Isthmic-cervical insufficiency. management of pregnancy

- a violation associated with the opening of the cervix during embryogenesis, which leads to spontaneous abortion or premature delivery. Clinically, this pathology usually does not manifest itself in any way, sometimes there may be a slight pain and a feeling of fullness, the release of mucus with blood. Ultrasound scanning is used to determine pathological changes and confirm the diagnosis. Medical assistance consists of placing a Meyer ring (a special pessary) in the vagina or surgical suturing. Medical therapy is also indicated.

General information

Isthmic-cervical insufficiency (ICN) is a pathology of pregnancy that develops as a result of weakening of the muscle ring located in the area of ​​​​the internal pharynx and unable to hold the fetus and its membranes. In obstetrics, this condition occurs in every tenth patient, usually occurs in the second trimester, and is less commonly diagnosed after 28 weeks of pregnancy. The danger of isthmic-cervical insufficiency lies in the absence of early symptoms, despite the fact that this pathological condition can lead to fetal death in the later stages or the onset of premature birth. If a woman has recurrent miscarriage, in about a quarter of clinical cases, the cause of this condition is CI.

With isthmic-cervical insufficiency, there is a decrease in muscle tone from the area of ​​​​the internal pharynx, which leads to its gradual opening. As a result, part of the membranes descends into the lumen of the cervix. At this stage, isthmic-cervical insufficiency poses a real threat to the child, since even a slight load or active movements can cause a violation of the integrity of the membranes, subsequent premature birth or death of the fetus. In addition, with ICI, it is possible to introduce an infection to the fetus, since a certain microflora is always present in the genital tract.

Causes of isthmic-cervical insufficiency

The etiology of isthmic-cervical insufficiency is to reduce the tone of the muscle fibers that form the uterine sphincter. Its main role is to maintain the cervix in a closed state until the onset of labor. With isthmic-cervical insufficiency, this mechanism is disrupted, which leads to premature opening of the cervical canal. Often the cause of ICI is traumatic injuries of the cervix in history. The likelihood of developing isthmic-cervical insufficiency increases in women who have undergone late abortions, ruptures, operative births (imposition of obstetric forceps).

Isthmic-cervical insufficiency often occurs after fruit-destroying operations, childbirth in breech presentation and surgical interventions on the cervix. All these factors cause traumatization of the cervix and a possible violation of the location of the muscle fibers relative to each other, which ultimately contributes to their failure. Also, the cause of isthmic-cervical insufficiency can be congenital anomalies associated with the incorrect structure of the organs of the reproductive system of a pregnant woman. Congenital ICI is quite rare, which can be determined even in the absence of conception - in such a case, at the time of ovulation, the opening of the cervical canal by more than 0.8 cm will be noted.

Isthmic-cervical insufficiency is often observed against the background of hyperandrogenism - an increased content of male sex hormones in the patient's blood. An increase in the likelihood of developing pathology is noted when this problem is combined with a deficiency in progesterone production. An aggravating factor in isthmic-cervical insufficiency is multiple pregnancies. Along with increased pressure on the cervix, in such cases, an increase in the production of the hormone relaxin is often detected. For the same reason, cervical insufficiency is sometimes diagnosed in patients who have undergone ovulation induction with gonadotropins. The likelihood of developing this pathology increases in the presence of a large fetus, polyhydramnios, the presence of bad habits in the patient, and the performance of heavy physical work during the gestation period.

Classification of isthmic-cervical insufficiency

Taking into account the etiology, two types of isthmic-cervical insufficiency can be distinguished:

  • traumatic. It is diagnosed in patients with a history of surgery and invasive manipulations on the cervical canal, which resulted in the formation of a scar. The latter consists of connective tissue elements that do not withstand increased load with fetal pressure on the cervix. For the same reason, traumatic isthmic-cervical insufficiency is possible in women with a history of ruptures. ICI of this type manifests itself mainly in the 2-3 trimester, when the weight of the pregnant uterus is rapidly increasing.
  • functional. Typically, such isthmic-cervical insufficiency is provoked by a hormonal disorder, caused by hyperandrogenism or insufficient production of progesterone. This form often occurs after the 11th week of embryogenesis, which is due to the beginning of the functioning of the endocrine glands in the fetus. The endocrine organs of the child produce androgens, which, together with substances synthesized in the body of a woman, lead to a weakening of muscle tone and premature opening of the cervical canal.

Symptoms of isthmic-cervical insufficiency

Clinically, isthmic-cervical insufficiency, as a rule, does not manifest itself in any way. In the presence of symptoms, the signs of pathology depend on the period at which the changes occurred. In the first trimester, isthmic-cervical insufficiency may be indicated by spotting, which is not accompanied by pain, in rare cases, combined with minor discomfort. In the later stages (after 18-20 weeks of embryogenesis), ICI leads to fetal death and, accordingly, miscarriage. Blood smearing occurs, discomfort in the lower back, abdomen is possible.

The peculiarity of isthmic-cervical insufficiency lies in the fact that even with a timely visit to an obstetrician-gynecologist, due to the lack of obvious symptoms, it is not easy to identify pathological changes. This is due to the fact that routinely during each consultation an objective gynecological examination is not carried out in order to reduce the likelihood of introducing pathogenic microflora. However, even in the course of a gynecological examination, it is not always possible to suspect manifestations of isthmic-cervical insufficiency. The reason for instrumental diagnostics may be excessive softening or reduction in the length of the neck. It is these symptoms that often indicate the onset of isthmic-cervical insufficiency.

Diagnosis of isthmic-cervical insufficiency

Ultrasound scanning is the most informative method in identifying isthmic-cervical insufficiency. A sign of pathology is the shortening of the cervix. Normally, this indicator varies and depends on the stage of embryogenesis: up to 6 months of pregnancy it is 3.5-4.5 cm, in the later stages - 3-3.5 cm. With isthmic-cervical insufficiency, these parameters change downwards. The shortening of the canal to 25 mm indicates the threat of interruption or premature birth of the baby.

The V-shaped opening of the cervix is ​​a characteristic sign of isthmic-cervical insufficiency, which is observed in both parous and nulliparous patients. It is possible to detect such a symptom during ultrasound monitoring. Sometimes, to confirm the diagnosis, a test with an increase in the load is performed during the scan - the patient is asked to cough or put a little pressure on the bottom of the uterine cavity. In patients giving birth, isthmic-cervical insufficiency is sometimes accompanied by an increase in the lumen of the cervix throughout. If a woman is at risk or has indirect signs of CCI, monitoring should be carried out twice a month.

Treatment of isthmic-cervical insufficiency

With isthmic-cervical insufficiency, complete rest is indicated. It is important to protect a pregnant woman from negative factors: stress, harmful working conditions, intense physical exertion. The question of the conditions for the subsequent management of pregnancy is decided by the obstetrician-gynecologist, taking into account the patient's condition and the severity of pathological changes. Conservative care for isthmic-cervical insufficiency involves the installation of a Meyer ring in the vagina, which reduces the pressure of the fetus on the cervix. The procedure is recommended to be carried out during the period of embryogenesis of 28 weeks or more with a slight opening of the pharynx.

Surgical intervention for isthmic-cervical insufficiency makes it possible to bring the baby to the desired time with a high probability. Manipulation involves the imposition of a seam on the neck, preventing its premature opening. The operation is performed under anesthesia, for its implementation the following conditions are necessary: ​​signs of the integrity of the membranes and the vital activity of the fetus, the gestation period is up to 28 weeks, the absence of pathological discharge and infectious processes from the genital organs. Sutures and a pessary for isthmic-cervical insufficiency are removed upon reaching the embryogenesis period of 37 weeks, as well as in the event of childbirth, opening of the fetal bladder, fistula formation, or blood smearing.

During conservative therapy and in the postoperative period, patients with isthmic-cervical insufficiency are prescribed antibacterial drugs to prevent the development of infection. The use of antispasmodics is also shown, with uterine hypertonicity - tocolytics. With a functional form of isthmic-cervical insufficiency, hormonal agents can additionally be used. Delivery is possible through the natural genital tract.

Forecast and prevention of isthmic-cervical insufficiency

With isthmic-cervical insufficiency, a woman can bring the baby to the expected date of birth. Due to a weak muscle sphincter, the risk of rapid delivery increases, if there is a likelihood of developing this condition, pregnant women are hospitalized in the obstetric department. Prevention of isthmic-cervical insufficiency involves timely examination and treatment of identified diseases (especially hormonal ones) even at the planning stage of conception. After fertilization, the patient should normalize the regime of work and rest. It is important to eliminate stress factors, hard work. Specialists should carefully monitor the condition of the woman and determine as early as possible whether she is at risk for developing CCI.

Isthmic-cervical insufficiency is one of the causes of miscarriage. It accounts for 30–40% of all late spontaneous miscarriages and preterm births.

Isthmic-cervical insufficiency(ICN) is the insufficiency or failure of the isthmus and cervix, in which it shortens, softens and opens slightly, which can lead to spontaneous miscarriage. In a normal pregnancy, the cervix plays the role of a muscular ring that holds the fetus and prevents it from leaving the uterine cavity ahead of time. As pregnancy progresses, the fetus grows, the amount of amniotic fluid increases, and this leads to an increase in intrauterine pressure. With isthmic-cervical insufficiency, the cervix is ​​​​not able to cope with such a load, while the membranes of the fetal bladder protrude into the cervical canal, become infected with microbes, and then open, and the pregnancy is terminated ahead of schedule. Very often miscarriage occurs in the second trimester of pregnancy (after 12 weeks).

Symptoms of ICI are very poor, since the disease is based on the opening of the cervix, which proceeds without pain and bleeding. A pregnant woman may be disturbed by a feeling of heaviness in the lower abdomen, frequent urination, abundant mucous discharge from the genital tract. Therefore, it is very important to report these symptoms to the obstetrician-gynecologist leading the pregnancy in time.

ICI: causes

Due to the occurrence, organic and functional isthmic-cervical insufficiency is distinguished.

Organic ICN occurs after abortion, curettage of the uterine cavity. During these operations, the cervical canal is expanded with a special instrument, as a result of which trauma to the cervix may occur. Cervical ruptures during previous births can also lead to organic CCI. With poor healing of the sutures, scar tissue forms at the site of the ruptures, which cannot ensure full closure of the cervix in the next pregnancy.

Functional ICN observed with hyperandrogenism (increased production of male sex hormones). Under the action of androgens, softening and shortening of the cervix occurs. Another reason for the formation of functional ICI is insufficient ovarian function, namely, a deficiency of progesterone (a hormone that supports pregnancy). Malformations of the uterus, a large fetus (weight more than 4 kg), multiple pregnancy also contribute to the emergence of functional CI.

ICI: diagnosis of the disease

Before pregnancy, this disease is detected only in cases where there are gross scars or deformities on the cervix.

Most often, isthmic-cervical insufficiency is first diagnosed after the spontaneous termination of the first pregnancy. The method for detecting CCI is a vaginal examination. Normally, during pregnancy, the cervix is ​​long (up to 4 cm), dense, deflected backwards and its external opening (external pharynx) is closed. With ICI, there is a shortening of the cervix, its softening, as well as the disclosure of the external and internal pharynx. With severe ICI, when examining the cervix, hanging membranes of the fetal bladder can be found in the mirrors. The condition of the cervix can also be assessed by ultrasound. With the help of an ultrasound probe, which the doctor inserts into the vagina, the length of the cervix is ​​​​measured and the condition of the internal os is assessed. The length of the cervix, equal to 3 cm, requires an additional ultrasound examination in dynamics. And if the length of the cervix is
2 cm, then this is an absolute sign of isthmic-cervical insufficiency and requires appropriate surgical correction.

Isthmic-cervical insufficiency: treatment

A pregnant woman is advised to limit physical and psycho-emotional stress, refrain from sexual activity throughout the entire period of pregnancy, and also not to play sports. In some situations, the appointment of drugs that reduce the tone of the uterus (tocolytics) is indicated. If the cause of functional ICI was hormonal disorders, they are corrected by prescribing hormonal drugs.

There are two methods of treatment of CI: conservative (non-surgical) and surgical.

Non-surgical method of treatment has several advantages over surgery. The method is bloodless, simple and safe for mother and fetus. It can be used on an outpatient basis at any stage of pregnancy (up to 36 weeks). This method is used for minor changes in the cervix.

Non-surgical correction of CCI is carried out with the help of a pessary - an obstetric ring (this is a special anatomical design with a closing ring for the cervix). The pessary is put on the cervix, due to which the load is reduced and the pressure on the cervix is ​​redistributed, i.e. he plays the role of a kind of bandage. The technique of setting a pessary is simple, does not require anesthesia and is well tolerated by a pregnant woman. When using this method, the patient is insured against technical errors that may occur during surgical treatment.

After the installation procedure, a pregnant woman should be under the dynamic supervision of a doctor. Every 3-4 weeks smears are taken from the vagina for the flora, the condition of the cervix is ​​​​assessed using ultrasound. The pessary is removed at 37–38 weeks of gestation. Extraction is easy and painless. In the event of the appearance of spotting or with the development of labor, the pessary is removed ahead of schedule.

Currently, various methods of surgical treatment of CI have been developed.

With gross anatomical changes in the cervix due to old ruptures (if this is the only cause of miscarriage), surgical treatment is necessary outside of pregnancy (cervical plasty). A year after the operation, a woman can plan a pregnancy.

Indications for surgery during pregnancy are a history of spontaneous miscarriages, premature births, as well as progressive insufficiency of the cervix: its flabbiness, shortening, increased gaping of the external os or the entire cervical canal. Surgical correction of ICI is not carried out in the presence of diseases in which pregnancy is contraindicated (severe diseases of the cardiovascular system, kidneys, liver, etc.); with identified fetal malformations; with recurring bloody discharge from the genital tract.

In most cases, with ICI, the uterine cavity is infected with microbes due to a violation of the obturator function of the cervix. Therefore, before surgical correction of the cervix, it is imperative to conduct a study of a smear from the vagina for flora, as well as bacteriological seeding or a study of the genital tract by PCR. In the presence of an infection or pathogenic flora, treatment is prescribed.

The surgical method of treatment consists in applying sutures from a special material to the cervix. With their help, further opening of the cervix is ​​​​prevented, as a result, it is able to cope with the growing load. The optimal time for suturing is the 13–17th week of pregnancy, however, the time of the operation is determined individually, depending on the time of occurrence and clinical manifestations of CI. With an increase in the gestational age due to the failure of the cervix, the fetal bladder descends and sags. This leads to the fact that its lower part is infected with microbes that are in the vagina, which can lead to premature rupture of the fetal bladder and outflow of water. In addition, due to the pressure of the fetal bladder, an even greater expansion of the cervical canal occurs. Thus, surgery in later pregnancy is less effective.

The suturing of the cervix takes place in a hospital under intravenous anesthesia. In this case, drugs are used that have a minimal effect on the fetus. After suturing the cervix, the appointment of drugs that reduce the tone of the uterus is indicated.

In some cases, antibiotics are used. In the first two days after the operation, the cervix and vagina are treated with antiseptic solutions. The length of stay in the hospital depends on the course of pregnancy and possible complications. Usually, 5-7 days after the operation, the pregnant woman can be discharged from the hospital. In the future, outpatient monitoring is carried out: every 2 weeks, the cervix is ​​examined in the mirrors. According to indications or once every 2-3 months, the doctor takes a smear on the flora. The stitches are usually removed at 37-38 weeks of pregnancy. The procedure is carried out in a hospital without anesthesia.

Labor can begin within 24 hours after the stitches are removed. If childbirth begins with “unremoved” stitches, the expectant mother needs to go to the nearest maternity hospital as soon as possible. In the emergency room, you should immediately tell the staff that you have stitches in your cervix. The stitches are removed regardless of the gestational age, since during contractions they can cut through and thereby injure the cervix.

Prevention of CCI

If during pregnancy you were diagnosed with "isthmic-cervical insufficiency", then when planning the next one, be sure to contact the antenatal clinic. An obstetrician-gynecologist will conduct examinations, based on the results of which he will prescribe the necessary treatment.

It is recommended to observe an interval between pregnancies of at least 2 years. When pregnancy occurs, it is advisable to register with the antenatal clinic as soon as possible and follow all the recommendations prescribed by the doctor. By contacting a doctor in time, you will provide your baby with favorable conditions for further growth and development.

If you have identified isthmic-cervical insufficiency, do not despair. Timely diagnosis, correctly chosen tactics of pregnancy management, medical and protective regimen, as well as a favorable psychological attitude will allow you to deliver to the due date and give birth to a healthy baby.

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Miscarriage remains an important problem of modern obstetrics and perinatology. Relevance is determined by its social and medical significance. The frequency of miscarriage is 10-25% of all pregnancies. FIGO's 2015 guidelines for overcoming ultra-early and early pregnancies state that over the past 40 years, the rate of preterm birth has not decreased, but that there is a trend towards an increase in miscarriage due to an increase in the number of not developing pregnancies. Prematurity is the leading cause of death among newborns. Premature babies account for over 50% of stillbirths, perinatal morbidity and mortality reaches 75-80%.

Isthmic-cervical insufficiency - ICI (lat. insufficientia isthmicocervicalis; anat. isthmus "isthmus of the uterus" + cervix "cervix") - a pathological condition of the isthmus and cervix during pregnancy, in which they are not able to withstand intrauterine pressure and keep the growing fetus in uterine cavity until timely delivery. The frequency of ICI ranges from 7.2 to 13.5%, and the relative risk of this pathology increases with an increase in the number of induced labor. In the structure of habitual pregnancy loss, ICI in the II trimester of pregnancy accounts for 40%, and in the III trimester, ICI occurs in every third case. There are organic and functional ICI. Organic, or secondary, or post-traumatic CCI occurs as a result of previous curettage of the uterus, accompanied by mechanical expansion of the cervical canal, as well as pathological childbirth, including the use of small obstetric operations (vacuum extraction of the fetus, application of obstetric forceps), leading to cervical ruptures uterus. Functional ICI is the result of a change in the proportional relationship between muscle and connective tissue and, as a result, pathological reactions of the cervix to neurocirculatory stimuli.

The mechanism of termination of pregnancy in ICI does not depend on its type and lies in the fact that due to the shortening of the neck, its softening, gaping of the internal pharynx and cervical canal, the fetal egg does not have physiological support in the lower segment. With an increase in intrauterine pressure on the area of ​​​​a functionally insufficient lower segment of the uterus and the internal pharynx, the fetal membranes protrude into the cervical canal, they become infected and open.

Making an accurate diagnosis of CCI is possible only during pregnancy, since there are conditions for a functional assessment of the state of the cervix and isthmus.

Pregnancy in cases of ICI usually proceeds without symptoms of threatened miscarriage. The pregnant woman does not complain, there is a normal uterine tone on palpation. When examining the cervix in the mirrors, a gaping external pharynx of the cervix with flaccid edges is visible, prolapse of the fetal bladder is possible. In a bimanual vaginal examination, shortening and softening of the cervix is ​​​​determined, the cervical canal passes a finger beyond the area of ​​\u200b\u200bthe internal pharynx. For the diagnosis of ICI, obstetrician-gynecologists use scoring systems for the state of the cervix.

In recent years, transvaginal echographic examination has been used as a monitoring of the state of the cervix. Despite the widespread use of echography in the diagnosis of fetal anomalies and other pathologies of pregnancy, there are still no clearly regulated criteria for the diagnosis of CCI.

According to A.D. Lipman, the following criteria should be taken into account: the length of the cervix, equal to 30 mm, is critical in first- and second-pregnant women with a gestation period of less than 20 weeks and requires intensive monitoring of the woman with her inclusion in the risk group. A neck length of 20 mm or less is an absolute criterion for CI and requires intensive treatment. In multiparous women, ICI is indicated by a shortening of the cervix at 17-20 weeks to 29 mm. In women with multiple pregnancies up to 28 weeks of gestation, the lower limit of the norm is the length of the cervix of 37 mm in primigravidas and 45 mm in multipregnant women.

According to L.B. Markina, A.A. Korytko, the ratio of the length of the cervix to the diameter of the cervix at the level of the internal os less than 1.16 is a criterion for ICI at a rate of 1.53.

A.I. Strizhakov et al. consider that the characteristic of ICI is a V-shaped deformation of the internal pharynx with prolapse of the fetal bladder.

According to S.L. Voskresensky, changes in the echostructure of the cervix (small liquid inclusions and hyperechoic linear echoes) indicate hemodynamic changes in the vessels of the cervix and may be the initial signs of cervical insufficiency.

According to the Fetal Medicine Foundation (Fetal Medicine Foundation), the length of the cervical canal during transvaginal examination at 22-24 weeks of gestation normally has an average value of 36 mm (Fig. 1). The risk of spontaneous abortion is inversely proportional to the length of the cervix and increases exponentially when the length of the cervical canal is less than 15 mm. In multiple pregnancies, the threshold for an exponential increase in risk is a cervical length of 25 mm. Dilatation of the internal os, which is manifested by the appearance of a funnel in this area on ultrasound, is nothing more than an echographic criterion that reflects the process of shortening of the cervix, which subsequently leads to premature birth (Fig. 2).

Rice. one.


Rice. 2.

As recommended by the FIGO Congress in 2012, and then by the resolution of the Expert Council at the 16th World Congress on Human Reproduction in 2015, the use of vaginal progesterone is indicated for the prevention of preterm birth in singleton pregnancies with a cervical length of 25 mm or less using transvaginal ultrasound with a gestational age of 19-24 weeks.

According to the FIGO 2015 recommendations, the length of the cervical canal with transvaginal ultrasound cervicometry of 35 mm or less indicates a threat of preterm labor, 25 mm or less indicates a high risk of directly preterm labor. The expansion of the internal os to 5 mm or more, especially up to 10 mm, also indicates a high risk of preterm birth.

We conducted our own study to compare data obtained from bimanual vaginal examination and transvaginal echography of the cervix in pregnant women with suspected CI.

Material and methods

A prospective analysis included 103 pregnant women admitted to the hospital. The criteria for selecting pregnant women for the study were: singleton pregnancy, the absence of regular labor and rupture of amniotic fluid, the absence of prolapse of the fetal bladder. Transvaginal echography was performed within 30 minutes after a vaginal examination of a pregnant woman on an armchair by an obstetrician-gynecologist.

Ultrasound examinations were performed on a SonoAce-9900 device (Samsung Medison) with a 3.5-6 MHz transabdominal probe and a 4.5-7.5 MHz transvaginal probe. Initially, with transabdominal echography, fetometric parameters, the absence of congenital malformations and markers of chromosomal abnormalities, the absence of placenta previa, signs of placental abruption and prolapse of the fetal bladder were evaluated. Then, the length of the cervix was measured with a transvaginal sensor according to the following method:

  • a woman empties her bladder and lies on her back, while her legs should be bent at the knees;
  • an ultrasonic sensor is inserted into the vagina and located in the anterior fornix (you should try to avoid excessive pressure on the cervix, which can lead to an artificial increase in its length);
  • the screen should display a sagittal section of the cervix, and the echogenic mucosa of the endocervix is ​​used as a guide to the true location of the internal os, thus avoiding erroneous measurement of the lower uterine segment;
  • use calipers to measure the linear distance between the triangular area, increased echogenicity of the external os and the V-shaped notch in the area of ​​the internal os;
  • each measurement should be carried out with a break of 2-3 minutes. In 1% of cases, the length of the cervix may change due to uterine contractions, and in these cases, the smallest value of the length of the cervical canal is documented.

Measurement of the cervical length by the transvaginal method is highly reproducible, and in 95% of cases the difference between two measurements performed by the same specialist or two different ones is 4 mm or less.

Statistical processing of the obtained material was carried out using the STATISTICA 6.0 package. In cases of distribution other than normal, the results of the study were presented as Me (25.75%), where Me is the median, and 25.75% are the upper and lower quartiles. In all cases, the critical significance level p was taken equal to 0.05.

Results and discussion

The mean gestational age was 26 weeks 2 days (23 weeks 1 day; 30 weeks 2 days). The average length of the cervix in a bimanual study was significantly lower (p

CI was diagnosed after bimanual examination in 13 cases. Only in 3 cases it was confirmed by transvaginal echography of the cervix. Hyperdiagnosis of CI was noted in 10 cases after vaginal examination. However, in 14 cases, transvaginal echography was diagnosed with CCI, despite the normal length and consistency of the cervix on vaginal examination.

In 28 pregnant women, in addition to transvaginal echographic measurement of the length of the cervix, transabdominal cervicometry was performed. In 6 cases, it was not possible to measure the length of the cervix and assess the state of the internal os during a transabdominal examination due to the low position of the fetal head, the lack of bladder filling, and the characteristics of subcutaneous fat.

Conclusion

Transvaginal echography in the diagnosis of CI has 100% sensitivity and 80% specificity. With transabdominal sonography, the measured length of the cervix may not correspond to the true length in most cases, especially with a shortened cervix. Moreover, successful imaging requires a full woman's bladder, which, by squeezing it, increases the length of the cervix by an average of 5 mm.

When carrying out routine ultrasound examinations of the fetus, according to the protocol, at 18-22 weeks of gestation, a transvaginal echographic assessment of the state of the cervix is ​​necessary to form a risk group for the development of CCI and the prevention of preterm birth.

In women at risk for the formation of CCI, dynamic monitoring of the state of the cervix using transvaginal cervicometry is necessary, since a bimanual vaginal examination has a high subjectivity, and repeated studies can lead to increased excitability and contractile activity of the uterus.

Despite the fact that the effectiveness and reliability of the assessment of the cervix using transvaginal ultrasound has long been undeniable, the criteria for making the diagnosis of CCI are constantly being adjusted.

Literature

  1. 2015 International Federation of Obstetricians and Gynecologists (FIGO) guidelines. Improvement of practical approaches in obstetrics and fetal medicine. Newsletter / Ed. Radzinsky V.E. M.: Editorial Board of Status Praesens. 2015. 8 p.
  2. Prevention of miscarriage and premature birth in the modern world. Resolution of the Expert Council within the framework of the 16th World Congress on Human Reproduction (Berlin, March 18-21, 2015) Newsletter. M.: Editorial Board of Status Praesens. 2015. 4 p.
  3. Zhuravlev A.Yu., Dorodeiko V.G. The use of an unloading obstetric pessary in the treatment and prevention of miscarriage in isthmic-cervical insufficiency // Protection of motherhood and childhood. 2000. No. 1. S. 24-35.
  4. Sidorova I.S., Kulakov V.I., Makarov I.O. Guide to obstetrics. M.: Medicine, 2006. S. 331-335.
  5. Sidelnikova V.M. Habitual pregnancy loss. M.: Triada-X, 2002. S. 304.
  6. Lipman A.D. Ultrasound criteria for isthmicocervical insufficiency // Obstetrics and Gynecology. 1996. No. 4. S. 5-7.
  7. Markin L.B., Korytko A.A. 1st Congress of the Association of Specialists in Ultrasound Diagnostics in Medicine: Abstracts of Reports, Moscow, 1991. P. 37.
  8. Strizhakov A.I., Bunin A.T., Medvedev M.V. Ultrasound diagnostics in an obstetric clinic. M., Medicine, 1991. S. 23-31.
  9. Voskresensky S.L. Possibilities of ultrasound in the diagnosis of miscarriage// Ultrasound diagnostics in obstetrics, gynecology and pediatrics. 1993. No. 3. S. 118-119.
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ICD-10: N96 - Habitual miscarriage;

O26.2 - Medical care for a woman with recurrent miscarriage.

Women with a history of 2 or more miscarriages or preterm births should be advised to be screened before pregnancy to identify causes, correct abnormalities, and prevent subsequent complications.

    Genetic causes of recurrent miscarriage (3-6%):

    hereditary diseases in family members;

    the presence of congenital anomalies in the family;

    the birth of children with mental retardation;

    the presence of a married couple and relatives of infertility or miscarriage of unknown origin;

    the presence of cases of perinatal mortality;

    study of the karyotype of parents;

    cytogenetic analysis of abortus;

    genetic counseling.

With the onset of pregnancy:

    prenatal diagnosis: chorion biopsy, cordocentesis.

    Anatomical causes of recurrent miscarriage (10-16%):

    acquired anatomical defects:

    • intrauterine synechia;

      submucosal uterine fibroids;

    Isthmic-cervical insufficiency (ICN).

    history (more often late termination of pregnancy);

    hysterosalpingography (7-9 days of the cycle). For the diagnosis of ICI HSG on the 18-20th day of the cycle;

    hysteroscopy;

    Ultrasound in the first phase of the cycle: submucosal fibroids, intrauterine synechia; in the II phase of the cycle: bicornuate uterus, intrauterine septum;

    MRI - pelvic organs.

    hysteroresectoscopy: intrauterine septum, submucosal uterine myoma, synechia;

    drug treatment: cyclic hormone therapy 3 cycles

14 days 17β - estradiol 2 mg

14 days 17β – estradiol 2 mg + dydrogesterone 20 mg

Features of the course of pregnancy (with a bicornuate uterus):

    in the early stages - bleeding from the "empty" horn: antispasmodics and hemostatic drugs;

    the threat of interruption throughout the entire gestation period;

    development of ICI;

    IUGR against the background of chronic placental insufficiency.

Duphaston from early gestation 20-40 mg to 16-18 weeks of gestation.

No-shpa 3-6 tablets/day courses.

Isthmic-cervical insufficiency (ICI): risk factors for CI

    history of cervical trauma:

    • damage to the cervix during childbirth,

      invasive methods of treatment of cervical pathology,

      induced abortions, late pregnancy terminations;

    congenital anomalies in the development of the uterus;

    functional disorders

    • hyperandrogenism,

      connective tissue dysplasia

    increased stress on the cervix during pregnancy

    • multiple pregnancy,

      polyhydramnios,

      large fruit;

    anamnestic indications of painless rapid abortions in the second trimester.

Assessment of the cervix outside of pregnancy:

    Hysterosalpingography on the 18-20th day of the cycle.

Cervical plasty according to Eltsov-Strelkov. Cervical plastic surgery does not exclude the formation of CI during pregnancy. Childbirth only by caesarean section.

Preparation for pregnancy:

    treatment of chronic endometritis, normalization of the vaginal microflora.

Monitoring the state of the cervix during pregnancy.

    monitoring includes:

    • examination of the neck in the mirrors;

      vaginal examination;

      Ultrasound - the length of the neck and the condition of the internal pharynx;

      monitoring is carried out from 12 weeks.

Clinical manifestation of CI:

    feeling of pressure, fullness, aching pain in the vagina;

    discomfort in the lower abdomen and lower back;

    mucous discharge from the vagina, may be streaked with blood;

    scanty spotting from the genital tract;

    measuring the length of the cervix:

24-28 weeks - neck length 45-35 mm,

32 weeks or more - 30-35 mm;

    shortening of the cervix up to 25 mm in the period of 20-30 weeks is a risk factor for preterm birth.

Criteria for diagnosing CCI during pregnancy:

  • prolapse of the fetal bladder,

    shortening of the cervix less than 25-20 mm,

    opening of the internal os,

    softening and shortening of the vaginal part of the cervix.

Conditions for surgical correction of CI:

    live fetus without malformations;

    gestational age no more than 25 weeks of gestation;

    a whole fetal bladder;

    normal uterine tone;

    no signs of chorioamnionitis;

    absence of vulvovaginitis;

    no bleeding.

After suturing:

    bacterioscopy and examination of the state of the seams every 2 weeks.

Indications for suture removal:

    gestational age 37 weeks,

    leakage, outpouring of water,

    bloody issues,

    cutting seams.

3. Endocrine causes of recurrent miscarriage (8-20%).

Diagnosis. luteal phase deficiency

    history (late menarche, irregular cycle, weight gain, infertility, early recurrent miscarriages);

    examination: hirsutism, striae, galactorrhea;

    tests of functional diagnostics of the 3rd cycle;

    hormonal examination:

    • Day 7-8 FSH, LH, prolactin, TSH, testosterone, DGAS, 17OP;

      on days 21-22 - progesterone;

    Ultrasound: 7-8 days - endometrial pathology, polycystic ovaries

20-21 days - change in the thickness of the endometrium (No. 10-11 mm)

    endometrial biopsy: 2 days before menstruation.

Luteal phase deficiency:

    with NLF and hyperprolactinemia, an MRI of the brain is performed

    • Bromocriptine 1.25 mg/day for 2 weeks, then up to 2.5 mg/day. When pregnancy occurs, Bromkriptin is canceled;

      Duphaston 20 mg/day for the 2nd phase of the cycle. During pregnancy Continue taking Duphaston 20 mg/day for up to 16 weeks.

    Hyperandrogenism of ovarian origin:

    Duphaston 20-40 mg / day up to 16 weeks;

    Dexamethasone only in the first trimester ¼ - ½ tablets;

    ICI monitoring.

    Adrenal hyperandrogenism:

    increase in plasma 17OP

    treatment: Dexamethasone 0.25 mg until pregnancy. During pregnancy from 0.25 mg to 1 mg - throughout the entire gestation period. Dose reduction from day 3 postpartum to 0.125 mg every 3 days.

    Hyperandrogenism of mixed origin:

    Duphaston 20-40 mg up to 16 weeks of pregnancy

    Dexamethasone 0.25 mg up to 28 weeks of gestation

    ICI monitoring.

    Antiphospholipid Syndrome:

    From early gestation:

        VA, antiphospholipid antibodies

        anticardiolipin antibodies

        hemostasiogram

        individual selection of doses of anticoagulants, antiaggregants.

      every week - platelet count, complete blood count, from the II trimester 1 time - in 2 weeks;

      Ultrasound from 16 weeks every 3-4 weeks;

      II - III trimesters - examination of the function of the liver and kidneys;

      Ultrasound + dopplerometry from 24 weeks of pregnancy;

      CTG from 33 weeks of pregnancy;

      control of hemostasiogram before and during childbirth;

      control of the hemostasis system on the 3rd and 5th day after birth.

Medicines used in miscarriage:

    Drotaverine hydrochloride - in the first trimester (No-shpa)

    Magne B6, Magnerat - in the first trimester

    Magnesium sulfate 25% - in the II-III trimester

    β-agonists - from 26-27 weeks

(Partusisten, Ginipral) in the III trimester

    non-steroidal anti-inflammatory drugs - after 14-15 weeks in the II and III trimesters, the total dose of Indomethacin is not more than 1000 mg

    Duphaston 20 mg up to 16 weeks

    Utrozhestan 200-300 mg up to 16-18 weeks

    Chorionic gonadotropin 1500 - 2500 IU / m 1 time per week with chorionic hypoplasia

    Etamzilat - I trimester of pregnancy

    Aspirin - II trimester of pregnancy.

Isthmicocervical insufficiency (ICI) is a pathological condition characterized by insufficiency of the isthmus and cervix, leading to spontaneous abortion in the II and III trimesters of pregnancy. In other words, this is a condition of the cervix during pregnancy, in which it begins to thin, become soft, shorten and open, losing the ability to hold the fetus in the uterus for up to 36 weeks. ICI is a common cause of miscarriage between 16 and 36 weeks.

Causes of ICI

According to the causes, ICI are divided into:

- organic ICN- as a result of previous injuries of the cervix during childbirth (ruptures), curettage (during abortion / miscarriage or for the diagnosis of certain diseases), in the treatment of diseases, for example, erosion or cervical polyp by conization (excision of part of the cervix) or diathermocoagulation (cauterization). As a result of injury, normal muscle tissue in the neck is replaced by scar tissue, which is less elastic and more rigid (harder, tougher, inelastic). As a result, the cervix loses the ability to both contract and stretch and, accordingly, cannot fully contract and keep the contents of the uterus inside.

- functional ICN, which develops for two reasons: due to a violation of the normal ratio of connective and muscle tissues in the composition of the cervix or in violation of its susceptibility to hormonal regulation. As a result of these changes, the cervix becomes too soft and pliable during pregnancy and dilates as pressure from the growing fetus increases. Functional CI may occur in women with ovarian dysfunction or may be congenital. Unfortunately, the mechanism of development of this type of ICI has not yet been sufficiently studied. It is believed that in each individual case it is individual and there is a combination of several factors.

In both cases, the cervix is ​​not able to resist the pressure of the growing fetus from inside the uterus, which leads to its opening. The fetus descends into the lower part of the uterus, the fetal bladder protrudes into the cervical canal (prolapses), which is often accompanied by infection of the membranes and the fetus itself. Sometimes, as a result of infection, amniotic fluid is released.

The fetus goes down and puts even more pressure on the cervix, which opens more and more, which ultimately leads to a late miscarriage (from 13 to 20 weeks of pregnancy) or premature birth (from 20 to 36 weeks of pregnancy).

Symptoms of ICI

Clinical manifestations of CI during pregnancy and beyond are absent. The consequence of ICI in the II and III trimesters is spontaneous abortion, which is often accompanied by premature rupture of amniotic fluid.

Outside of pregnancy, isthmicocervical insufficiency does not threaten anything.

Diagnosis of CCI during pregnancy

The only reliable way to diagnose is a vaginal examination and examination of the cervix in the mirrors. Vaginal examination reveals the following signs (individually or in combination with each other): shortening of the neck, in severe cases - sharp, softening it and thinning; the external pharynx can be either closed (more often in primiparas) or gape; the cervical (cervical) canal may be closed or pass the tip of a finger, one or two fingers, sometimes with dilution. When viewed in the mirrors, a gaping of the external os of the cervix with a protruding (protruding) fetal bladder can be detected.

Sometimes, with doubtful data from a vaginal examination in the early stages of development, ultrasound helps to diagnose ICI, in which an expansion of the internal pharynx can be detected.

Complications of ICI during pregnancy

The most severe complication is termination of pregnancy at various times, which may begin with or without amniotic fluid. Often, ICI is accompanied by infection of the fetus due to the lack of a barrier for pathogenic microorganisms in the form of a closed cervix and cervical mucus, which normally protects the uterine cavity and its contents from bacteria.

Treatment of CI during pregnancy

Methods of treatment are divided into operational and non-operative/conservative.

Surgical treatment of CI

The operative method consists in suturing the cervix in order to narrow it, and is carried out only in a hospital. There are various methods of suturing, their effectiveness is almost the same. Before treatment, an ultrasound of the fetus is performed, its intrauterine condition, the location of the placenta, and the condition of the internal pharynx are assessed. Of the laboratory tests, it is mandatory to prescribe a smear analysis for the flora, and in the case when inflammatory changes are found in it, treatment is carried out. The operation is performed under local anesthesia, after the operation, the patient is prescribed antispasmodic and analgesic drugs for prophylactic purposes for several days.

After 2-3 days, the viability of the sutures is assessed and, if their condition is favorable, the patient is discharged under the supervision of a antenatal clinic doctor. Complications of the procedure can be: increased tone of the uterus, prenatal rupture of amniotic fluid, infection of the sutures and intrauterine infection of the fetus.

In the absence of effect and progression of ICI, pregnancy is not recommended to be prolonged, since the sutures can erupt, causing bleeding.

Contraindications for suturing the uterus are:

Untreated infections of the genitourinary system;
- the presence in the past of abortions in the II and III trimesters (recurrent miscarriage);
- the presence of intrauterine malformations of the fetus that are not compatible with life;
- uterine bleeding ;
- severe concomitant diseases that are a contraindication for prolonging pregnancy (severe cardiovascular diseases, impaired renal and / or liver function, some mental illnesses, severe gestosis of the second half of pregnancy - nephropathy of II and III degrees, eclampsia and preeclampsia);
- increased tone of the uterus, not amenable to drug treatment;
- progression of ICI - rapid shortening, softening of the cervix, opening of the internal os.

Conservative treatment of CI

A non-operative method consists in narrowing the cervix and preventing its opening by installing a pessary. A pessary is a latex or rubber ring that is “put on” around the cervix so that its edges rest against the walls of the vagina, holding the ring in place. This method of treatment can only be used in cases where the cervical canal is closed, i.e. in the early stages of CI or if it is suspected, and can also be an addition to suturing.

Every 2-3 days, the pessary is removed, disinfected and reinstalled. The method is less effective than the first one, but it has several advantages: bloodlessness, ease of implementation and no need for inpatient treatment.

Prediction of pregnancy outcome in ICI

The prognosis depends on the stage and form of CI, on the presence of concomitant infectious diseases and on the duration of pregnancy. The shorter the gestational age and the more open the cervix, the worse the prognosis. As a rule, with early diagnosis, pregnancy can be prolonged in 2/3 of all patients.

Prevention of CCI

It consists in careful curettage, examination and suturing of ruptures of the cervix after childbirth, plasty of the cervix when old ruptures are found outside of pregnancy, treatment of hormonal disorders.

Obstetrician-gynecologist Kondrashova D.V.