Causes for Concern during Your Second Trimester

By Joanne Stone, Keith Eddleman, Mary Duenwald

Following are descriptions and symptoms of some problems that can develop during the second trimester of your pregnancy. Should you have any of these symptoms, discuss them with your practitioner.

Bleeding

Some women experience bleeding in the second trimester. Possible causes include a low-lying placenta (placenta previa), premature labor, cervical incompetence, or placental abruption. Sometimes the doctor can’t find a cause.

If you do experience bleeding, it doesn’t necessarily mean you will have a miscarriage, but you should call your doctor. Most often he’ll recommend you have an ultrasound exam and be monitored to make sure that you’re not contracting. Bleeding may increase the risk for premature delivery, so your doctor may recommend that your pregnancy come under extra-close surveillance.

Fetal abnormality

Although the vast majority of pregnancies proceed normally, about 2 to 3 percent of infants are born with some abnormality. Most of these abnormalities are minor, although some do lead to significant problems for the newborn. Some are due to chromosomal problems, and others stem from abnormal development of organs and structures.

For example, some newborns may have heart defects or abnormalities of the kidneys, bladder, or gastrointestinal tract. Many of these problems, though not all of them, can be diagnosed on a prenatal ultrasound exam.

When confronted with any such problem, the most important first step is to gather all the available information about it, so that you know what to expect and what the treatment options are. Keep in mind that even specialists may not be able to tell you everything to expect until your baby is born and they can further evaluate the situation.

Cervical insufficiency/incompetent cervix

During the second trimester, usually between 16 and 24 weeks, some women develop a problem known as cervical insufficiency or incompetent cervix. The cervix opens up and dilates, even though the woman feels no contractions. This condition may lead to miscarriage.

Indeed, an incompetent cervix is most often diagnosed after the miscarriage occurs and, in most cases, couldn’t have been predicted. A woman who develops this condition ordinarily doesn’t notice any symptoms, although sometimes she may report feeling pelvic heaviness or pressure that’s out of the ordinary, or she may notice some spotting.

Most women who experience cervical insufficiency do so for no identifiable reason. Others may have one of the following risk factors:

  • Cervical trauma: Some evidence suggests that multiple D&Cs (dilation and curettage) or procedures called cervical cone biopsy or LEEP (in which a cone-shaped portion of the cervix is removed in the diagnosis or treatment of cervical abnormalities) can increase the risk of cervical insufficiency. A significant tear of the cervix during a prior delivery may also increase the risk for this disorder.

  • Multiple gestations: Some obstetricians believe that carrying multiple babies, especially triplets or more, may increase the risk for cervical insufficiency. This issue is very controversial because some doctors feel strongly about putting them in, but placing a cerclage (a stitch in the cervix) in all patients with triplets or more does not appear to help based on the available literature surrounding this subject.

    Some patients who have undergone a procedure called multi-fetal pregnancy reduction may also be at increased risk for incompetent cervix, although routine cerclage placement isn’t recommended for them at this time.

  • Prior history of cervical insufficiency: After you have had a cervical insufficiency, your risk of having it again in a subsequent pregnancy is increased.

In cases in which a cervical insufficiency is diagnosed before the pregnancy is lost, attempts can be made to hold the cervix shut with a stitch, called a cerclage, around the cervix. The cerclage is usually placed at 12 to 14 weeks, although it’s occasionally performed as an emergency procedure later in the pregnancy.

Doctors most commonly perform the procedure in the hospital under spinal or epidural anesthesia, but the woman is usually discharged later the same day.

Some women with a cerclage notice they have a heavy discharge throughout pregnancy. If you need to have a cerclage, talk to your doctor about how active you can be — whether you can have sex and how much exercise is advisable.

Complications associated with emergency cerclage include infection, contractions, rupture of membranes, bleeding, and miscarriage. The same complications can occur with elective cerclage, but they’re unusual.

Many doctors are now using a pessary, which is a plastic/rubber device that is inserted into the vagina to take some of the pressure off of the cervix. The device is easily inserted and removable, so it doesn’t carry the same risks as a cerclage since there are no needles involved.

Knowing when to seek help

The following is a list of second-trimester symptoms that require some attention. If you experience any of them, call your practitioner:

  • Bleeding

  • An unusual sense of pressure or heaviness

  • Regular contractions or strong cramping

  • A lack of normal fetal movement

  • High fever

  • Severe abdominal pain