1) Disease Description (Causes and Symptoms)
- Disease name: Cervical insufficiency (Korean: 자궁경관무력증; English: Incompetent internal os of cervix, commonly referred to as “cervical insufficiency” or “자궁경관 무력증”) is a medically used diagnostic name.
- Definition/pathophysiology: A condition in which the cervix dilates without labor due to a structural or functional defect of the cervix, resulting in fetal loss or preterm birth during mid-pregnancy (mainly the second trimester). The key pathological process is shortening or opening of the cervix without external stimulation or contractions.
- Causes: Congenital factors (cervical defects), acquired factors (injury from previous delivery, cervical procedures such as cervical conization or LEEP), the effects of certain medications or hormones during pregnancy, and cervical infection may be associated. In many cases, the exact cause is unknown.
- Main symptoms: It is often asymptomatic. When symptoms occur, they may include vaginal bleeding, increased vaginal discharge, pelvic pressure (vaginal pressure), abdominal cramps or pain, back pain, and a sensation of needing to have a bowel movement. It may be suspected in people with a history of recurrent (habitual) miscarriage or second-trimester miscarriage.
2) Treatment Methods
- Basic principles: Treatment is determined comprehensively based on obstetric history and the current pregnancy status (cervical length and whether dilation is present), as well as the presence or absence of infection and labor.
- Surgical treatment
- Vaginal cerclage (McDonald, Shirodkar, etc.): A standard method performed in early to mid-pregnancy for patients with a relevant history (recurrent second-trimester miscarriage or preterm birth) or for preventive purposes. It is usually performed through the vagina, and the timing and indications are individualized (early to mid-pregnancy).
- Transabdominal cerclage (laparoscopic or open): Selected when vaginal cerclage is not possible, has repeatedly failed, or the cervix is severely damaged.
- Emergency cerclage: May be attempted depending on the circumstances when the cervix has already shortened or partially dilated (with consideration of the risk of infection, membrane rupture, etc.).
- Medication and nonsurgical support
- Vaginal progesterone (injection or vaginal tablet): May be considered in some cases involving a relevant history or a short cervix on ultrasound.
- A cervical pessary may also be used (indications and effectiveness vary by patient and according to the studies).
- Tocolytics (medications that suppress uterine contractions) and antibiotics are used selectively when necessary (indiscriminate use is not recommended).
- Post-procedure care
- Timing of cerclage suture removal: Generally near term (e.g., 36–37 weeks) or immediately before delivery/at the time of cesarean section. The removal method and timing vary depending on the procedure used.
- Complications such as infection, membrane rupture, bleeding, and cerclage failure (continued cervical dilation) may occur, so follow-up monitoring is necessary.
- Lifestyle management and precautions
- Limiting excessively heavy labor and strenuous exercise and temporarily restricting sexual intercourse may be recommended, but evidence is limited, so follow the treating physician’s instructions.
- Visit a medical institution immediately if bleeding, persistent abdominal pain or pressure, an elevated temperature (suspected infection), or suspected leakage of amniotic fluid occurs.
- Prognosis
- Treatment, such as appropriate cerclage, can reduce the risk of second-trimester miscarriage and preterm birth, but cannot guarantee prevention. Individual prognosis varies according to the medical history and current pregnancy status.
3) Outpatient Visit Checklist (Items and Preparation)
- Items/documents to bring or submit
- List of currently used medications and supplements (including dosages)
- Previous obstetric history: number of previous miscarriages and preterm births, delivery history (vaginal or cesarean), and records of cervical procedures (such as conization or LEEP)
- Copies of recent prenatal test results and ultrasound results (especially cervical length measurements)
- Allergies (including drug allergies) and chronic diseases (such as hypertension and diabetes)
- Symptom records
- Amount, color, and onset of bleeding or vaginal discharge; abdominal pain (frequency and intensity); temperature changes; and whether leakage of amniotic fluid is suspected
- Gestational age (based on the first day of the last menstrual period or a previous ultrasound)
- Information to check during the outpatient visit
- Cervical length on the previous ultrasound (note the measurement if available)
- Whether cerclage was performed previously and the method used (if so, the procedure date and whether it was removed)
4) Examples of General Questions to Ask the Doctor
- “At my current gestational age, are there findings suggestive of cervical insufficiency? What are the significant risk factors?”
- “What treatment options do you recommend (e.g., preventive cerclage, progesterone, or pessary), and what are the advantages and disadvantages of each?”
- “What are the main complications of the procedure (cerclage), and how likely are they to occur?”
- “What precautions should I take in daily life after the procedure (exercise, sexual activity, returning to work, etc.)?”
- “Even with treatment, how likely are recurrent miscarriage or preterm birth? What prognosis can be expected?”
5) Examples of Condition-Specific Questions
- “I have a history of cervical conization (or LEEP). Do you recommend preventive cerclage because of this?”
- “At what cervical length on ultrasound (e.g., at or below a certain number of mm) do you recommend cerclage, and what is your recommendation in my case based on my current cervical length?”
(Note: The final treatment decision and the timing and method of the procedure are individualized based on a comprehensive assessment by an obstetrician-gynecologist, ultrasound findings, the presence or absence of infection, and the overall obstetric history. If abnormal findings or emergency symptoms occur, visit a medical institution immediately.)