HISTORY. Obtain a detailed obstetric and medical history. Ask about the date of the last menstrual period to determine the gestational age of the fetus. Inquire about risk factors that are related to cervical incompetence. Women experiencing cervical dilation because of cervical incompetence may have symptoms that range from feelings of low pelvic pressure or cramping to vaginal bleeding, loss of amniotic fluid, and spontaneous passage of the fetus and placenta. Patients who experience cervical incompetence frequently report a history of previous second-trimester pregnancy loss, induced abortion, dilation and curettage, cervical biopsy, or prenatal exposure to DES. A history of fertility problems may also be reported.

PHYSICAL EXAMINATION. Inspect the perineum for bleeding and fluid. Patients frequently have pink or dark red spotting, increased vaginal discharge, passage of the mucous plug, or leakage of amniotic fluid. Cervical incompetence can be predicted by examining the cervical length with transvaginal ultrasound. A cervical length of less than 25 mm between 16 and 24 weeks' gestation indicates potential cervical incompetence and a risk of preterm birth. A cervical length greater than 35 mm between 18 and 24 weeks' gestation is correlated with preterm birth in 4% of patients. Thus, a shortened cervical length is an excellent predictor of cervical incompetence and eventual preterm birth, especially in high-risk women. Perform a sterile vaginal examination. The cervix is effaced and dilated, with progression in the absence of painful uterine contractions. A bulging amniotic sac or the fetal presenting part may be palpated through the cervix during the vaginal examination.

PSYCHOSOCIAL. The patient who experiences pregnancy loss because of an incompetent cervix is in a state of psychological crisis. If this is a first episode, the patient is likely to be bewildered because of the rapid progress of dilation and the unexpectedness of the loss. In patients who have experienced infertility or previous fetal loss, psychosocial reactions may be complicated by unresolved feelings or cumulative effects of grief experiences. Anger, fear, numbness, guilt, severe grief, and feelings of loss of control are common in both the pregnant woman and her significant others.

Diagnostic Highlights

General Comments: Diagnosis is clinically based on a history of habitual second trimester abortions, painless cervical dilation, and spontaneously ruptured membranes.


Normal Result

Abnormality with Condition


Ultrasound (transvaginal)

Long, noneffaced, closed, Internal cervical os; cervical length greater than 35 mm (at 18-24 weeks)

Cervix shortening; dilation of the internal os noted; cervical length less than 25 mm (at 16-24 weeks)

Cervix will usually shorten or efface before dilation; the internal os dilates before the external os; thus serial imaging can alert one to cervical incompetence and potential loss

218 Cervical Incompetence

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