Isthmic-cervical insufficiency (ICI) during pregnancy: causes, symptoms, treatment. Isthmic-cervical insufficiency

Each future mom dreams that her pregnancy will proceed easily and calmly and end with the birth of a long-awaited baby. But, unfortunately, this is not always the case. Some disorders in the female body can cause a threat of termination of pregnancy in the first trimester, while others, which is even more sad, in the second or even third. And among such problems, which often become the cause of late spontaneous miscarriages or premature birth, includes isthmic-cervical insufficiency (ICI).

What is ICN and why is it dangerous?

The uterus is muscular organ, which includes the body and neck. The fetus develops in the body cavity, and the cervix helps hold it and protects it from infection. The cervical canal from the side of the uterine body is limited by the internal pharynx, and from the side of the vagina - by the external pharynx. Normally, during pregnancy, the cervical muscles close into a ring and relax gradually as labor approaches. But sometimes the muscles of the neck weaken earlier than required, and it begins to shorten and open. This state is called isthmic-cervical insufficiency. It occurs in 1-9% total number pregnant women and in 15-42% of women with recurrent miscarriage. Dilatation of the cervix leads to the descent of the amniotic sac into the lower part of the uterine cavity, as a result of which the membranes of the fetus become infected and open prematurely. Then labor develops, leading to late miscarriage (up to 22 weeks of pregnancy) or premature birth (up to 37 weeks) with the appearance of a premature baby.

Risk factors for ICI

The reasons that can cause the development of isthmic-cervical insufficiency during pregnancy are considered:

• injury to the cervix (severe ruptures and damage) during childbirth or abortion
• treatment of cervical pathologies by conization or amputation
• abnormalities of the uterus
• functional changes for dysplasia connective tissue, hyperandrogenism, sex hormone deficiency
• carrying out IVF
• multiple births, polyhydramnios, large fetus.

Symptoms and signs of ICN

It is difficult to suspect the development of ICI on your own. In the first trimester of pregnancy, its symptoms are usually absent. In the future, signs characteristic of a threatened miscarriage may appear: a large number of bloody or mucous discharge streaked with blood, pain in the lower back and lower abdomen, a feeling of “fullness” or “pressure” in the vagina. But most often, ICI is asymptomatic, so every pregnant woman should regularly visit an obstetrician-gynecologist in order to recognize it in time. Doctors determine ICI by examining the cervix with a speculum, by performing a digital vaginal examination, or by performing an ultrasound.

Upon examination the doctor may notice softening and shortening of the cervix, and then the opening of its canal, in which the amniotic sac is visible. But since the external os nulliparous women may be closed, it is important to confirm the diagnosis using transvaginal ultrasound.

On ultrasound signs of ICN are determined according to the following criteria:

• cervical length

Normally, at 24-28 weeks of pregnancy it is 35-45 mm, after 32 weeks - 30-35 mm. Shortening at 20-30 weeks to 25 mm or less confirms the doctor’s fears.

• the presence of a V-shaped opening of the internal throat

it is easy to determine, and additional tests can be performed with pressure on the fundus of the uterus or cough.

Upon confirmation of the diagnosis, the gynecologist makes a decision on methods for correcting ICI and the possibility.

Treatment of ICN

There are two main methods: surgical and conservative. They are often used simultaneously.

Surgical method

It involves placing sutures on the cervix, in which the internal os is mechanically narrowed and the external os is sutured, which significantly reduces the likelihood of miscarriage.

The timing of the operation is set individually, but most often - up to 17 weeks, in order to avoid progression of the process, and no later than 28 weeks of pregnancy. Sutures are placed in a hospital under short-term intravenous anesthesia, which does not affect harmful influence for the fruit. Usually, a few days before the intervention, a smear is taken from the cervical canal to determine pathogenic microflora and carry out preliminary sanitation of the vagina. There are also contraindications to surgical treatment of ICI: severe maternal illness, non-developing pregnancy, congenital pathologies fetus, placenta previa. To prevent complications after surgery, the composition of the microflora is examined again, and the vagina is treated with antiseptics. Drugs that reduce uterine tone (such as ginipral, indomethacin, magnesia) and antispasmodics (papaverine) are often prescribed. Hormonal therapy is used according to indications. Sutures are inspected every 2-3 weeks and removed in the following cases:

• after 37-38 weeks of pregnancy
• at the onset of labor at any stage
• with leakage and rupture of amniotic fluid
• when bleeding occurs
• during teething

After removal of the sutures, in case of complications, necessary treatment. If repeated correction is not possible, bed rest and long-term use tocolytics.

Conservative way

It consists of installing an obstetric unloading pessary (Meyer ring) - a specially shaped plastic structure that is placed in the vagina on different dates pregnancy (including after 28 weeks, when suturing is not possible). It redistributes the weight of the fetus and helps the cervix hold it. Installation of a pessary is effective in case of suspicion and early stages ICN. In case of severe manifestations, the method is used as an auxiliary one. The presence of a foreign body in the vagina can cause dysbiosis, so doctors prescribe preventive courses of sanitation with antiseptics and regularly take smears. Antibiotics are prescribed if necessary. The pessary is removed at 37-38 weeks of pregnancy or immediately after the onset of labor at any stage.

Compliance with the regime

Do not forget that the success of treatment for ICI also depends on the woman’s compliance with special caution in all household activities: she needs to reduce physical activity as much as possible, avoid sexual intercourse, avoid stress, regularly visit the doctor and take prescribed medications. You should rest more and, if possible, delegate household chores to loved ones. Equally important is positive psychological attitude and faith in success. All this will help to prolong your pregnancy as much as possible and give birth to a healthy baby.

My story is about how you can endure Pregnancy with ICI or what helped me on this difficult path.

My history

I knew I was pregnant even before the test showed it. Which I couldn’t resist and did on the first day of the delay at 4 am. I still remember the feelings of unreality, absolute happiness and ecstasy, and then fear.

My first pregnancy is over. And this pregnancy began with a strong tug in the lower abdomen. So much so that I even went to the gynecologist, who confirmed the pregnancy and said that everything was fine and there was no need to be nervous.

I registered at 12 weeks. Before this, all that tormented me was fatigue, so I had to sleep during the day and also an aversion to certain smells. There was no toxicosis, I didn’t feel sick.

I signed up for pregnancy yoga and the pool. We started taking courses for pregnant women (which helped us a lot). All tests were good. And the doctor even persuaded me to have an ultrasound, which I agreed to only because of the outcome of my previous pregnancy.

I told my doctor that I suspected ICI or isthmic-cervical insufficiency. The doctor waved me off and said that everything was fine with me. But the second screening was scheduled for 18 weeks, in order to do more cervicometry- measuring the length of the cervix. Back then I had no idea how many times I would have to do this procedure.

It was at this screening that we found out that we were expecting a son and that my neck was good and long, 35 mm. I relaxed and even stopped worrying. The doctor said to repeat cervicometry only at 24 weeks, but I myself went to an ultrasound specialist, explained my fears and she agreed to see me after her work shift In 2 weeks. And it saved my son’s life.

During the May holidays we went to my parents in St. Petersburg, where we had a wonderful time. We were at the dacha, walked in the forest and went to the mall.

Immediately upon arrival, as I agreed with the ultrasound doctor, I went for cervicometry. I immediately realized that something was wrong; The doctor’s face changed dramatically and she even asked her colleague to look at the screen. My cervix has shortened to 7mm! From 35!!! And this was in just 2 weeks! And the opening of the cervix from above began.

They loaded me straight from there on a gurney into an ambulance and took me to the maternity hospital, where after 2 days they urgently stitched my cervix, as the only way support her and not lose the baby.

Then I spent another week in the hospital under the supervision of doctors. The cervix became 1.7 cm.

They discharged me with orders to lead a normal life. But since I had a lot of free time and the Internet, I climbed a bunch of American, British and Russian forums devoted to the problem of ICN (and there were a lot of them!) and decided that I would be on bed rest for at least up to 28 weeks. That is, until the time when my baby can survive if premature birth suddenly begins.

I was in bed for 7 weeks. I only went to the toilet and showered twice a week. And I also went in the back seat of the car, lying down, to the doctor for an appointment and for cervicometry (the length of the cervix was monitored by ultrasound and it was such a great joy for me to hear that it had not decreased and that the sutures were holding). We went for cervicometry every 2 weeks until 32 weeks, then the doctor said that there was no point in monitoring further.

All this time I thought I was going crazy. Lying down all day and doing nothing is already deadly, and at the same time being afraid of any sensation inside, perceiving it as something bad with the baby, is 1000 times worse.

As a result, I stood up for the first time on my husband’s birthday. My back hurt and my legs didn’t obey me. And this continues almost until childbirth. They only saved me manual therapy and massage.

I gave birth at 35 weeks and 3 days, that is, 8 one month old baby. My water broke at home and the stitches were removed in the maternity hospital. I already wrote about how my husband and I gave birth in.

What is ICN?

If we talk in simple language, that is inability of the cervix to perform its function, namely, to play the role of a kind of barrier between the vagina and the amniotic sac.

Normally, the cervix is ​​long, longer than 3 cm, and begins to contract before childbirth. If the cervix during pregnancy is shorter than 3 cm, then there is a high risk of premature birth. This is what happened during my first pregnancy, my cervix shortened and I went into premature labor at 18 weeks. So I lost my baby and realized that I had ICN.

Typically, ICN is placed if there has already been a failed pregnancy that ended due to an incompetent cervix.

No one could explain to me where I got such happiness from; there were no gynecological operations, no abortions.

How can you carry a pregnancy to term with ICN?

Firstly, everyone who reads this post and who has ICI - know that it is possible to carry a pregnancy to term with ICI! I'm living proof of that.

Secondly, it will most likely be difficult. But it's definitely worth it. Below I will describe what I did and what I followed. And what I think helped me now hold my son in my arms.

Supplements

Pregnancy is a special delicate state of the body that requires additional nutrition. Therefore, throughout my pregnancy I took:

• Probiotics specially formulated for pregnant women; I increased the dosage to 2 capsules per day.

Vitamin C

I found a study suggesting that taking this vitamin may reduce the risk of preterm birth. In addition, it helps support the immune system and prevents the development of infection, which is very useful when you have stitches on the cervix. I drank natural vitamin C, 1 capsule 2 times a day with meals.

Garlic

is a powerful natural antibiotic that does not destroy our precious intestinal microflora and preventing the development of infections. Eating raw garlic is not always convenient or desirable, so I took it as a supplement, 1 capsule 2 times a day with meals.

Cranberry extract

Or rather special active substances, which it contains are famous for the fact that they can treat and prevent infections urinary system. During pregnancy, and especially stitches, this is very important. I took cranberry extract once a day with meals.

Medications

Vaginorm-S

This drug was recommended to me by a friend, who, in turn, was strongly recommended to her “for stitches” by an eminent professor of obstetrics and gynecology. This ascorbic acid, which normalizes vaginal pH and is used for bacterial vaginosis. I decided that this was in every way better than Hexicon, which my doctor prescribed for me.

I used Vaginorm 2 times a week immediately after I had stitches and before giving birth. Seams are foreign material and fertile ground for possible infection therefore, it is very important to try to maintain normal vaginal pH and its microflora.

Duphaston

I am an ardent opponent of hormonal therapy, but I agree that sometimes it becomes vital. Duphaston is a drug female hormone progesterone. I found a study saying that taking progesterone “keeps the cervix normal” and prevents it from shortening.

I took it from the moment I was admitted to the hospital (they gave me injections), then I switched to the tablet form and began to “come off” it very slowly and gradually, starting at 34 weeks, as the doctor told me).

Nifedipine

This drug is commonly used to lower blood pressure.

In the States he is already very for a long time used for uterine tones/contractions. In Russia, Ginepral was previously used for this reason, but many people were shaking from it in the literal sense of the word, so some gynecologists now prescribe Nifedipine.

I drank it from 24 to 32 weeks. Now I doubt if this should have been done. Because after studying the topic of uterine tone, I realized that this is generally the wrong term. The uterus is a muscular organ that must contract and relax. In addition, there are so-called training contractions or Braxton-Hicks contractions, which do not in any way affect the length of the cervix.

But then I was in a panic, I was very afraid of losing my son, and so I started taking them.

These pills should not be taken in the first trimester, as they affect organogenesis and can lead to defects.

Water

I drank a lot of water. About 3 liters a day. Firstly, during pregnancy you need to drink so that the baby has sufficient quantity amniotic fluid. Secondly, drinking enough water can prevent infection in the vagina, which can again lead to premature birth. And stitches are a good breeding ground for infection.

Bed rest

This was another thing that I did not do as the doctor told me. But I’ve read a lot of American forums dedicated specifically to the problem of ICN. And there, some of the doctors prescribed bed rest, some did not. But a lot positive feedback from those who adhered to it. And I decided that I would do it too.

This was the hardest part of my pregnancy. Stay for a month and a half. Get up only to go to the toilet and shower 2 times a week. And see a doctor once every 2 weeks.

I thought I was going crazy, but now I don’t even remember it because it was not in vain. I read a lot, worked on the blog (prepared posts in advance during childbirth and recovery), talked with friends, ordered things for my son. My mother and sister moved in with us one by one and helped at home. We couldn't have done it without them.

Positive attitude

It was very difficult for me to set myself up for a good outcome.

I didn’t sleep well because every sensation was perceived by me as something scary and wrong or as a signal of premature labor. It was very scary, I was constantly worried. But then I realized that I need to talk to my son and my body on the contrary.

I made stickers with positive and in short phrases, which I pasted all over the house and repeated them several times a day. I listened to meditations and beautiful Celtic music. I talked to my baby and said that everything would be fine.

Before they found ICN, I was very active image life. I walked a lot, went to the pool and prenatal yoga. After I got stitches I had to forget about all this.

I started doing gymnastics while lying in bed, stretching my arms, legs and back. Massage also helped a lot. And of course, frequent rolling from side to side.

Subsequent pregnancies

During childbirth, the doctor told me that I had true ICI and that in all subsequent pregnancies I would need to have so-called preventive sutures at 11-13 weeks of pregnancy.

I read on the forums that if you put stitches in advance at an early stage, then there is a chance that the cervix will not “float” and you will be able to lead a normal life without bed rest. That's what I plan to do next time. But in any case, even with stitches, the cervix will have to be monitored every 2 weeks with cervicometry.

According to statistics, emergency suturing allows pregnancy to be carried out in about 50% of cases, while preventive suturing allows for pregnancy to be carried out in 80-90%.

I used to always say that pregnancy is not a disease and I still think so. But now I consider this as a special delicate state, when a woman changes not only outside, but also inside, her inner world. And it is important to maintain this peace inside.

It was very difficult for me to maintain this peace, my pregnancy was very difficult also because there was not enough information about ICI, especially the natural approach to treating this condition. I had to combine two completely different approaches to treatment: conservative and more natural. And I decided that my experience can help all those who are in a panic looking for answers to such difficult questions, does not know where to turn and where to look for support.

ICN turns out to be a fairly common phenomenon in our time, but this is far from a death sentence; you can and should bear babies with it. Know that you are not alone, believe in the best and soon you will also be holding your baby in your arms!,

For almost any woman, pregnancy is a long-awaited and joyful event that is perceived as a holiday. Moreover, both parents are expecting the baby. However, no matter what progress there is in the field of obstetrics and gynecology, not every pregnancy ends without any abnormalities. One of these pathologies includes ICI during pregnancy.

Statistics show that the share of ICI is approximately 30 to 40% of all cases of late spontaneous miscarriage (including premature birth).

What is ICN?

Many expectant mothers may be frightened by these three letters, so let’s consider whether this is justified or not, maybe all the fears are in vain? The reproductive organ of a woman is, one might say, a muscular structure, where there is, in fact, the body of the uterus and the cervix. The fetus develops in the cavity, and with the help of the cervix it is held, and it does not allow it to leave the uterus. In addition, protection against infections is provided. Its canal is limited by the internal os in relation to the body and the external os in relation to the vagina.

IN in good condition the muscles of the cervix contract and form a ring, and as labor approaches, they gradually relax. During pregnancy, the fetus gradually grows, which leads to an increase in amniotic fluid. As a result, intrauterine pressure also increases, and it is sometimes difficult for the cervix to withstand such a load. That's what it is - ICI during pregnancy.

Therefore, in some cases, the cervix begins to weaken prematurely, and as a result, shortens and dilates. Fully this pathology stands for isthmic-cervical insufficiency.

Certain risks

If the cervix is ​​not able to cope with the load under the influence of the fetus, this can lead to various undesirable consequences. In particular, these may be following cases:

• The fetus descends - the fetal membrane may appear in the uterine cavity, which is easily damaged when sudden movements.
• Infection of the fetus - this can occur during contact of the membrane with the vagina, which contains a large number of microorganisms, most of which are harmful.
• Threat of miscarriage, and during the 3rd trimester.
• Premature labor may occur (around the 37th week), resulting in the baby being born premature.

All these risks give an almost complete picture of what it is - ICI during pregnancy. In most cases, the disease can develop after the 16th week of pregnancy. But sometimes this kind pathology also occurs in women who are pregnant at 11 weeks.

Types of pathology

There are several types of this pathology:

• traumatic;
• functional.

Traumatic ICI usually occurs as a result of surgery to the uterus before conception. Moreover, if the need for this was associated with stretching of the cervix, then damage to the integrity of the cervix is ​​possible. Adhesions could form in the connective tissue at the surgical site. As a result, these areas are no longer capable of stretching and contracting.

Similar types of surgical procedures include abortions and curettage. In addition, this also includes situations of rupture of the cervix during the previous delivery of a child.

Functional ICI of the cervix during pregnancy is usually provoked by a disorder hormonal levels, which is caused by a lack of the female sex hormone progesterone or an excess of another - male hormone androgen. The latter leads precisely to softening the muscles of the cervix. Most often, this form occurs after the 11th week of pregnancy.

At this time, the fetal glands begin to function internal secretion. His endocrine organs Androgens are what form. And as you know, due to excess of their quantity, even if insignificant, the cervix softens under their influence, shortens, which, in turn, leads to its premature dilatation.

What should pregnant women take into account?

It is usually possible to diagnose the presence of ICI already in the period from the 11th to the 27th week of pregnancy, but in most cases this is the 16th-27th week. It is during this period that the child begins to produce androgens, as mentioned above. At the same time, the tone of the uterus can remain normal. And if a woman does not visit a gynecologist, as required, then she may not even suspect that she has ICI during pregnancy.

The vagina is home to various bacteria. Moreover, during any inflammatory process their number increases significantly. And this already has a bad effect on the development of the child in the womb, since there are no longer any obstacles for microorganisms to penetrate into the uterine cavity, as soon as the cervix opens a little.

As a result, the fetal membrane loses its protective properties. In addition, everything can end with the rupture of amniotic fluid. In such a situation, as a rule, a miscarriage is not accompanied by pain, and the beginning of this process is the discharge of amniotic fluid.

Main causes of pathology

Isthmic-cervical insufficiency is caused by decreased tone muscle tissue, which forms the uterine sphincter, the main role of which is to keep the cervix closed. Moreover, it should last throughout the entire period of pregnancy, right up to the birth of the child.

However, with such a pathology, this mechanism does not work properly, which leads to premature opening of the cervical canal. As you can understand, this happens for a reason - there must be reasons for ICI during pregnancy. In most cases it is caused by injury uterine cervix.

In addition, ICI can often occur in women who have undergone one of the fertility-destroying operations, or, in other words, medical language, embryotomy. As a result of such surgical interventions, not only the cervix is ​​injured, but the location of the uterus is disrupted. muscle cells in relation to each other. As a result, they are no longer able to fully function.

Who may be at risk?

Some factors contribute to the development of ICI, and therefore those women who have them automatically fall into the risk group for developing isthmic-cervical insufficiency. These include:

• Cervical rupture, as determined by research data.
• Excessive concentration of male sex hormones (hyperandrogenism).
• Abnormal development reproductive system female body.
• The presence of genital infantilism.
• Carrying out IVF.
• Insufficient amount of progesterone.

In addition, the risk of ICI during pregnancy can be caused by other factors. For example, multiple pregnancy or polyhydramnios. And here the cervix has to experience a much greater load than during a normal pregnancy (one child). This may also be a reason to begin the development of ICN. In addition, we should not forget cases when the uterus develops with defects.

Symptoms of ICI during pregnancy

From a clinical point of view, the pathology does not manifest itself in any way, since the opening of the internal pharynx occurs gradually and painlessly. For this reason, it is very difficult for a woman to find out what condition the cervix is ​​in and whether there is real threat baby. This is especially true in the first trimester of pregnancy.

Nevertheless, some symptoms by which cervical isthmus can be recognized are still present, although they are observed a little later. During the first three months of gestation, bleeding without pain can be a sign of ICI during pregnancy, and only in some cases is this accompanied by mild discomfort.

For more later pregnancy (usually the period from the 18th to the 20th week), ICI can cause fetal death and, accordingly, miscarriage. Signs that indicate such a threat may include the following:

• In addition to the bleeding itself, the discharge contains mucus and blood streaks.
• Painful sensations or noticeable discomfort in the back and lower abdomen.
• Feeling of vaginal distension.

But since in most cases the development of pathology is painless and practically in the absence of any symptoms, it is necessary to regularly visit a gynecologist to check your condition. This is the only way to detect pathology in a timely manner and quickly determine the course of treatment.

Diagnosis of ICI during pregnancy

How is the diagnosis done? To do this, doctors conduct a mirror examination of the cervix, palpation of the vagina, and ultrasound. During the examination of the woman, the doctor can determine the shortening of the cervix, as well as the fact that it has become softer. It is also able to detect the opening of the canal and whether the amniotic sac is visible.

If this is a woman’s first pregnancy, then in this case the external os is usually closed. Therefore, for the decision accurate diagnosis Transvaginal ultrasound is prescribed. Ultrasound scanning is the most informative method for determining ICN. The main symptom is shortening of the cervix, and depending on the stage of pregnancy, there are different normal indicators:

• up to six months: canal size is 34-45 mm;
• V later periods this figure is already slightly less - 30-35 mm.

If a woman has obvious symptoms of ICI during pregnancy, then the size of the canal is even smaller. That is, if it is shortened to 25 mm or less, then this indicates a probable miscarriage or premature pregnancy.

What is characteristic is that the cervix in the presence of ICI opens in a V-shape, which is clearly detected during ultrasound examination. In some cases, a stress sample is taken during the scan to confirm the diagnosis. That is, the woman is asked to cough or pressure is applied to the body cavity of the uterus.

If the expectant mother is at risk or is present indirect signs pathologies, ultrasound scanning is prescribed at least twice a month.

Features of treatment

If a woman has been diagnosed with isthmic-cervical insufficiency, treatment must begin immediately, for which the obstetrician-gynecologist is responsible. To be effective, it is carried out in a hospital setting, which allows you to choose the optimal technique.

In total, there are two main ways to correct ICI during pregnancy:

• operational;
• conservative.

The first type includes surgical intervention, which avoids further dilatation of the cervix. The second is the installation of a special design called the Meyer ring. It can also also be assigned hormone therapy.

Surgery

The essence this method treatment consists of mechanical narrowing of the internal pharynx by suturing the external pharynx. The applied suture can be:

• U-shaped.
• Circular.
• Kisetny.

Before the procedure, a vaginal smear is taken for detailed examination. This is done in order to find out whether the woman has contraindications to the operation. These include:

• congenital anomalies fetus;
• presence of severe vaginitis;
• diseases chronic form in which it is not recommended to bear a child;
• bleeding of the uterus;
• complications caused by gestosis;
• intractable uterine hypertonicity;
• rapid progression of ICI.

The operation itself to eliminate ICI during pregnancy takes place in several stages:

1. Diagnostics.
2. Preparation - vaginal sanitation may be provided here.
3. The procedure itself - suturing the pharynx is carried out under local anesthesia using silk threads. After which the seam is treated with antiseptics.
4. Rehabilitation course.

To minimize the risk of complications, various medical supplies in the form of antispasmodics (drotaverine hydrochloride), antibiotics (if necessary) and tocolytics (Ginipral, magnesia). The latter should be taken when the uterus is toned.

As for the timing for this operation, everything is individual. Usually no later than the 17-28th week of pregnancy, so that the progression of the pathology can be avoided.

On the second or third day after the operation, the cervix is ​​examined, and if the patient has no complaints, she is discharged under the supervision of a specialist. Further routine inspection is carried out every two weeks during treatment with ICI during pregnancy.

During normal pregnancy, sutures are removed at 37-38 weeks. This also includes the onset of labor (regardless of the period), the appearance of regular contractions, bleeding, and the cutting of a suture.

Conservative treatment

Using a rubber or latex structure (also called a “pessary”), you can redistribute the pressure inside the uterine cavity, including the weight of the fetus, which slightly relieves the load on the cervix. The method is different high efficiency on initial stage development of pathology. If the disease is already progressing, the ring is used as an adjuvant treatment.

Typically, a pessary can be installed even in late stages of pregnancy - more than 28 weeks, while stitches are no longer possible. Since the ring, which helps eliminate ICI during pregnancy, is perceived by the woman’s body as foreign body, then doctors prescribe sanitation antiseptics and smears are taken regularly. If necessary, antibiotics are prescribed.

Every two weeks, the ring is removed and processed to eliminate the possibility of infection of the fetus. It is completely removed after 37-38 weeks of pregnancy or with the onset of labor, regardless of the period.

What's the prognosis?

A pathology such as isthmic-cervical insufficiency is fraught with miscarriage, which in most cases occurs spontaneously, or with premature birth. In addition, dilation of the cervix threatens infection of the fetus, which negatively affects its further development.

The prognosis of the stage of ICI depends on how much the cervix is ​​dilated, the period of gestation, how effectively procedure in progress treatment and the presence of infectious agents.

The shorter the gestation period of the child and the more it opens cervical canal, the less chance of a successful outcome. This is confirmed by reviews of ICI during pregnancy.

Statistics show that ICI occurs in every 10th woman in labor who has it for the first time. Women with “experience” take risks much more often. And what is characteristic than large quantity a woman bears children, the higher the risk of pathology in the next pregnancy.

Therefore, those mothers who want another child need good preparation. First of all, you need to get rid of chronic endometritis(if any) and normalize the vaginal microflora. During the violation protective function the cervix, pathogens of various infectious diseases can enter her body.

In this regard, it is necessary to take a course of antibiotics, and since all women different features body, then taking medications is prescribed strictly individually. The effectiveness of such therapy is assessed based on bacteriological research taken sample.

Preventive actions

As many reviews about the treatment of ICI during pregnancy note, the effectiveness of the procedure depends on whether the pregnant woman is careful in everything. It is necessary to refrain from large physical activity, sexual intercourse, avoid stressful situations, do not ignore visits to the doctor and take the necessary medications.

During pregnancy, it is important to rest as much as possible, and close people can do all the housework. It is also important to maintain your emotions in a positive way and prepare yourself in advance for the successful birth of your baby without any complications!

To prevent premature birth, for the period from the 20th to the 40th week of gestation, the doctor may prescribe medications that contain progesterone. One such remedy is Utrozhestan. For ICN during pregnancy, it is often prescribed. This hormone is produced by the placenta, and it is simply vital for proper development pregnancy. In this connection, “Utrozhestan” is well known both to many gynecologists and to women who have already passed the path from conception to the birth of a child.

To console expectant mothers, we can cite many cases where a woman loses her child due to ICI, but ultimately ends up with a healthy and fully developed baby. This proves in practice that a lot depends on the efforts of doctors, the mother herself and the timeliness of treatment.

ICNs are considered the most common cause termination of pregnancy in the second trimester, and its frequency in patients with recurrent miscarriage reaches 13–20%. The pathognomonic signs of ICN are the painless shortening and subsequent opening of the cervix ending in miscarriage, which in the second trimester of pregnancy leads to prolapse of the amniotic sac and/or rupture of amniotic fluid, and in III trimester- to the birth of a premature baby.

Risk factors for ICI are listed below.

· History of cervical trauma (post-traumatic ICI).
- Damage to the cervix during childbirth [ruptures not repaired surgically, surgical birth through natural birth canal(overlay obstetric forceps, birth of a large fetus, fetus in breech, fruit-destroying operations, etc.)].
- Invasive methods of treating cervical pathology (conization, amputation of the cervix).
- Induced abortions, late pregnancy terminations.
· CD of the cervix (congenital ICI).
· Functional disorders(functional ICI) for hyperandrogenism, connective tissue dysplasia, increased content relaxin in the blood (noted when multiple pregnancy, induction of ovulation by gonadotropins).
· Increased load on the cervix (polyhydramnios, multiple births, large fetus).

DIAGNOSTICS ICN

It is usually impossible to assess the likelihood of developing ICI before pregnancy. Such an assessment is possible only in post-traumatic ICI, accompanied by gross anatomical disorders. In this situation, hysterosalpingography is performed on days 18–20 of the menstrual cycle to determine the condition of the internal pharynx. Its expansion by more than 6–8 mm is regarded as an unfavorable prognostic sign.

In patients suffering from recurrent miscarriage in the second trimester, during pregnancy weekly or at intervals of 2 weeks, the condition of the cervix should be monitored starting from 12 weeks if post-traumatic ICI is suspected and from 16 weeks if functional ICI is suspected. Monitoring includes examination of the cervix in speculum, if indicated, vaginal examination, ultrasound assessment of the length of the cervix and the condition of the internal os during transvaginal ultrasound.

Up to 20 weeks of pregnancy, the length of the cervix is ​​very variable and cannot serve as a criterion for predicting the occurrence of future premature births. ICI is evidenced by the pronounced dynamics of the condition of the cervix in a particular patient (shortening, opening of the internal pharynx).

· Up to 20 weeks of pregnancy, the length of the cervix is ​​very variable and cannot serve as a criterion for diagnosing the occurrence of future premature birth. At a period of 24–28 weeks, the average length of the cervix is ​​35–45 mm, at a period of 32 weeks or more - 35–30 mm. Shortening of the cervix to 25 mm or less at 20–30 weeks is considered a sign of ICI and in this case it is necessary surgical correction. However, the diagnosis of ICI includes not only ultrasound data, but also the results vaginal examination(since the neck should not only be shortened, but also softened).

· Additional diagnostic ultrasound criteria for ICN obtained during examination with a transvaginal sensor (test with pressure on the fundus of the uterus, cough test, position test when the patient stands up) are proposed.

PREPARATION FOR PREGNANCY

Preparing for pregnancy in patients with recurrent miscarriage and ICI should begin with sanitization of the genital tract, normalization of the vaginal microflora and treatment of chronic endometritis. Due to the fact that the obturator function of the cervix is ​​impaired, the risk of infection of the cervical canal and uterine cavity with opportunistic flora and/or other microorganisms (chlamydia, E. coli) is very high. In this case, appropriate therapy is carried out with subsequent assessment of the effectiveness of treatment.

CLINICAL PICTURE (SYMPTOMS) ICI

Clinical manifestations of ICI are nonspecific, manifested by the threat of miscarriage (discomfort in the lower abdomen and lower back, mucous discharge from the vagina, may be streaked with blood, scanty bloody issues from the vagina). Sometimes there is a feeling of pressure, fullness, stabbing pain in the vagina. ICI may be asymptomatic.

TREATMENT OF ICI

Treatment of ICI depends on the presence of pregnancy.

Outside of pregnancy with post-traumatic ICI in each specific case together with a gynecological surgeon, determine the possibility of cervical plastic surgery. It is necessary to take into account the patient's medical history (number of late abortions, ineffectiveness of correction during pregnancy) and the anatomical condition of the cervix uterus. The most common method is Eltsov-Strelkov. The operation does not exclude the possibility of surgical correction of the cervix during pregnancy and determines mandatory delivery through CS surgery due to the danger of cervical rupture with transition to the lower uterine segment.

· During pregnancy. It has been shown that suturing the cervix in women with ICI reduces the incidence of preterm birth up to 33 weeks of pregnancy. The period at which surgical correction is performed (from 13 to 27 weeks of pregnancy) is determined individually, depending on the time of onset of symptoms. In this case, the risk of intrauterine infection should be taken into account, which increases after 13–17 weeks due to mechanical descent and prolapse of the membranes.

The indication for surgical treatment is progression of ICI: change in consistency and shortening of the cervix, gradual increase(“gaping”) of the external pharynx and opening of the internal pharynx.

Contraindications to surgical treatment of ICI in pregnant women are: diseases and pathological conditions, which are a contraindication to continuing pregnancy ( severe forms diseases cardiovascular systems, liver, kidneys, infectious, mental and genetic diseases), symptoms of threatened miscarriage, congenital birth defects of the fetus, NB, III–IV degree of purity of the vaginal flora, the presence of pathogenic microflora in the discharge of the cervical canal. In the last 2 cases, preliminary sanitation of the genital tract is necessary.

At the 17th Congress of the International Federation of Obstetricians and Gynecologists (FI-O), surgical correction of ICI using a circular suture in the area of ​​the internal os using the Shirodkar method was recognized as the most effective for prolonging pregnancy.

Activities required in postoperative period, are given below:

– bacterioscopy of vaginal discharge;

– correction of microbiocenosis;

– if there are signs of myometrial excitability, tocolysis is performed. The drug of choice for tocolysis is hexoprenaline sulfate (ginipral©). Ginipral© 10 mcg (2 ml) is diluted in 10 ml of sodium chloride or glucose solution and administered intravenously slowly. In the future, if necessary, treatment can be continued with infusions or tablets of 0.5 mg 4-6 times a day;

– during subsequent pregnancy management, inspection of the sutures on the cervix is ​​necessary every 2–3 weeks.

Indications for removing sutures from the cervix are listed below:

– gestational age 37 weeks;

– leakage or overflow of fluid, bloody discharge from the uterine cavity, cutting of sutures (formation of a fistula), the onset of regular labor at any stage of pregnancy.

IN difficult cases, when the vaginal portion of the cervix is ​​so small that suturing transvaginally is impossible (after amputation of the cervix), there is evidence of suturing through transabdominal laparoscopic access (about 30 operations have been described during pregnancy).

IN last years V clinical practice The least traumatic method of correcting ICI using a pessary - a Meyer ring, placed on the cervix, has become widespread.

One of the reasons for termination of pregnancy in the second and third trimester is isthmic-cervical insufficiency (ICI) or insufficiency (inferiority) of the cervix.

ICI is a very serious pathology that is not at all dangerous for a non-pregnant woman, but during pregnancy it can lead to a late miscarriage or the birth of a premature baby.

ICI during pregnancy: what is it.

During pregnancy, the cervix should remain closed until birth, keeping the fetus inside the uterus. Isthmic-cervical insufficiency (ICI) during pregnancy is the premature dilatation of the cervix under the influence of the growing fetus.

The cervix shortens and dilates prematurely, which can result in rupture of the membranes and loss of pregnancy. During the next pregnancy, cervical insufficiency usually recurs, so when such a diagnosis is made, observation and treatment are mandatory.

Isthmic-cervical insufficiency: causes.

The main cause of isthmic-cervical insufficiency is trauma to the cervix during childbirth, abortion, and cervical surgery. Moreover, abortions early stages using a vacuum, although they increase the risk of infertility in the future, have virtually no effect on the occurrence of ICI. Abortion and diagnostic curettage with the use of cervical dilators significantly increase the likelihood of ICI.

Improper management of labor and delivery of a large fetus can lead to rupture of the cervix and subsequently cause isthmic-cervical insufficiency. However, external cervical ruptures do not affect pregnancy; only damage to the internal os poses a danger.

A common cause of isthmic-cervical insufficiency is also surgery cervical erosion, especially if it is accompanied by complications. It is believed that laser and cold treatment are more gentle and slightly increase the risk of ICI.

Rarely, the cause of isthmic-cervical insufficiency is an anatomical birth defect, when the cervix is ​​short and small from birth.

However, some women with isthmic-cervical insufficiency have no risk factors at all, suggesting that hormonal levels during pregnancy can also affect the condition of the cervix.

The infection itself cannot be the cause of isthmic-cervical insufficiency, but it significantly increases the risk of miscarriage. Also, an additional risk factor is smoking and diseases of the pelvic organs.

Isthmic-cervical insufficiency: symptoms.

Unfortunately, there are no obvious symptoms of isthmic-cervical insufficiency. The cervix can open completely painlessly. Symptoms such as heaviness and aching pain in the lower abdomen may be observed, frequent urination. Excessive mucous membranes, possibly streaked with blood, and discharge in the second and third trimester should also alert you.

You can determine the ICN using ultrasound examination, take into account, first of all, the length of the cervix, as well as whether the internal os is closed. The normal length of the cervix during pregnancy is 2.5 centimeters or more. The size of the internal os of the cervix should be up to 10 mm.

When the cervical length is 2-2.5 cm, observation is necessary, as there is a possibility of premature birth. The length of the cervix less than two centimeters is considered critical; without treatment there is Great chance termination of pregnancy within one to two weeks.

It is important not only one ultrasound indicator, but also the dynamics. Usually the ultrasound is repeated after one to two weeks to see whether the cervix shortens or remains unchanged.

If the first pregnancy was terminated and ICI was diagnosed, or if there was a repeat pregnancy loss after 16 weeks in the absence of other causes, then careful monitoring of cervical length in the second and third trimester is necessary.

Isthmic-cervical insufficiency: treatment.

Basic and very effective method Treatment of isthmic-cervical insufficiency is a suture on the cervix. In 90% of cases, timely suture allows the pregnancy to be carried to term.

In order for the operation to be effective, it must be performed at 12-17 weeks of pregnancy, but a suture can be placed later, up to 24 weeks. If ICI is known before pregnancy, the suture is usually placed at 8-10 weeks.

During and after surgery, tocolytic (conservation) therapy is performed. Bed rest is recommended for 1-2 days after suturing. The suture is removed at 37-38 weeks or after the rupture of amniotic fluid or the onset of premature labor.

There are contraindications to suturing, for example, fetal malformations or intrauterine infection. It is also possible to carry a pregnancy to term without a stitch, but the chances are significantly reduced.

Later in pregnancy, doctors may suggest a pessary, a ring that fits around the cervix. Unfortunately, the effectiveness of this method is questionable and there are studies showing that the pessary does not reduce the incidence of preterm birth.

In addition, the pessary is a foreign body that irritates the cervix and can even provoke labor. Abroad, the application of pessaries in Lately practically not used.

In case of isthmic-cervical insufficiency, restriction is necessary physical activity, sexual life, avoiding heavy lifting. In some cases, bed rest may be recommended.

Drug treatment of isthmic-cervical insufficiency is very limited. In later stages, when suturing is impossible, progesterone suppositories are used in the vagina. This treatment has little effectiveness compared to surgery and is used from 24 to 32 weeks.

Also from 24 to 34 weeks of pregnancy with short neck uterus, dexamethasone is prescribed for rapid maturation of the fetal lungs in case of premature birth. This measure significantly increases the survival rate of premature babies.

In any case, if the cervix is ​​shortened, the pregnant woman should be in the hospital under observation. Timely diagnosis isthmic-cervical insufficiency allows you to take appropriate measures and prevent pregnancy loss.