Evidence based management of cervical insufficiency

Suganthi*

Senior Staff Nurse, Kauvery Hospital, Salem, Tamil Nadu

*Correspondence

Abstract

A 28-years aged female, G3A2 at 23 weeks + 5 days gestation, with a history of recurrent cervical insufficiency, was admitted with USG findings of short cervix with funneling. Despite cervical encirclage at 15 weeks and Arabin pessary at 20 weeks, patient developed spontaneous preterm labour and underwent Emergency LSCS at 27 weeks. This report highlights clinical presentation, obstetric management, surgical intervention, post-operative ICU care, nursing management and maternal-neonatal outcome of preterm labour.

Key words: Cervical insufficiency; Cervical trauma; Tocolysis

Introduction

Cervical insufficiency is painless cervical dilation in the second trimester without contraction, leading to recurrent mid-trimester loss or extreme preterm birth. It is commonly associated with prior cervical trauma, D&C or congenital weakness. Despite prophylactic measures like cerclage and pessary, some patients progress to inevitable preterm labour. Multidisciplinary management with steroids, tocolysis, antibiotics and timely delivery improve maternal-fetal outcomes.

Patient History

Age/Sex28yrs/F
Obstetric ScoreG3A2
LMP3-10-2025
EDD10-07-2026
Chief ComplaintsAdmitted at 23+5 days with USG S/O Short cervix with funnelling. Fetal movements well. No C/O Abdominal pain.

Obstetric History

1st Pregnancy17weeks-Mtp: Cervical Insuffiency-2023
2nd Pregnancy17weeks-Mtp: Cervical Insuffiency-2025
3rd PregnancyPresent Pregnancy: Cervical Cerclage @ 15 Weeks: Arabian Pessary Inserted at 20 Weeks.

Past Medical History: K/C/O Type 2 Diabetes mellitus for 3 years, on OHA and Insulin.

Menstrual History: Regular 5/30 days cycle, Normal flow, married since 4.5 years.

Relevant Clinical Finding

On admission: GC – Afebrile, Conscious, No pallor.

Vitals

Bp90/50 mmHg
HR94 /Min
RR22/ Minute
Spo298%

Systemic Exam: CVS- S1, S2, RS -B/L, AE (+), PA -UT – Dates: FHR (+)

Blood group: A Positive

Relevant Investigation

  • USG: short cervix with funneling at 23weeks+5days
  • Routine Blood investigation done
  • High Vaginal Swab: Sent to rule out infection

Management

  • Antenatal: Admitted on 18/03/2026 treated with IV Antibiotics, antacids, PPIS, oral medication, strict bed rest and catheterisation.
  • Intrapartum: Developed spontaneous labour pain on 15/04/2026.
  • Surgical: Emergency LSCS done on 15/04/2026 at 1:49am under SA Pfannenstiel incision. Delivered live preterm male baby, 980gms, Apgar 6/10 at 1min, 8/10 at 5min. Myomectomy done for 2x1cm fundal subserosa fibroid
  • Postnatal: IV Antibiotics, insulin for DM, Wound Care, DVT prophylaxis

Nursing Management

  • Pre-Op: Strict bed rest, FHR monitoring 92hourly, vitals 4th hourly, psychological support for high – risk pregnancy.
  • Intra-Op: Assist in emergency LSCS, neonatal resuscitation team standby.
  • Post-Op: Monitor vitals, I/O Charts, fundal height, lochia, wound site, encourage early ambulation. Blood sugar monitoring and insulin administration as per sliding scale.
  • Baby Care: NICU admission for extreme prematurity, condition explain to parents.

Patient Outcome

Mother: Delivered by emergency LSCS at 27weeks+5days.post-op period uneventful. Vitals stables at discharge-BP 100/70mmhg wound healthy. Discharged on 21/04/2026 in stable condition.

Baby: Line preterm male, 980gms admitted to NICU for extreme prematurity care.

Discharge Advice

  • Advised oral medication including iron supplementations and diabetic drugs and insulin.
  • Counselling provided regarding wound care, warning signs, contraception.
  • Follow-up appointment schedule with gynaecology.

Discussion

This care highlights refractory cervical insufficiency with repeated mid- trimester losses despite prophylactic cerclage and pessary. The patient delivered at the threshold of viability. Management of followed ACOG guidelines for cervical insufficiency and extreme prematurity requiring strict glycaemic control.

Conclusion

Cervical insufficiency remains a challenging cause of recurrent pregnancy loss and extreme preterm birth. Early diagnosis, cerclage, progesterone and pessary may prolong pregnancy, but some cases are refractory. Multidisciplinary team approach and NICU Backup are critical for managing previable births.

 

 

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