Re: Incompetent cervix question for HSM (For Dr McIntosh)

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I really do understand what you are saying about the weight of pregnancy not being heavy. I also know that it is common for Drs to follow wait and see and follow the cervix with scans. I think its a matter of Dr philosphy. Does one want to gamble and play catch up if the cervix tries to change in a hurry, or play it safe (with some low infection risks from the procedure itself) and place a stitch preventatively. I know its consdered rare to loose a baby in this fashion but honestly I know more ladies that had bad outcomes when the stitch was placed after cervical change than I know who had the stitch place before one got into trouble. Its just my general feeling that cerclages real well liked here. I really believe in my case I would not have living children had it not been tried in lieu of all the descrepencies.

I did have an additional question. Are there better tests out there to rule out an uterine abnormality other than the HSG? I just wonder if maybe the HSG or even when I had a c-section done that something could get missed. The other thing I wondered and never asked my own Dr, are there any tests that can be done during pregnancy to check that the amniotic fluid (besides amnio) is not getting infected and maybe catch that problem and treat with antibiotics?

This final question is a personal professional one and feel free to ignore if you rather not respond to it in this forum set up as I would understand. If a woman consistently lost baby after baby in the scenerio I gave you earlier would you still not place a cerclage until they had these losses after 24 weeks, meet all the criteria of the "definition"? Would you possibly try a cerclage(ruling out other causes of course) before they had to lose many babies? I guess I am asking you this because I am a little freaked out that you think the IC is so rare and I fear that you might not consider it at all in repeative losses if a patient didn't meet the criteria.

Thanks again for your time.

At Tue, 26 Dec 2000, William D. McIntosh MD wrote: >
>At Tue, 26 Dec 2000, Anonymous wrote:
>>
>>Dr McIntosh I mean no disrespect but wondered if I might probe you
>>further about your statements? I really want to try and understand where
>>you are coming from on your thoughts.
>>
>>Hypothetically if a woman presented to you in L&D because they were
>>worried about spotting they were having, upon exam advanced dilation say
>>+4 +5was found with bulging membranes (not ruptured yet) no fever and
>>painless contractions every 2-3 minutes. All effrots of meds to stop
>>contractions failed therefor water breaks and delivery occurs. This all
>>happening before 24 weeks (say approx weeks 16- 18). If you would never
>>place a diagnosis of an incompetent cervix then what would you attribute
>>the loss too? A chromosome error? Or do you diagnose the patient as loss
>>due to infection everytime if its before 24 weeks? Could not funneling
>>occur before 24 weeks and be seen via u/s and suspicion that it could be
>>an incompetent cervix getting ready to rear its ugly head be made. Do
>>you honestly believe that no loss before 24 weeks can be due to a
>>cervical problem? Ever?
>>
>>Thank you for any insight you can give
>>
>By definition, the primary characteristic of the pregnancy loss due to
>cervical incompetence is cervical dilation in the complete ABSENCE of
>uterine contractions, painless or otherwise. That is why incompetent
>cervix is so rare in general, and especially before 24 weeks, as prior
>to that time, the pregnancy is not heavy enough to apply much pressure
>to the cervix.
>
>The word "never" has no place in medicine, and your own physician has a
>better idea as to what happened in your specific case. It is possible
>that I would concur with that diagnosis were I in his or her shoes.
>However, I would require a lot of convincing that this is an accurate
>diagnosis. There are other things that cause 2nd trimester pregnancy
>loss, including chromosomal abnormalities (though again, you have to
>have specific information to make that diagnosis), infection, uterine
>anomalies.
>
>I did not say before, nor do I say now, that cervical problems cannot
>lead to early 2nd trimester loss, but it is extremely rare, much more
>rare than the alternatives.
>
>As far a subsequent pregnancies are concerned, we no longer have to
>treat incompetent cervix based on fear. With the use of vaginal probe
>ultrasound, you can track the length and contour of the cervix, and
>apply a cerclage in the event that the cervix begins to shorten
>inappropriately, or demonstrate funneling. There is a difference
>between early U/S signs of incompetent cervix, and actually losing a
>pregnancy. Signs are frequently apparent before 24 weeks, but actual
>pregnancy losses are extremely rare.
>
>--
>William D. McIntosh, MD, FACOG
>
>Intended for educational purposes only, and not intended to replace examination
> and consultation with a qualified medical professional.
>
>No private e-mails, please.
>

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