She Had A Weak Uterus

A REAL LIFE ACCOUNT AS WITNESSED BY A MATERNITY NURSE

Alice arrived at the hospital at around 11.00 a.m., in tears. She was hysterical and repeatedly exclaimed that her baby was coming out. I tried to calm her down and get her to explain what the problem was. She was twenty weeks into her second pregnancy and was experiencing mild contractions. Her first pregnancy was miscarried at sixteen weeks: and she was experiencing the same symptoms-hence her panic.

After asking her some more questions. I immediately did an examination. It showed that her cervix was open. This meant that it was not strong enough to hold the baby in the uterus, a condition clinically referred to as cervical incompetence. Since her membranes were not ruptured. I decided to perform a speculum examination.

In the circumstances, I did not need to do a digital vaginal examination. Performing it in such a situation would only make the cervix to open more. On further examination. I found out that she had dilated two centimetres. I told her to rest on the bed as I went to call the gynaecologist. I immediately explained her condition to the doctor who came very fast and did another speculum examination. He too. found that she had dilated two centimetres.

I was then requested to call the radiologist to do an urgent ultrasound scan. The scan confirmed that she was twenty weeks pregnant. It was concluded that she needed to undergo a cervical cerclage, which is a minor surgical stitch of the cervix (opening to the uterus) to dose it in order to prevent a miscarriage or premature birth.

Before Alice was taken for the operation, the doctor explained to her the procedure—she was going to be stitched. She looked worried but I consoled her and assured her that everything was going to be fine.

A hospital counsellor was called in to give psychotherapy, which was done successfully.

I prepared her and took her to the theatre where a the stitch was administered. At the theatre, she was put under anaesthesia to prevent her from experiencing pain. Later, l was called and asked to escort her to the ward. She came back having mild spotting which was as a result of the stitch. I observed that it was not excessive and that it was normal. We advised her to stay in bed and later assisted her to bath. We discouraged her from sitting up for long: she was cooperative and complied. I continued giving her antibiotics to prevent infections, and anti-contraction drugs.

Soon the contractions ceased, and one day later Alice was discharged. She was also booked for review in two weeks time to check for any infections and rule out further complications.

At 38 weeks the stitches were removed. Alice delivered safely.

WHAT CAUSES CERVICAL INCOMPETENCE?
By Dr. Blasio Omuga

A weak cervix is medically known as cervical incompetence. It is a condition in which a pregnant woman’s cervix (opening of the lowest part of the uterus which extends into the vagina) —as a result of structural or functional weakness in the cervix itself—dilates (widens) and gets thin (effaces) while her pregnancy is progressing and the baby is not yet mature.

Cervical incompetence causes miscarriage and pre-term delivery during the second and third trimesters.

What is the cause?
It may be either due to a cervical defect present since birth (inherent or congenital weakness), a past injury of the cervix caused by a vaginal delivery process or forced abortion during which the cervix was dilated by force.

How does it happen?
The cervix will dilate without contractions or pain. Due to the weakness of the opening, the cervix is not strong enough to support a growing foetus in the uterus. This results in the amniotic membranes bulging through the cervix and may rupture. When one stands, the weight of the growing foetus pressing on the cervix causes it to open and let go. The foetus can thus slip out of the womb due to force of gravity. These effects irritate the uterus, resulting in a miscarriage or pre-term labour.

Cervical incompetence usually occurs when the pregnancy is in the second trimester, after fourteen weeks, but may also occur later in pregnancy.

Is it painful?
The initial expansion of the cervix causes local production of a chemical substance called prostaglandin. In these initial stages there may be minimal pain. The prostaglandins stimulate uterine contraction which further forces opening of the cervix. This then becomes painful like any other labour pain.

What are the symptoms?
Early symptoms of cervical incompetence include irritating lower abdominal pain which may radiate to the back. This may be accompanied by some vaginal discharge (bloodstained). Normal labour follows, and rupture and flow of the waters through the birth canal occurs.The rest of the process is similar to normal labour.

Diagnosis of cervical incompetence is usually made through a combination of medical history, physical examination and ultrasound scan. Physical examination it done using a speculum, which is a sterilized instrument used to open the vagina so as to see the cervix dearly. When done properly the speculum examination is non-traumatic.

Cervical incompetence can cause habitual abortion (repeated in subsequent pregnancies) if not corrected. The pregnancies may proceed to late second trimester or early third trimester only to end up in premature delivery.

What is the treatment?
Detecting the condition early in pregnancy is a major plus in reducing the potential risks and long term effects of cervical incompetence. Women who have had repeated abortion or premature births in the past are especially at risk of having the condition.

Once it is established that cervical incompetence is developing or present, normally at around fourteen weeks of pregnancy, a special stitch is used to close the cervix. This surgical procedure is called cervical cerclage and is done in theatre while the patient is under anesthesia. Thereafter drugs to prevent contractions are prescribed sometimes.

The patient proceeds to carry the baby to term, and has the stitch removed at about 37 to 38 weeks of pregnancy. Normal labour and delivery follows.

In certain circumstances, depending on the kind of stitch applied, it may be necessary to deliver the baby by Caesarean section.

What happens in post-surgery treatment?

o Anti contraction drugs are given to prevent contractions at times.
o The patient is encouraged to have as much rest as possible especially in the first two weeks, o The patient is given pain killers and psychological support.
o Sex is discouraged after the procedure to reduce chances of infections and disruption of the stitch. The couple is counseled on the same.
o Counseling is also given on need of the stitch in all subsequent pregnancies and need for follow up in the clinic to monitor progress and manage any complications.

END:PG12/16-17