Elegy for Amy

Should I Stay or Should I Go Now? May 28, 2012

Filed under: Uncategorized — elegyforamy @ 1:35 am

This incompetent cervix diagnosis has really thrown me for a loop, and I’m having a hard time getting back into a positive headspace about a future pregnancy. I feel like, before this doctor’s appointment, we had a pregnancy plan from our OB, and it was a plan that I agreed with and a plan that I was fairly confident would give us a good shot at, if not a full-term pregnancy, certainly one that made it well into the viability territory of 28 weeks that will be our first goal with any future pregnancy. I couldn’t say for sure when I’d be ready to do it, but it was obvious to me that we would do it and probably sooner than later.

Now, I can’t even say for sure that I want to do it again, ever. It definitely doesn’t seem feasible that we’ll want to do it sooner than later, though hopefully I’m wrong about that.

Cervical cerclage.  There have been a lot of studies about their effectiveness, some as large as 1300 women. There have been none that demonstrate any significant improvement in overall outcomes, in duration of pregnancy, or in viability of babies born. None. And you look up the efficacy of cervical cerclage on hospital or doctor’s websites, on WebMD, and they’ll say they are 80-90% effective. What they mean by that is, in patients who receive a prophylactic cerclage, 80-90% of them go on to have a baby who lives and cries and goes home in an adorable little outfit. But here’s the thing – those are your odds, anyway. Somewhere in between 80-90% of women who had this happen will go on to have a successful subsequent pregnancy with no intervention at all.

The upside of the cerclage is that were I to get one, I would initially not have to go on bedrest and can theoretically continue my normal activity throughout the pregnancy. And were my cervix to randomly dilate, obviously, the cerclage is supposed to hold it closed. Those are two very big upsides.

The risks are pretty big to me, too, though. One of course is that it is possible for the cervix to dilate against the cerclage, causing bleeding and in some cases permanent damage to the cervix. But then there is the risk of infection from having the procedure at all, from having a foreign body in the cervix, and from having it removed. I firmly believe that whether or not my cervix dilated on its own or not, infection played a big role in our loss. At the time of my hospital admittance, I was 2 cm dilated, but my cervix was quite long still (between 3 and 4 cm) and at this point I had already begun having active contractions. Typically you don’t see a loss from incompetent cervix until the cervix has shortened considerably or entirely, triggering contractions and labor, unless there is an infection helping things along. It seems entirely possible that IC or not, I could have continued the pregnancy for several more weeks or even months without losing Amy had there been no infection. So risking an infection for a procedure that may or may not even work is scary.

The other risk is that inserting the cerclage or even just having it present in the cervix later can trigger preterm labor, the immediate cause of losing our baby. The doctors can argue all day about whether the chain of events was preterm labor->babyloss, dilation->preterm labor->babyloss, or dilation->infection->preterm labor->babyloss, but in the end had we not gone into labor, Amy might be kicking around in NICU right now, or even in my belly still.

However. There is some evidence because incompetent cervix is such a vague, difficult diagnosis, many women are included in the cerclage studies that do not actually have incompetent cervix, and that in a very specific patient population, cerclage can and does make a difference. Am I that specific patient? If I am, and I don’t get the cerclage, I’m putting our baby in danger. If I’m not, and I get the cerclage, I’m putting our baby (not to mention myself) in danger. Heads, you lose; tails… you lose. I want badly to win, and neither choice feels like a sure win anymore.


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