cervix, even if they have a cerclage, on bed rest. Medical Research does not support that this is always necessary.
A test has been developed that is able to predict whether or not a woman is going into preterm labor within the subsequent 2weeks. The fetal fibronectin test checks for the presence of fetal fibronectin, a pregnancy protein found in the cervical plug, in the vagina. If fetal fibronectin is found in the vagina, it means that the cervical plug has somehow been disturbed and a woman may in fact be at risk for preterm labor. If no fetal fibronectin is found, there is a 99% or greater chance that the pregnancy is proceeding and there is no current risk for preterm labor.
The fetal fibronectin test has significant indications for high risk obstetrics. Women at risk of preterm labor may now be tested using the fetal fibronectin test and may avoid prescribed bed rest. Some women may in fact still need to be on modified bed rest, but with the fetal fibronectin test, the current number of 700,000 American women who are prescribed bed rest annually may be reduced.
In my next post I’ll look more closely at the fetal fibronectin test.
