exposure to DES, or result from trauma (such as from
Incompetent Cervix
Medical Codes
2018 ICD-10-CM Diagnosis Code N88.3
Incompetence of cervix uteri
ICD-9-CM:
654.53 - Abnormality of Organs and Soft Tissues of
Pelvis, Cervical Incompetence; Presence of
Shirodkar Suture with or without Mention of
Cervical Incompetence, Antepartum Condition
or Complication
Related Terms
 Cervical Incompetence
 Cervical Insufficiency
Overview
The cervix is the lower, narrow end of the uterus that
communicates with the vagina. Uterine contractions at
the end of pregnancy trigger cervical dilation, and a
normal birth takes place. However, an incompetent cervix
opens without uterine contractions, simply as a result of
pressure from the growing fetus and its own weakness.
This generally occurs during the late second trimester or
early third trimester of pregnancy and results in
premature delivery or, more likely, miscarriage.
There is no confident method of determining before or
even during early pregnancy whether the cervix will be
incompetent. However there are certain risk factors that
suggest the possibility such as a previous history of an
incompetent uterus, cervical trauma, exposure to
diethylstilbestrol (DES), and abnormalities of the cervix. A
family of disorders called congenital Müllerian duct
abnormalities, and a connective tissue problem called
Ehler-Danlos syndrome have also been implicated. In
most cases, however, the cause is unknown.
If history suggests incompetency, the surgeon may close
the cervix in a stitching procedure called cerclage to
prevent premature delivery.
Incidence and Prevalence: Although cervical
incompetence is a complicating factor in as few as 0.1%
to 2% of all pregnancies (Norwitz), 20% of the time, when
miscarriage occurs between the sixteenth and twenty-
fourth weeks of pregnancy, incompetent cervix is the
cause (Schwarz), and it factors into 10% of all the
preterm deliveries ("Cervical Incompetence").
Causation and Known Risk Factors
Factors that increase the risk of cervical incompetence
(CI) include structural weaknesses or abnormalities of the
cervix. They may be congenital (inherited), involve
D&C procedures). Pap smear biopsy does not increase
risk, but the removal of a wedge of cervix used in the
treatment of precancerous conditions called the cold
knife cone biopsy is associated with a 2% risk of cervical
incompetence. There may be little added risk from two
first-trimester surgical terminations of pregnancy (surgical
dilatation of the cervix); beyond that, successive
procedures result in a 12% risk (Tucker).
Diagnosis
History: The only telling history of CI is a miscarriage
between the sixteenth and twenty-eighth week of an
otherwise uneventful pregnancy. A similar event having
occurred during a previous pregnancy is the best
predictor of cervical incompetence and will alert the
physician to an increased likelihood in future
pregnancies.
Physical exam: Physical examination of the cervix
during the second or third trimester may reveal partial
opening of the cervix (dilation) with shortening and
thinning of the vaginal part of the cervix (effacement).
This results in cervical structural weakness which may
cause premature labor and delivery.
Tests: There are no absolute tests to predict this
condition, but the health care provider may order serial
transvaginal ultrasound studies (TVS) after the sixteenth
week in women with a history suggesting cervical
incompetence. Ultrasoundstudies determine the length of
the cervix, which in a compromised cervix may be
shortened. Even in this case, there is no certainty that
imaging studies are superior to digital examination.
Further, the imaging studies are poor predictors of the
condition in woman with no history of second- or third-
trimester miscarriages.
Treatment
There is usually no treatment without a history suggesting
an incompetent cervix. When the condition is anticipated,
the surgeon may close the cervix using a procedure
called cervical cerclage. There are two approaches to
cerclage: the transabdominal approach, which reaches
the cervix through an incision made into the abdomen
exposing the cervix, or the transvaginal approach, which
enters the cervix through the vagina (transvaginally).
There are advantages and disadvantages to each
procedure. In both cases the cervix is banded or stitched
so it will remain closed under the weight of the growing
fetus. The cerclage is removed just before the time of
delivery or during cesarean section. Studies surrounding
the absolute value of cerclage are often contradictory, but
at this time it seems to offer the best treatment option.
The physician might also consider bed rest, antibiotics,
progestins, and the use of medications to stop labor
(tocolysis); however, there are no firm studies validating
the benefits conferred.
Prognosis
The outlook for a woman with an incompetent cervix will
be an ongoing tendency to premature
labor and miscarriage. The damage is more likely to be
emotional rather than physical. Physical trauma to the
mother following a premature birth is generally modest,
and recovery should be uneventful. Other than premature
births and possible pregnancy and treatment
complications, there are no health risks directly
associated with an incompetent cervix.
Differential Diagnosis
 Abruptio placentae
 Chorioamnionitis
 Infections causing preterm labor
 Uterine and placental insufficiencies
 Uterine contractions
 Uterine distension
 Uterine distortion
Specialists
Obstetrician/Gynecologist
 Comorbid Conditions
 Acute or chronic lung disease
 Anemia
 Diabetes
 Genital herpes
 Heart disease
 Hemoglobinopathy
 High blood pressure (hypertension)
 Obesity
 Uterine bleeding
Complications
General complications will be associated with the general
health of the patient. Complications arising from cerclage
are the same as those associated with any invasive
procedure. Specifically, emergency cervical cerclage may
result in excessive blood loss, abortion, cervical
laceration, complications from anesthesia, infection or
rupture of the fetal membranes, suture displacement, and
stricture of the cervix (cervical stenosis).
Factors Influencing Duration
Duration depends on the consequences of the cervical
incompetence, the therapeutic and surgical methods
used in support of the condition, and the general health
of the individual. In the event of premature birth, the
patient's emotional strength and family support will be
critical.
Ability to Work (Return to Work Considerations)
The degree of mental and physical trauma will dictate any
work restrictions. For some, work may prove emotionally
therapeutic.
Failure to Recover
If an individual fails to recover within the expected
maximum duration period, the reader may wish to
consider the following questions to better understand the
specifics of an individual's medical case.
Regarding diagnosis:
 Has individual had previous pregnancies
spontaneously terminated, approximately between the
fourteenth and twenty-eighth weeks?
 Does individual have a history of DES exposure or
congenital cervical weakness?
 Has individual had prior trauma to the cervix from
D&C procedures or cold knife cone biopsy?
 Has ultrasound cervical measurement been
considered?
Regarding treatment:
 Has individual undergone cervical cerclage?
 Have bed rest, antibiotics, progestins, or tocolysis
been considered?
 Is individual receiving emotional support?
Regarding prognosis:
 Has miscarriage resulted?
 Has cerclage been performed to help bring the fetus
to term?
 Has individual developed complications from
treatment of the condition, such as infection or heavy
bleeding?
Diagnosis Index entries containing back-references to N88.3:
 Incompetency, incompetent, incompetence
o cervix, cervical (os) N88.3
 Infertility
o female N97.9
 associated with
 congenital anomaly
 cervix N88.3
 cervical N88.3 (mucus)
 dysmucorrhea N88.3
 due to
 cervical anomaly N88.3
 origin
 cervical N88.3
 Patent - see also Imperfect, closure
o cervix N88.3
 Short, shortening, shortness
o cervical (complicating pregnancy) O26.87-
 non-gravid uterus N88.3
 Premature Labor
Medical Codes
2018 ICD-10-CM Diagnosis Code O60.10
Preterm labor with preterm delivery, unspecified
trimester
ICD-9-CM:
644.03 - Early or Threatened Labor, Antepartum
Condition or Complication
644.10 - Threatened Labor, Other, Unspecified as to
Episode of Care or Not Applicable
644.13 - Threatened Labor, Other, Antepartum
Condition or Complication
644.21 - Early Onset of Delivery, Delivered, with or
without Mention of Antepartum Conditions
Related Terms
 Early Onset of Delivery
 Early or Threatened Labor
 Preterm Labor
 Threatened Premature Labor
Overview
Premature or preterm labor refers to the onset of labor
contractions before 37 weeks of gestation. In preterm
labor, contractions are intense and frequent enough to
result in the cervical dilation and effacement that normally
precedes birth. Unlike the irregular nature of false labor
contractions (Braxton-Hicks contractions), premature
labor contractions can dilate the cervix and lead to
premature delivery.
Although the exact cause usually is unknown, many
factors have been associated with premature labor.
Mechanical factors may be involved such as an overly
distended uterus that occurs in multiple gestation (i.e.,
twins, triplets, quadruplets), an excess of amniotic fluid
(polyhydramnios), a weakened cervix (cervical
incompetence), defects of the uterus or the presence
of fibroids, or infection and inflammation of the cervix.
The mother's health status also may play a role. Preterm
labor can be influenced by hormonal changes resulting
from fetal distress or maternal stress and chronic
conditions such as diabetes, asthma, or high blood
pressure (hypertension). Managing preterm labor
requires identifying the factors associated with the
preterm birth, evaluating the status of the fetus,
prolonging gestation if possible, and careful monitoring of
the mother and fetus to achieve the optimum neonatal
outcome.
Incidence and Prevalence: Premature labor is a
complication in approximately 12.5% of all pregnancies;
preterm births occurring after 32 weeks gestation are the
majority of cases; births before 32 weeks are only about
2% of all preterm births (Iams 669). Preterm births,
especially those before 32 weeks, are the leading cause
of infant illness (morbidity) and death (mortality) in the US
(Iams 670).
Causation and Known Risk Factors
Although specific risk factors are not always identified,
pregnant women with certain conditions or history may be
at increased risk for preterm labor, including those with
hypertension, inadequate or excessive weight gain
during pregnancy, chronic medical conditions (e.g.,
diabetes, heart disease, asthma), infections (including
systemic, vaginal, genital or urinary tract infections, and
amnionitis); anemia; pre-eclampsia; short interval
between pregnancies; previous preterm labor; cervical
incompetence; prior Rh incompatibility (isoimmunization
when an Rh-negative mother gives birth to an Rh-positive
fetus); multiple pregnancies (multiparity or grand
multiparity in women with 7 or more births); ovulation
induction via assisted reproductive technologies;
overdistended uterus (polyhydramnios, multiple
gestation); history of infertility; prior abdominal or
gynecologic surgical complications; uterine anomalies
such as müllerian fusion defects; fibroids; retained IUD;
and cervical trauma as a result of elective abortion or
surgery for cervical dysplasia (Ross).
Nonexistent or poor prenatal care can increase risk of
preterm labor. A history of drug abuse, smoking, or
alcohol consumption also can contribute to increased risk
of preterm labor.
Risk factors for premature labor in an otherwise
uncomplicated pregnancy include standing for periods
greater than 4 hours without a break, lifting weights
greater than 25 lb (12 kg) more than 50 times per week,
working more than 36 hours per week or more than 10
hours per shift, and high stress. Estimates are the 15-
40% of premature deliveries are genetic (Muglia).
The risk of premature labor is greatest in women younger
than 15 or older than 35. Black women have twice the
rate of premature labor than other racial groups; 17.8% of
preterm births are to non-Hispanic blacks, 11.9% to
Hispanics, and 11.3% to whites (Iams 673). Women of
low socioeconomic status also are at increased risk of
premature labor, believed due to lack of prenatal care
and proper nutrition and not a factor in racial differences.
Fetal factors that predispose a woman to preterm labor
and/or threatened abortion may include the presence of
birth defects (congenital anomalies) and intrauterine
death [See Miscarriage].
Diagnosis
History: Symptoms of premature labor may include
frequent contractions (more than 4 per hour), cramping,
pelvic pressure, excessive vaginal discharge, and
backache. Premature rupture of membranes often occurs
with the onset of premature labor. The individual’s
obstetric and health history is important to the
management of preterm labor, especially a history of
prior preterm deliveries or complications of pregnancies.
Physical exam: The woman may present with
contractions, cervical dilation (>1 centimeter), cervical
thinning (effacement) exceeding 80%, ruptured
membranes, or a change in cervical dilation or
effacement as noted in serial examinations (Iams 673).
The individual also will be assessed for uterine irritability
or abnormalities and for general physical and mental
health status. Examination will include assessment for
any conditions that threaten the health of either the
mother or fetus, including acute maternal conditions such
as kidney disease (pyelonephritis), pneumonia or
asthma, peritonitis, or hypertension, and obstetric
conditions such as pre-eclampsia, placental
abruption, placenta previa, or chorioamnionitis, which
may indicate that delivery is the only course.
Tests: Nitrazine paper testing may be performed to
evaluate pH levels in order to rule out ruptured
membranes. In cases associated with hemorrhage,
laboratory tests may include complete blood count (CBC)
and hematologic workup (hematocrit, hemoglobin,
prothrombin time [PT], partial thromboplastin time [PTT]).
Blood chemistries may be performed, including
electrolytes, kidney and liver function profiles, and serum
glucose testing if the mother’s health status warrants or if
suppression of contractions (tocolysis) is a possible
treatment. A urine culture and sensitivity may be done to
rule out urinary tract infection. Ultrasound scanning is
used to determine fetal size, position, and placental
location. Transvaginal ultrasound is used to assess
cervical integrity and length as indicators of risk.
Continuous uterine monitoring may be necessary,
including possible home uterine activity monitoring
(HUAM). Amniocentesis may be performed to obtain fluid
for assessing fetal maturity. A fetal fibronectin test is used
primarily to rule out premature labor during the
subsequent 14 days.
Treatment
Treatment depends on whether labor is allowed to
continue. Critical factors in this decision include
gestational age, fetal maturity, and the amount of dilation
and effacement of the cervix. The likelihood of survival of
the fetus is reduced if significant complications are
present, such as infection, hypertension, acute obstetric
conditions, hemorrhage in the mother, or fetal distress,
which may suggest that labor should not be stopped.
Standard treatment to prolong gestation usually involves
bed rest with the individual lying on the left side (left
lateral decubitus position). Treatment also includes
sedation, increased fluid intake (hydration), antibiotics,
fetal heart rate monitoring, uterine monitoring, and
antenatal corticosteroids to accelerate lung maturation of
the fetus.
In more urgent situations, labor often can be stopped with
drugs (pharmacologic intervention). Uterine contractions
may be inhibited with beta-mimetic adrenergic agents,
magnesium sulfate, prostaglandin synthetase inhibitors,
and calcium channel blockers. However, these agents
carry potential morbidity, and are used only when risks
and benefits of use are established for the individual
situation. If labor can be stopped, the individual may have
the cervix bound (cervical cerclage). If the labor cannot
be stopped, the individual is transferred to a hospital with
a neonatal intensive care unit for immediate care of a
preterm infant. Internal fetal monitoring is done to
determine the most effective mode of delivery.
Regular prenatal visits to a physician or maternity clinic
are essential for a healthy, safe pregnancy, delivery, and
postpartum period. Evaluation of risk for preterm birth is
essential early in pregnancy and can help prevent
premature labor in women at high risk.
Prognosis
Premature labor can be successfully treated with bed rest
alone if maternal or fetal complications are not present.
The addition of sedation and hydration can prolong
gestation for two or more weeks. Administration of
tocolytic agents between 24 and 33 weeks' gestation is
able to delay delivery for 48 hours, allowing the use of
glucocorticoids to prevent respiratory distress syndrome
in the pre-term fetus; however, tocolytics carry a high risk
of morbidity and neonatal mortality if used at 24 weeks or
less (Ross). Clinical studies have shown that the use of
tocolytic agents only slightly improves the prognosis
compared to bed rest and hydration, which do not
increase morbidity. If labor cannot be stopped, a
premature infant will be delivered. Survival of the fetus is
greatly influenced by the gestational age; for example,
survival of a 24-week fetus is 40%, survival of a 30-week
fetus is 93% and survival of a 34-week fetus is 97%
(Ross). Long-term morbidities that may affect an infant
born before 26-weeks gestation include chronic lung
disease, neurosensory impairment, cerebral palsy,
reduced cognition and motor performance, attention
deficit disorders, and vision and hearing problems (Iams).
 Differential Diagnosis
 Braxton Hicks contractions (false labor)
 Specialists Gynecologist
 Obstetrician/Gynecologist
 Comorbid Conditions
 Anemia,
 Cardiovascular disorders
 Circulatory disorders
 Diabetes
 Fibroids
 Obesity
 Rh incompatibilities
 Systemic infections
Complications
Complications include maternal infection, hemorrhage,
stress, and depression from delivering a premature
infant, along with increased morbidity and mortality of the
premature infant. Death and disability are more likely in
infants born before 32 weeks gestation; prematurity is
responsible for more than 70% of fetal and neonatal
deaths, and conditions such as visual and hearing
impairment, chronic lung disease, cerebral palsy, and
delayed childhood development (Iams 670).
Factors Influencing Duration
Length of disability is influenced by how far the
pregnancy has progressed before labor begins, methods
used to stop premature labor, response to treatment, and
presence of bleeding, infection, or other complications.
Bed rest may be required until delivery.
Ability to Work (Return to Work Considerations)
Possible work restrictions and accommodations may
include extended leave or placement on short-term
disability. If the individual is allowed to return to work,
shortened work hours, increased rest breaks, and
transfer to sedentary duties with no lifting and limited
standing may be required.
Failure to Recover
If an individual fails to recover within the expected
maximum duration period, the reader may wish to
consider the following questions to better understand the
specifics of an individual's medical case.
Regarding diagnosis:
 Has diagnosis of premature labor been confirmed?
 Is there a history of prior preterm delivery?
 Have confirmatory tests such as transvaginal
ultrasound, fetal fibronectin, or amniocentesis been
done?
 What underlying conditions may have caused
contractions to begin?
 What is the gestational age of the fetus? Was lung
maturity evaluated?
 What neonatal morbidity and mortality was expected
given the gestational age and other indicators?
 Were any conditions present that endangered the
health of mother or fetus?
on the left side?
 Can contributing underlying conditions be treated?
 Did regimen include appropriate sedation, increased
hydration, antibiotics, fetal heart rate monitoring,
uterine monitoring, and antenatal corticosteroids to
accelerate fetal lung maturation?
 If the situation was more urgent, were drugs able to
stop the uterine contractions?
 If the labor could not be stopped, was individual
transferred to a hospital with a neonatal intensive care
unit?
 Was internal fetal monitoring done to determine the
most effective mode of delivery?
Regarding prognosis:
 Did individual respond to treatment? Was premature
labor stopped?
 If the labor could not be stopped, was there a
premature delivery?
 Did mother or infant experience any complications
that may affect recovery?
Diagnosis Index entries containing back-references to O60.10:
 Delivery (childbirth) (labor)
o preterm O60.10 - see also Pregnancy, complicated
by, preterm labor
 Pregnancy (single) (uterine) - see also Delivery and
Puerperal
o complicated by (care of) (management affected by)
 preterm labor
 with delivery O60.10
 preterm O60.10
 preterm delivery O60.10
 Premature - see also condition
o delivery O60.10 - see also Pregnancy, complicated
by, preterm labor
 Preterm
o delivery O60.10 - see also Pregnancy, complicated
by, preterm labor

Regarding treatment:

Was it determined that labor should be stopped in this

case?

Did treatment include bed rest with the woman lying