Contraindications to surgical correction of icn. Clinical protocol miscarriage

One of the most common causes of early termination of pregnancy in the second and third trimesters is CCI (insolvency, incompetence of the cervix). ICI - asymptomatic shortening of the cervix, expansion of the internal os, leading to rupture of the fetal bladder and loss of pregnancy.

CLASSIFICATION OF ISTHMIC-CERVICAL INSUFFICIENCY

Congenital ICI (with genital infantilism, malformations of the uterus).
· Acquired ICN.
- Organic (secondary, post-traumatic) ICI occurs as a result of medical and diagnostic manipulations on the cervix, as well as traumatic childbirth, accompanied by deep ruptures of the cervix.
- Functional CI is observed in endocrine disorders (hyperandrogenism, ovarian hypofunction).

DIAGNOSTICS OF ISTHMIC-CERVICAL INSUFFICIENCY

Criteria for diagnosing CCI during pregnancy:
Anamnestic data (history of spontaneous miscarriages and premature births).
Vaginal examination data (location, length, consistency of the cervix, condition of the cervical canal - patency of the cervical canal and internal os, cicatricial deformity of the cervix).

The severity of ICI is determined by the Stember point scale (Table 141).

A score of 5 or more requires correction.

Ultrasound (transvaginal echography) is of great importance in the diagnosis of CCI: the length of the cervix, the condition of the internal os and the cervical canal are assessed.

Table 14-1. Scoring of the degree of isthmic-cervical insufficiency according to the Stember scale

Ultrasound monitoring of the state of the cervix should be carried out starting from the first trimester of pregnancy for a true assessment of the reduction in the length of the cervix. A cervical length of 30 mm is critical at less than 20 weeks and requires intensive ultrasound monitoring.

Ultrasound signs of ICI:

· Shortening of the cervix to 25–20 mm or less, or opening of the internal os or cervical canal to 9 mm or more. In patients with the opening of the internal os, it is advisable to evaluate its shape (Y, V or U-shaped), as well as the severity of the deepening.

INDICATIONS FOR SURGICAL CORRECTION OF ISTHMICOCERVICAL INSUFFICIENCY

· History of spontaneous miscarriages and premature births.
Progressive CI according to clinical and functional research methods:
- signs of ICI according to vaginal examination;
- ECHO signs of CI according to transvaginal sonography.

CONTRAINDICATIONS TO SURGICAL CORRECTION OF ISTHMICOCERVICAL INSUFFICIENCY

Diseases and pathological conditions that are a contraindication to the prolongation of pregnancy.
· Bleeding during pregnancy.
Increased tone of the uterus, not amenable to treatment.
fetal CM.
· Acute inflammatory diseases of the pelvic organs (PID) - III-IV degree of purity of the vaginal contents.

CONDITIONS FOR THE OPERATION

· The gestation period is 14–25 weeks (the optimal gestation period for cervical cerclage is up to 20 weeks).
· A whole fetal bladder.
Lack of significant smoothing of the cervix.
No pronounced prolapse of the fetal bladder.
No signs of chorioamnionitis.
Absence of vulvovaginitis.

PREPARATION FOR OPERATION

Microbiological examination of the vaginal discharge and cervical canal.
Tocolytic therapy according to indications.

PAIN RELIEF METHODS

Premedication: atropine sulfate at a dose of 0.3–0.6 mg and midozolam (dormicum ©) at a dose of 2.5 mg intramuscularly.
· Ketamine 1–3 mg/kg body weight intravenously or 4–8 mg/kg body weight intramuscularly.
· Propofol at a dose of 40 mg every 10 seconds intravenously until the onset of clinical symptoms of anesthesia. The average dose is 1.5-2.5 mg / kg of body weight.

SURGICAL METHODS FOR CORRECTION OF ISTHMIC-CERVICAL INSUFFICIENCY

The most accepted method currently is:

The method of suturing the cervix with a circular purse-string suture according to MacDonald.
Operation technique: At the border of the transition of the mucous membrane of the anterior vaginal fornix, a purse-string suture is applied to the cervix from a durable material (lavsan, silk, chrome-plated catgut, mersilene tape) with the needle passed deep through the tissues, the ends of the threads are tied in a knot in the anterior vaginal fornix. The long ends of the ligature are left so that they are easy to detect before childbirth and can be easily removed.

It is also possible to use other methods of correction of ICI:

· Shaped sutures on the cervix according to the method of A.I. Lyubimova and N.M. Mammadaliyeva.
Operation technique:
At the border of the transition of the mucous membrane of the anterior vaginal fornix, 0.5 cm away from the midline on the right, the cervix is ​​pierced with a needle with mylar thread through the entire thickness, making a puncture in the back of the vaginal fornix.
The end of the thread is transferred to the left lateral part of the vaginal fornix, the mucous membrane and part of the thickness of the cervix are pierced with a needle, making an injection 0.5 cm to the left of the midline. The end of the second lavsan thread is transferred to the right lateral part of the vaginal fornix, then the mucous membrane and part of the thickness of the uterus are pierced with a prick in the anterior part of the vaginal fornix. The tampon is left for 2-3 hours.

· Sewing of the cervix according to the method of V.M. Sidelnikova (with gross ruptures of the cervix on one or both sides).
Operation technique:
The first purse-string suture is applied according to the MacDonald method, just above the rupture of the cervix. The second purse-string suture is carried out as follows: below the first 1.5 cm through the thickness of the wall of the cervix from one edge of the gap to the other, a thread is passed circularly along a spherical circle. One end of the thread is injected inside the cervix into the posterior lip and, having picked up the lateral wall of the cervix, the puncture is made in the anterior part of the vaginal fornix, twisting the torn lateral anterior lip of the cervix like a cochlea, and is brought out into the anterior part of the vaginal fornix. The threads are connected.
For suturing, modern suture material "Cerviset" is used.

COMPLICATIONS

· Spontaneous abortion.
· Bleeding.
Rupture of the amniotic membranes.
Necrosis, eruption of the cervical tissue with threads (lavsan, silk, nylon).
Formation of bedsores, fistulas.
Chorioamnionitis, sepsis.
Circular avulsion of the cervix (at the onset of labor and the presence of sutures).

FEATURES OF THE POSTOPERATIVE PERIOD

You are allowed to get up and walk immediately after the operation.
Treatment of the vagina and cervix with a 3% solution of hydrogen peroxide, benzyldimethyl-myristoylaminopropylammonium chloride monohydrate, chlorhexidine (in the first 3-5 days).
For therapeutic and prophylactic purposes, the following drugs are prescribed.
- Antispasmodics: drotaverine 0.04 mg 3 times a day or intramuscularly 1-2 times a day for 3 days.
- b Adrenomimetics: hexoprenaline at a dose of 2.5 mg or 1.25 mg 4 times a day for 10-12 days, at the same time verapamil is prescribed at a dose of 0.04 g 3-4 times a day.
- Antibacterial therapy according to indications with a high risk of infectious complications, taking into account the data of a microbiological study of a vaginal discharge with sensitivity to antibiotics.
Discharge from the hospital is carried out on the 5-7th day (with an uncomplicated course of the postoperative period).
On an outpatient basis, examination of the cervix is ​​carried out every 2 weeks.
The sutures from the cervix are removed at 37–38 weeks of gestation.

INFORMATION FOR THE PATIENT

· With the threat of termination of pregnancy, especially with recurrent miscarriage, it is necessary to monitor the condition of the cervix using ultrasound.
· The effectiveness of surgical treatment of CCI and pregnancy is 85-95%.
· It is necessary to observe the medical-protective regimen.

Among the various causes of miscarriage, isthmic-cervical insufficiency (ICI) occupies an important place. In its presence, the risk of miscarriage increases by almost 16 times.

The overall incidence of CI during pregnancy is 0.2 to 2%. This pathology is the main cause of miscarriage in the second trimester (about 40%) and premature birth in every third case. It is detected in 34% of women with habitual spontaneous abortion. According to most authors, almost 50% of late pregnancy losses are caused precisely by isthmic-cervical incompetence.

In women with a full-term pregnancy, childbirth with ICI often has a rapid character, which negatively affects the child's condition. In addition, rapid labor is very often complicated by significant ruptures of the birth canal, accompanied by massive bleeding. ICN - what is it?

Definition of the concept and risk factors

Isthmic-cervical insufficiency is a pathological premature shortening of the cervix, as well as the expansion of its internal os (muscular "obturator" ring) and the cervical canal as a result of an increase in intrauterine pressure during pregnancy. This can cause the fetal membranes to fall into the vagina, rupture and lose the pregnancy.

Reasons for the development of ICI

In accordance with modern concepts, the main causes of inferiority of the cervix are three groups of factors:

1. Organic - the formation of cicatricial changes after a traumatic injury to the neck.
2. Functional.
3. Congenital - genital infantilism and malformations of the uterus.

The most frequent provoking factors are organic (anatomical and structural) changes. They may result from:

• ruptures of the cervix during childbirth with a large fetus, and;
• and extraction of the fetus by the pelvic end;
• rapid childbirth;
• imposition of obstetric forceps and vacuum extraction of the fetus;
• manual separation and allocation of the placenta;
• carrying out fruit-destroying operations;
• artificial instrumental abortions and;
• operations on the cervix;
• various other manipulations accompanied by its instrumental extension.

The functional factor is represented by:

• dysplastic changes in the uterus;
• ovarian hypofunction and an increased content of male sex hormones in the body of a woman (hyperandrogenism);
• elevated levels of relaxin in the blood in cases of multiple pregnancy, induction of ovulation by gonadotropic hormones;
• long-term chronic or acute inflammatory diseases of the internal genital organs.

Risk factors are also age over 30 years, overweight and obesity, in vitro fertilization.

In this regard, it should be noted that the prevention of CI consists in the correction of the existing pathology and in the exclusion (if possible) of the causes that cause organic changes in the cervix.

Clinical manifestations and diagnostic possibilities

It is rather difficult to make a diagnosis of isthmic-cervical insufficiency, except for cases of gross post-traumatic anatomical changes and some developmental anomalies, since the currently existing tests are not completely informative and reliable.

The main symptom in the diagnosis, most authors consider a decrease in the length of the cervix. During a vaginal examination in the mirrors, this symptom is characterized by flaccid edges of the external pharynx and the gaping of the latter, and the internal pharynx freely passes the gynecologist's finger.

The diagnosis before pregnancy is established if it is possible to introduce dilator No. 6 into the cervical canal during the secretory phase. It is desirable to determine the state of the internal pharynx on the 18th - 20th day from the onset of menstruation, that is, in the second phase of the cycle, with the help of which the width of the internal pharynx is determined. Normally, its value is 2.6 mm, and a prognostically unfavorable sign is 6-8 mm.

During pregnancy itself, as a rule, women do not present any complaints, and clinical signs suggesting the possibility of a threatened abortion are usually absent.

In rare cases, indirect symptoms of CI are possible, such as:

• sensations of discomfort, "bursting" and pressure in the lower abdomen;
• stabbing pains in the vaginal area;
• discharge from the genital tract of a mucous or sanious nature.

During the period of observation in the antenatal clinic, such a symptom as prolapse (protrusion) of the fetal bladder is of considerable importance in relation to the diagnosis and management of a pregnant woman. At the same time, the degree of threat of termination of pregnancy is judged by 4 degrees of location of the latter:

• I degree - above the internal pharynx.
• II degree - at the level of the internal pharynx, but not visually determined.
• III degree - below the internal pharynx, that is, in the lumen of the cervical canal, which already indicates a late detection of its pathological condition.
• IV degree - in the vagina.

Thus, the criteria for preliminary clinical diagnosis of isthmic-cervical insufficiency and the inclusion of patients in risk groups are:

1. Past history of mildly painful miscarriages in late gestation or rapid preterm labor.
2. . This takes into account that each subsequent pregnancy ended in premature birth at ever earlier gestational dates.
3. Pregnancy after a long period of infertility and use.
4. The presence of prolapse of the membranes in the cervical canal at the end of the previous pregnancy, which is established according to the anamnesis or from the dispensary record card located in the antenatal clinic.
5. Data of vaginal examination and examination in the mirrors, during which signs of softening of the vaginal part of the cervix and its shortening, as well as prolapse of the fetal bladder into the vagina, are determined.

However, in most cases, even a pronounced degree of prolapse of the fetal bladder proceeds without clinical signs, especially in primiparas, due to a closed external pharynx, and risk factors cannot be identified until the onset of labor.

In this regard, ultrasound in isthmic-cervical insufficiency with the determination of the length of the cervix and the width of its internal os (cervicometry) acquires a high diagnostic value. More reliable is the technique of echographic examination by means of a transvaginal sensor.

How often should cervicometry be done in CCI?

It is carried out at the usual screening terms of pregnancy, corresponding to 10-14, 20-24 and 32-34 weeks. In women with habitual miscarriage in the second trimester, in cases of an obvious presence of an organic factor or if there is a suspicion of the possibility of post-traumatic changes from 12 to 22 weeks of pregnancy, it is recommended to conduct a dynamic study - every week or 1 time in two weeks (depending on the results of examining the cervix in the mirrors ). Assuming the presence of a functional factor, cervicometry is carried out from 16 weeks of gestation.

The criteria for evaluating the data of an echographic study, mainly on the basis of which the final diagnosis is carried out and the treatment of CI during pregnancy is chosen, are:

1. In first- and second-pregnant women at terms less than 20 weeks, the length of the neck, which is 3 cm, is critical in terms of threatening spontaneous abortion. Such women need intensive monitoring and inclusion in the risk group.
2. Up to 28 weeks in multiple pregnancies, the lower limit of the normal length of the neck is 3.7 cm in primigravidas, and 4.5 cm in multipregnant women.
3. The norm of the length of the neck in multiparous healthy pregnant women and women with ICI at 13-14 weeks is from 3.6 to 3.7 cm, and at 17-20 weeks the cervix with insufficiency is shortened to 2.9 cm.
4. The absolute sign of miscarriage, which already requires appropriate surgical correction for ICI, is the length of the cervix, which is 2 cm.
5. The width of the internal os is normal, which is 2.58 cm by the 10th week, increases evenly and reaches 4.02 cm by the 36th week. A decrease in the ratio of the length of the neck to its diameter in the area of ​​the internal os to 1.12 is of prognostic value. -1.2. Normally, this parameter is 1.53-1.56.

At the same time, the variability of all these parameters is affected by the tone of the uterus and its contractile activity, low placental attachment and the degree of intrauterine pressure, which create certain difficulties in interpreting the results in terms of differential diagnosis of the causes of threatened abortion.

Ways to maintain and prolong pregnancy

When choosing methods and drugs for the correction of pathology in pregnant women, a differentiated approach is necessary.

These methods are:

• conservative - clinical recommendations, treatment with drugs, the use of a pessary;
• surgical methods;
• their combination.

Includes psychological impact by explaining the possibility of successful pregnancy and childbirth, and the importance of following all the recommendations of a gynecologist. Advice is given regarding the exclusion of psychological stress, the degree of physical activity depending on the severity of the pathology, the possibility of decompression gymnastics. It is not allowed to carry loads weighing more than 1 - 2 kg, long walking, etc.

Can I sit with ICI?

Long stay in a sitting position, as well as a vertical position in general, contributes to an increase in intra-abdominal and intrauterine pressure. In this regard, during the day it is desirable to be in a horizontal position more often and longer.

How to lie down with ICI?

You need to rest on your back. The foot end of the bed should be raised. In many cases, strict bed rest is recommended, mainly following the above provisions. All these measures can reduce the degree of intrauterine pressure and the risk of prolapse of the fetal bladder.

Medical therapy

Treatment begins with a course of anti-inflammatory and antibacterial therapy with drugs from the fluoroquinolone or cephalosporin group of the third generation, taking into account the results of a preliminary bacteriological study.

To reduce and, accordingly, intrauterine pressure, antispasmodic drugs such as Papaverine orally or in suppositories, No-shpa orally, intramuscularly or intravenously are prescribed. With their insufficient effectiveness, tocolytic therapy is used, which contributes to a significant decrease in uterine contractility. The optimal tocolytic is Nifedipine, which has the least number of side effects and their insignificant severity.

In addition, with ICI, it is recommended to strengthen the cervix with Utrozhestan of organic origin up to 34 weeks of pregnancy, and with a functional form through Proginov's preparation for up to 5-6 weeks, after which Utrozhestan is prescribed for up to 34 weeks. Instead of Utrogestan, the active ingredient of which is progesterone, analogues of the latter (Dufaston, or dydrogesterone) can be prescribed. In cases of hyperandrogenism, the basic drugs in the treatment program are glucocorticoids (Metipred).

Surgical and conservative methods of correction of CI

Can the cervix lengthen with CCI?

In order to increase its length and reduce the diameter of the internal os, such methods as surgical (suturing) and conservative are also used in the form of installing perforated silicone obstetric pessaries of various designs that help to shift the cervix towards the sacrum and keep it in this position. However, in most cases, the lengthening of the neck to the required (physiological for a given period) value does not occur. The use of the surgical method and the pessary is carried out against the background of hormonal and, if necessary, antibiotic therapy.

What is better - sutures or a pessary for CCI?

The procedure for installing a pessary, in contrast to the surgical technique of suturing, is relatively simple in terms of technical implementation, does not require the use of anesthesia, is easily tolerated by a woman and, most importantly, does not cause circulatory disorders in the tissues. Its function is to reduce the pressure of the fetal egg on the incompetent cervix, preserve the mucous plug and reduce the risk of infection.

Obstetric unloading pessary

However, the application of any technique requires a differentiated approach. With an organic form of ICI, the imposition of circular or U-shaped (better) sutures is advisable in terms of 14-22 weeks of pregnancy. If a woman has a functional form of pathology, an obstetric pessary can be installed within a period of 14 to 34 weeks. In case of progressive shortening of the cervix to 2.5 cm (or less) or an increase in the diameter of the internal os to 8 mm (or more), surgical sutures are applied in addition to the pessary. Removal of the pessary and removal of sutures in CCI is carried out in a hospital at the 37th - 38th weeks of pregnancy.

Thus, ICI is one of the most common causes of abortion before 33 weeks. This problem has been studied to a sufficient extent and an adequately corrected ICI of 87% or more makes it possible to achieve the desired results. At the same time, methods of correction, ways to control their effectiveness, as well as the question of the optimal timing of surgical treatment, are still debatable.

The article considers a number of publications regarding the complicationsthe course of pregnancy. The leading background of early preterm birth is isthmic-cervical insufficiency.
The prospects for the use of modern methods of prevention and treatment of this pathology are highlighted in detail.
Modifications of the surgical method for correcting isthmic-cervical insufficiency in recurrent miscarriage are presented.

Keywords: isthmic-cervical insufficiency, early preterm birth, miscarriage, transvaginal and transabdominal cerclage.

Isthmic-cervical insufficiency (ICN) (Latin insufficientia isthmicocervicalis: isthmus - isthmus of the uterus + cer-vix - cervix) is a pathological condition of the isthmus and cervix (CC) during pregnancy, in which they are not able to withstand intrauterine pressure and hold an increasing fetus in the uterine cavity until timely delivery.

The condition of the CMM plays one of the key roles for the normal course of pregnancy. ICI occupies a significant place among the factors leading to miscarriage. It accounts for 25 to 40% of cases of miscarriage in the II-III trimester of gestation [,]. Multiple (2 or more) cases of abortion due to ICI are known, which are regarded as habitual miscarriage. ICI is the leading cause of abortion at 22-27 weeks, while the body weight of the fetus is 500-1000 g, and the outcome of pregnancy for the child is extremely unfavorable due to deep prematurity.

For the first time, ICI as a complication of pregnancy leading to spontaneous abortion was described by Geam in 1965. The processes of shortening and softening of the cervix in the second trimester, which are clinically manifested by its failure, are an important diagnostic and therapeutic problem and the subject of a lively discussion among practitioners.

In this period of time, the mechanisms, causes and conditions for the occurrence of CI are quite well studied, among which there are cervical injuries, as well as its anatomical and functional congenital defects. Based on the underlying cause of CCI, organic and functional cervical insufficiency are distinguished.

Diagnosis of CI is based on the results of examination and palpation of the cervix. The severity of ICI can be determined using a score on the Stember scale (Table)

Table. Scoring of the degree of ICI on the Stember scale

Clinical signs	Score in points
The length of the vaginal part of the neck		shortened
CMM channel status		Partially pass	Missing a finger
CMM location	Sacred	Central	Directed anteriorly
CMM consistency		softened
Localization of the adjacent part of the fetus	Above the entrance to the pelvis	Pressed to the entrance to the pelvis	At the entrance to the pelvis

However, the most information about the presence of CI is obtained using ultrasound. With transvaginal scanning of the cervix, it is possible to visualize the smoothness (or shortening) of the cervix, dynamic changes in its structure, changes in the anatomy of the internal os, expansion of the cervical canal with prolapse of the membranes into its lumen (a formation in the form of a funnel).

Ultrasound monitoring of the condition of the cervix must be started from the first trimester of pregnancy. The length of the CMM, equal to 30 mm, is critical for the term< 20 нед и требует интенсивного ультразвукового мониторинга. Достоверными ультразвуковыми признаками ИЦН являются: укорочение ШМ ≤ 25-20 мм или раскрытие ее внутреннего канала ≥ 9 мм. У пациенток с открытым внутренним зевом целесообразно оценивать форму воронки, а также выраженность углубления.

Rice. 1. Types of CMM funnels on ultrasound The letters T, Y, V, U represent the relationship between the lower segment of the uterus and the cervical canal. The configuration of the cervix is ​​indicated in gray, the head of the fetus is indicated in blue, the CMM is in orange, and the modified cervix is ​​red.

M. Zilianti et al. described various forms of the CMM funnel - T-, Y-, V- and U-shaped types. The acoustic window was obtained by transperineal access of ultrasound scanning (Fig. 1).

The form T represents the absence of the funnel, Y the first stage of the funnel, U and V the expansion of the funnel (Fig. 2).

With the V-shaped type, the fetal membranes protrude into the cervical canal with the formation of a triangular funnel. With the U-shaped type, the pole of the prolapsing membranes has a rounded shape.

N. Tetruashvili et al. developed an algorithm for managing patients with prolapse of the fetal bladder into the cervical canal and the upper third of the vagina, including the following examinations:

In addition to the above diagnostics, the algorithm for managing such pregnant women provides for the exclusion of the insolvency of the scar on the uterus - at the slightest suspicion, surgical correction of ICI and tocolysis is unacceptable. It is also necessary to exclude preeclampsia and extragenital pathology, in which prolongation of pregnancy is impractical.

The same researchers initiated tocolysis with atosiban and antibiotic therapy in 17 patients with ICI complicated by prolapse of the fetal bladder into the cervical canal or the upper third of the vagina at 24-26 weeks of gestation, after taking into account all contraindications. Then, a surgical correction of the ICI was performed with the “refueling” of the fetal bladder behind the region of the internal os. Tocolysis with atosiban was continued for 48 hours, and fetal respiratory distress syndrome was prevented. In 14 (82.4%) of 17 cases, the pregnancy ended in timely delivery at 37-39 weeks. In three cases, premature births occurred (on the 29th, 32nd, 34th week), after which the babies underwent a course of treatment and rehabilitation. The use of atosiban in the complex treatment of complicated CI at 24–26 weeks of gestation may be one of the ways to prevent very early preterm birth.

E. Guzman et al. recommend performing a cervical stress test during ultrasound. This study is aimed at early identification of women at high risk of developing CCI during ultrasonography. The technique is as follows: moderate pressure is exerted on the anterior abdominal wall along the axis of the uterus in the direction of the vagina for 15-30 seconds. A positive test result is considered when the length of the cervix decreases and the internal os expands by ≥ 5 mm.

Rice. 3. Transvaginal scanning of CMM. Presence of funnel-shaped expansion of the internal os and amniotic sludge

Before making a decision on the need and possibility of surgical correction of CI, it is desirable to exclude the presence of chorioamnionitis, which, as noted above, is a contraindication to surgery. According to R. Romero et al. , one of the characteristic ultrasound manifestations of chorioamnionitis (including subclinical in asymptomatic patients) is the visualization of the so-called amniotic sludge - the accumulation of an echogenic suspension of cells in the amniotic fluid in the area of ​​the internal os (Fig. 3).

As it turned out, in macro- and microscopic examination, the described amniotic sludge is a lump of banal pus from desquamated epithelial cells, gram-positive coccal flora, and neutrophils. Its detection on transvaginal ultrasound is an important manifestation of microbial invasion, inflammation, and a predictor of spontaneous preterm birth.

In a sample of amniotic fluid aspirated close to the amniotic sludge in the region of the internal cervical os, the authors found higher concentrations of prostaglandins and cytokines/chemokines compared to amniotic fluid samples obtained from the fundus of the uterus. In the study of amniotic sludge cell culture, Streptococcus mutans, Mycoplasma hominis, Aspergillus flavus. According to F. Fuchs et al. , amniotic sludge was diagnosed in 7.4% of patients (n = 1220) with singleton pregnancies at terms from 15 to 22 weeks. This marker was associated with a shortening of the cervix, an increased body mass index, the risk of cerclage of the cervix, and preterm birth before 28 weeks. The researchers noted that the administration of azithromycin to pregnant women with amniotic sludge significantly reduced the risk of preterm delivery up to 24 weeks of gestation.

At the same time, L. Gorski et al. in the study of clinical cases of 177 pregnant women who underwent McDonald's cerclage (from 14 to 28 weeks of gestation), we did not find a significant difference in the timing of delivery in 60 pregnant women who had amniotic sludge (36.4 ± 4.0 weeks), according to compared with 117 women without it (36.8 ± 2.9 weeks; p = 0.53). Also, there were no statistical differences in the incidence of preterm birth before 28, 32 and 36 weeks in these patients.

Ultrasound dynamic monitoring of the state of cervix up to 20 weeks of gestation allows timely diagnosis and surgical correction of CI in the most favorable terms. But at the same time, when making a diagnosis of CCI, only ultrasound data is not enough, since the neck can be short, but dense. For a more accurate diagnosis, a visual examination of the BL in the mirrors and a bimanual examination are required to identify a short and soft BL.

Surgical correction of ICI is performed in stationary conditions. Preliminary bacterioscopic and bacteriological studies of the vaginal contents are carried out, sensitivity to antibiotics is determined, and tests for sexually transmitted infections are performed. You should also identify other causative factors of miscarriage and eliminate them. Then, after discharge from the hospital, every 2 weeks on an outpatient basis, a visual examination of the CMM is performed using mirrors. The sutures are removed at the 37-39th week of pregnancy in each case individually.

The practitioner should remember that during the surgical treatment of ICI, complications such as cervical rupture, rupture of the fetal bladder, stimulation of labor activity due to the inevitable release of prostaglandins during manipulation, sepsis, cervical stenosis, eruption of sutures, anesthesia complications and maternal death can develop, which determines ambiguous attitude of obstetricians-gynecologists to the expediency of surgical correction of this disorder in pregnant women.

It is known that non-surgical cerclage using supporting obstetric pessaries of various designs has been used for more than 30 years.

Studies conducted by M. Tsaregorodtseva and G. Dikke demonstrate the advantage of non-surgical correction in the prevention and treatment of cervical insufficiency during pregnancy due to its atraumatic nature, very high efficiency, safety, and the ability to use it both on an outpatient basis and in a hospital at any gestational age. At the same time, the effectiveness of this method is somewhat lower than the surgical one. Nevertheless, scientists note that with the introduction of a pessary at the beginning of the second trimester (15-16 weeks) to patients at a high risk of miscarriage to prevent the progression of CCI, the effectiveness of the method increased to 97%.

As you know, the mechanism of action of pessaries is to reduce the pressure of the fetal egg on the incompetent CMM. Due to the redistribution of intrauterine pressure, the CMM is closed by the central opening of the pessary, the formation of a shortened and partially open CMM, and its unloading. All this together provides protection for the lower pole of the fetal egg. The retained mucus plug reduces the risk of infection. An indication for the use of an obstetric pessary is mild to moderate CCI of both traumatic and functional origin, a high risk of developing CCI at any stage of pregnancy.

In the last decade, the silicone ring pessary R. Arabin (Doctor Arabin, Germany) has gained the greatest popularity. Its feature is the absence of a steel spring and a large surface area, which reduces the risk of necrosis of the vaginal wall.

M. Cannie et al. , performing MRI in 73 pregnant women (at 14-33 weeks) with a high risk of preterm birth before and immediately after the correct installation of the Arabin cervical pessary, noted an immediate decrease in the cervical-uterine angle, which ultimately contributed to the prolongation of pregnancy or, as the authors write caused a delay in the onset of labor.

In the countries of the post-Soviet space, incl. and in Ukraine, the obstetric unloading pessaries "Yunona" produced by the medical enterprise "Simurg" (Republic of Belarus), made of soft medical plastic, have also found a fairly wide application.

The publications note that the outcomes of various methods of correction of ICI are not the same: after surgical correction, the threat of abortion more often develops, and after conservative correction - colpitis. According to I. Kokh, I. Satysheva, when using both methods of correction of ICI, the carrying of pregnancy to the term of delivery is 93.3%. In a multicentre retrospective cohort study, A. Gimovsky et al. with the participation of patients with a singleton asymptomatic pregnancy at 15-24 weeks and the opening of the cervix > 2 cm, we compared the effectiveness of the use of a pessary, the technique of suturing the cervix, and expectant management. The results indicated that cervix suturing is the best treatment for prolonging pregnancy in patients with singleton pregnancies and ruptured membranes in the second trimester. The use of a pessary did not outperform the effect of expectant management in this group of patients.

At the same time, K. Childress et al. inform that when comparing the characteristics of the course of pregnancy and perinatal outcomes when suturing the cervix with those when using a vaginal pessary in patients with a shortened cervix (< 25 мм) и одноплодной беременностью установлена одинаковая эффективность обеих методик в предотвращении преждевременных родов и неблагоприятных неонатальных исходов. Они являются более привлекательным выбором у беременных на поздних сроках гестации и ассоциированы с меньшим числом случаев таких осложнений, как хориоамнионит и вагинальные кровотечения.

J. Harger reports that the effectiveness of Shirodkar and McDonald methods exceeds 70-90% due to the creation of conditions for calendar prolongation of pregnancy after the correction of ICI. At the same time, the author points out that the Shirodkar cerclage applied more distally by vaginal access is more effective than the McDonald operation. Therefore, from the point of view of obstetric prognosis, the location of the prosthesis closer to the internal os is more preferable.

According to S. Ushakova et al. , it is necessary to single out the category of patients who underwent surgical interventions on the cervix, in which there is a significant shortening of its length, the absence of its vaginal portion. In such a situation, the implementation of vaginal cerclage during pregnancy is technically difficult.

Therefore, in 1965, R. Benson and R. Durfee proposed a technique for performing cerclage with abdominal access (TAS) to solve this problem. For the steps of the operation, see the link: http://onlinelibrary.wiley.com/doi/10.1046/j.1471-0528.2003.02272.x/pdf.

According to research results, the number of cases of perinatal losses due to their use does not exceed 4-9% with a complication rate of 3.7-7%. N. Burger et al. showed that the laparoscopic method of CMM cerclage has the highest efficiency. In a cohort study, it was found that preterm birth in this category of patients was observed in 5.7% of cases, complications - up to 4.5%.

In this period of time, CMM cerclage is increasingly performed by laparoscopic access or using robotics. It is necessary to draw the attention of practitioners to the high efficiency of the laparoscopic technique.

The studied publications show that in addition to the typical vaginal cerclage performed during pregnancy and the transabdominal cerclage of the cervico-isthmic cerclage, the technique of transvaginal cervical-isthmic cerclage (TV CIC) has been developed. Under the specified method of surgical correction is meant the intervention by vaginal access in order to correct CCI both during pregnancy and at the stage of its planning. After preliminary tissue dissection, the synthetic prosthesis is located at the level of the cardinal and sacro-uterine ligaments.

In a systematic review, V. Zaveri et al. compared the effectiveness of TV CIC and TAC in women who had previously had an unsuccessful vaginal cerclage complicated by perinatal losses. According to the results, the number of cases of termination of pregnancy in the group with abdominal access was 6 vs. 12.5% ​​in the group with vaginal access, indicating a higher efficiency of the superior prosthesis. But at the same time, intraoperative complications in the TAC group were observed in 3.4% of cases, while they were completely absent in the TV CIC group. Therefore, if there are technical possibilities, the operation of choice in patients with a preserved vaginal portion of the cervix, with the ineffectiveness of a previously performed vaginal cerclage, is transvaginal cervico-isthmic cerclage.

Researchers studying this problem indicate that special attention should be paid to the problem of carrying a pregnancy in patients who underwent radical organ-preserving treatment for cervical cancer. According to these publications, at present, organ-preserving surgeries are performed by oncogynecologists abroad for some forms of precancerous diseases and cervical cancer in a volume that leaves a woman the opportunity to realize her reproductive function (high knife amputation of cervical cancer, radical abdominal [RAT] or vaginal trachelectomy performed by laparotomy or laparoscopic access).

When studying the outcomes of both abdominal and vaginal trachelectomy, the high efficiency of this method of organ-preserving treatment, which preserves the conditions for childbearing, was found.

Despite the success of surgical techniques, the main problem for the rehabilitation of a woman's reproductive function remains the problem of the onset and calendar prolongation of pregnancy. In this situation, comments are unnecessary - in the complete absence of cervical cancer, the progression of pregnancy creates an increasing load on the uterovaginal anastomosis, which often leads to its loss in the II and III trimesters of gestation.

C. Kohler et al. report that during pregnancy after vaginal trachelectomy in 50% of patients, children are born prematurely, mainly due to rupture of the membranes and premature rupture of amniotic fluid.

Recently, publications have appeared in the literature on the technique of trachelectomy with the addition of an operation with one-stage fixation of the anastomosis with a synthetic prosthesis or circular ligatures, while at the same time, many oncologists do not perform this technical element.

Rice. 4. Features of performing cerclage in patients undergoing trachelectomy for cervical cancer

J. Persson et al. conducted an in-depth study of the features of the implementation of the cerclage of the uterus. They registered that in the group of women who underwent trachelectomy using robot-assisted laparoscopy, the level of the suture on the uterus was 2 mm higher than in the group of patients using vaginal access (Fig. 4).

Abroad, in patients with a preserved length of the cervix with a history of miscarriage, the operation of applying a vaginal cerclage to the cervix is ​​often performed by laparoscopic access. When carrying out the cerclage of the uterus, a polypropylene prosthesis or mersilene tape is used. It is better to use such surgical interventions at the stage of pregnancy planning. It is reasonable to note that performing cerclage of the uterus after RAT is a technically difficult procedure due to the pronounced adhesive process in the abdominal cavity and the pelvic cavity, associated with the previously performed ileo-obturator lymphadenectomy and pronounced anatomical changes in the area of ​​the uterovaginal anastomosis. Pregnancy is recommended 2-3 months after surgery.

When performing RAT, patients are provided with conditions for the implementation of reproductive function, but at the same time, this category of patients, who are at high risk of miscarriage, needs further careful monitoring and the need for surgical preparation for subsequent pregnancy. Thus, based on the conclusions set out in multiple publications, a thorough examination of cervical cancer at the stage of preconception preparation (especially among patients with recurrent miscarriage) is necessary to determine the risk group for developing CI.

For patients with a severe degree of traumatic CI, it is desirable to carry out correction before pregnancy using both transvaginal and transabdominal techniques.

Obstetricians-gynecologists of Ukraine should adhere to the principles of the clinical protocol "Miscarriage", regulated by the order of the Ministry of Health of Ukraine dated 03.11.2008 No. 624. According to this document, the treatment of CI consists in the imposition of a prophylactic or therapeutic suture on the cervix. At the same time, further studies of this problem may allow answering the questions of modern obstetrics regarding the choice of the optimal tactics for managing pregnant women with CI and preventing very early preterm birth.

List of used literature

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Timmons B. et al. Cervical remodeling during pregnancy and parturition //Trends Endocrin Metabolism. 2010; 21(6): 353-361.

Harger J. H. Comparison of success and morbidity in cervical cerclage procedures // Obstet Gynecol. 1980; 56:543-548.

Persson J., Imboden S., Reynisson P., Andersson B., Borgfeldt C., Bossmar T. Reproducibility and accuracy of robot-assisted laparoscopic fertility sparing radical trachelectomy //.Gynecol Oncol. 2012; 127:3:484-488.

Alfirevic Z., Owen J., Carreras Moratonas E., Sharp A. N., Szychowski J. M., Goya M. Vaginal progesterone, cerclage or cervical pessary for preventing preterm birth in asymptomatic singleton pregnant women with a history of preterm birth and a sonographic short cervix / / Ultrasound Obstet. Gynecol. 2013; 41(2): 146-51.

Fejgin M. D., Gabai B., Goldberger S., Ben-Nun I., Beyth Y. Once a cerclage, not always a cerclage // J Reprod Med. 1994; 39:880-882.

Kim C. H., Abu-Rustum N. R., Chi D. S., Gardner G. J., Leitao M. M. Jr, Carter J., Barakat R. R., Sonoda Y. Reproductive outcomes of patients undergoing radical trachelectomy for early-stage cervical cancer // Gynecol Oncol. 2012; 125:3:585-588.

American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No.142: Cerclage for the management of cervical insufficiency // Obstet. Gynecol. 2014; 123(2, Pt 1): 372-9. doi: 10.1097/01. AOG.0000443276.68274.cc.

Schubert R. A., Schleussner E., Hoffmann J., Fiedler A., ​​Stepan H., Gottschlich Prevention of preterm birth by Shirodkar cerclage-clinical results of a retrospective analysis //Z. Geburtshilfe Neonatol. 2014; 218(4): 165-70.

Aoki S., Ohnuma E., Kurasawa K., Okuda M., Takahashi T., Hirahara F. Emergency cerclage versus expectant management for prolapsed fetal membranes: a retrospective, comparative study // J. Obstet. Gynaecol. Res. 2014; 40(2): 381-6.

Brown R., Gagnon R., Delisle M. F.; Maternal Fetal Medicine Committee; Gagnon R., Bujold E., Basso M., Bos H., Brown R., Cooper S. et al. // Society of Obstetricians and Gynaecologists of Canada. Cervical insufficiency and cervical cerclage //J. obstet. Gynaecol. Can. 2013; 35(12): 1115-27.

Berghella V., Ludmir J., Simonazzi G., Owen J. Transvaginal cervical cerclage: evidence for perioperative management strategies // Am. J. Obstet. Gynecol. 2013; 209(3): 181-92.

Sidel'nikova V. M. Privychnaya poterya beremennosti. . Moscow: Triada-X. 2005; 105-107, 143, 166, 230-239. (In Russ.).

Ushakova S. V., Zarochentseva N. V., Popov A. A., Fedorov A. A., Kapustina M. V., Vrotskaya V. S., Malova A. N. Current procedures to correct isthmicocervical insufficiency // Rossiysky vestnik akushera-ginekologa, 2015; 5:117-123.

Berghella V., Kuhlman K., Weiner S. et al. Cervical funneling: sonographic criteria predictive of preterm delivery // Ultrasound Obstet Gynecol. 1997 Sep; 10(3):161-6.

Zilianti M., Azuaga A., Calderon F. et al. Monitoring the effacement of the uterine cervix by transperineal sonography: A new perspective // ​​J Ultrasound Med 1995; 14:719-24.

Tetruashvili N. K., Agadzhanova A. A., Milusheva A. K. Correction of cervical incompetence during prolapsed bladder: possible therapy // Journal of Obstetrics and ginekologiya. - 2015. - No. 9. - R. 106-19.

Guzman E. R., Joanne C., Rosenberg B. S., Houlihan C., Ivan J., Wala R., Dron DMS, and Robert K. A new method using vaginal ultrasound and transfundal pressure to evaluate the asymptomatic incompetent cervix // Obstet Gynec. 1994; 83:248-252.

Romero R. et al. What is amniotic fluid ‘sludge’? //Ultrasound Obstet Gynecol. 2007 Oct; 30(5): 793-798.

Fuchs F., Boucoiran I., Picard A., Dube J., Wavrant S., Bujold E., Audibert F. Impact of amniotic fluid "sludge" on the risk of preterm delivery // J Matern Fetal Neonatal Med. 2015 Jul;28(10):1176-80.

Gorski L. A., Huang W. H., Iriye B. K., Hancock J. Clinical implication of intra-amniotic sludge on ultrasound in patients with cervical cerclage // Ultrasound Obstet Gynecol. 2010 Oct; 36(4):482-5.

Tsaregorodtseva M. V., Dikke G. B. Pliatle approach. Obstetrical pessaries in the prophylaxis of casual loss of pregnancy. Status Praesens. 2012; 8:75-78. (In Russ.).

Http://www.dr-arabin.de/e/cerclage.html Cervical incompetence during pregnancy cerclage pessary.

Cannie M. M., Dobrescu O., Gucciardo L., Strizek B., Ziane S. et al. Arabin cervical pessary in women at high risk of preterm birth: a magnetic resonance imaging observational follow-up study // Ultrasound Obstet Gynecol 2013; 42:426-433.

Kokh L. I., Satysheva I. V. Diagnosis and results of treatment of isthmico-cervial insufficiency. Akusherstvo i ginekologiya. 2011; 7:29-32. (In Russ.).

Gimovsky A., Suhag A., Roman A., Rochelson B., Berghella V. Pessary vs cerclage vs expectant management of cervical dilation with visible membranes in the second trimester. 35th Annual Meeting of the Society for Maternal-Fetal Medicine: The Pregnancy Meeting San Diego, CA, United States. Am J Obstet Gynecol. 2015; 212:1: Suppl 1:152.

Childress K. S., Flick A., Dickert E., Gavard J., Bolanos R. Gross G. A comparison of cervical cerclage and vaginal pessaries in the prevention of spontaneous preterm birth in women with a short cervix. 35th Annual Meeting of the Society for Maternal-Fetal Medicine: The Pregnancy Meeting San Diego, CA, United States 2015-02-02 to 2015-02-07. Am J Obstet Gynecol. 2015; 212:1 suppl.1:101.

Benson RC, Durfee RB. Transabdominal cervicouterine cerclage during pregnancy for the treatment of cervical incompetency. Obstet Gynecol. 1965; 25:145-155.

Burger N. B., Einarsson J. I., Brolmann H. A., Vree F. E., McElrath T. F., J. A. Huirne, "Preconceptional laparoscopic abdominal cerclage: a multicenter cohort study". Am J Obstet Gynec. 2012; 207:4:273.e1-273. e12.

Zaveri V., Aghajafari F., Amankwah K. Abdominal versus vaginal cerclage after a failed transvaginal cerclage: A systematic review. Am J Obstet Gynec. 2002; 187:4:868-872.

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Clinical protocol for obstetric assistance "Vagination innocence", approved by order of the Ministry of Health of Ukraine dated 03.11.2008. No. 624.

Modern methods of diagnostics and correction of isthmic-cervical insufficiency as a cause of ovarian - vagility

M. P. Veropotvelyan, I. S. Tsekhmistrenko, P. M. Veropotvelyan, P. S. Goruk

In the article, there are a number of publications of a very complicated overshoot of vagity. The leading background of early prechasny slopes is istmiko-cervical insufficiency.

The report discusses the prospects for the development of modern methods of prevention and treatment of this pathology.

A modification of the surgical method for the correction of isthmic-cervical insufficiency in case of primary non-vinous vagility is presented.

Keywords Key words: isthmic-cervical insufficiency, early anterior canopies, innocence of vagity, transvaginal and transabdominal cerclage.

Modern methods of diagnosis and correction of cervical incompetence as a cause of miscarriage

N. P. Veropotvelyan, I. S. Tsehmistrenko, P. N. Veropotvelyan,P.S. Goruk

The article summarizes many publications related to complicated course of pregnancy. Leading background of early preterm birth is cervical incompetence.

The prospects for use of the modern methods of prevention and treatment of this disease are highlighted.

Details of the surgical correction methods of cervical incompetence in case of recurrent miscarriage are given.

keywords: cervical incompetence, early preterm birth, miscarriage, transvaginal and transabdominal cerclage.

In recent years, transvaginal echographic examination has been used as a monitoring of the state of the cervix. At the same time, for assessing the state and for prognostic purposes, the following points should be taken into account:

The length of the cervix, equal to 3 cm, is critical for the threat of termination of pregnancy in primigravidas and in re-pregnant women with a period of less than 20 weeks and requires intensive monitoring of the woman with her inclusion in the risk group.

The length of the cervix, equal to 2 cm, is an absolute sign of miscarriage and requires appropriate surgical correction.

The width of the cervix at the level of the internal os normally gradually increases from 10 to 36 weeks from 2.58 to 4.02 cm.

A prognostic sign of a threatened miscarriage is a decrease in the ratio of the length of the cervix to its diameter at the level of the internal os to 1.16±0.04 at a rate of 1.53±0.03.

Treatment of pregnant women with CI. Methods and modifications of surgical treatment of CCI during pregnancy can be divided into three groups:

1) mechanical narrowing of a functionally defective internal cervical os;

2) suturing the external os of the cervix;

3) narrowing of the cervix by creating muscle duplication along the side walls of the cervix.

The method of narrowing the cervical canal by creating muscle duplication along its side walls is the most pathogenetic justified. However, he did not find application due to complexity.

The method of narrowing the internal os of the cervix is ​​used more widely in all types of ICI. In addition, methods of narrowing the internal os are more favorable, since these operations leave a drainage hole. When the external os is sutured, a closed space is formed in the uterine cavity, which is unfavorable if there is a latent infection in the uterus. Among the operations that eliminate the inferiority of the internal cervical os, the most widely used are modifications of the Shirodkar method: the MacDonalda method, the circular suture according to the Lyubimova method, U-shaped sutures according to the method of Lyubimova and Mamedaliyeva.

Indications for surgical correction of CI:

The presence in the anamnesis of spontaneous miscarriages and premature births (in the II - III trimester of pregnancy);

Progressive, according to the clinical examination, cervical insufficiency: a change in consistency, the appearance of sagging, shortening, a gradual increase in the "gaping" of the external pharynx and the entire cervical canal and the opening of the internal pharynx.

Contraindications for surgical correction of ICI are:

Diseases and pathological conditions that are a contraindication to the preservation of pregnancy;

Increased excitability of the uterus, which does not disappear under the influence of medications;

Pregnancy complicated by bleeding;

Malformations of the fetus, the presence of non-developing pregnancy;

III - IV degree of purity of the vaginal flora and the presence of pathogenic flora in the discharge of the cervical canal. Erosion of the cervix is ​​not a contraindication to surgical treatment of CI, if pathogenic microflora is not released.

Surgical correction of ICI is usually performed between 13 and 27 weeks of gestation. The term for the production of surgical correction should be determined individually, depending on the time of occurrence of clinical manifestations of CI. In order to prevent intrauterine infection, it is advisable to perform the operation at 13-17 weeks, when there is no significant shortening and opening of the cervix. With an increase in the duration of pregnancy, the insufficiency of the "obturator" function of the isthmus leads to mechanical lowering and prolapse of the fetal bladder. This creates conditions for infection of the lower pole by its ascending path.

Maintaining the operating period with ICI.

You are allowed to get up and walk immediately after the operation. During the first 2-3 days, antispasmodics are prescribed for prophylactic purposes: suppositories with papaverine, no-shpa 0.04 g 3 times a day, magne-B6. In case of increased excitability of the uterus, it is advisable to use?-mimetics (ginipral, partusisten) 2.5 mg (1/2 tablet) or 1.25 mg (1/4 tablet) 4 times a day for 10-12 days; indomethacin 25 mg 4 times a day or in suppositories 100 mg 1 time a day for 5-6 days.

For the first time, 2-3 days after the operation, the cervix is ​​examined using mirrors, and the cervix is ​​treated with 3% p-rum of hydrogen peroxide or other antiseptics.

Antibacterial therapy is prescribed for extensive erosion and the appearance of a stab shift in the blood. At the same time, antimycotic drugs are prescribed. After 5-7 days after the operation, the patient can be discharged under outpatient observation. The suture is removed at 37-38 weeks of pregnancy.

The most common complication after surgical correction of CI is eruption of the cervix with a thread. This can occur if there is contractile activity of the uterus, and the stitches are not removed; if the operation is technically incorrectly performed and the cervix is ​​tightened with sutures; if the tissue of the cervix is ​​affected by the inflammatory process. In these cases, when applying circular sutures, pressure sores may form, and later fistulas, transverse or circular tears of the cervix. In case of eruption, the sutures must be removed. Treatment of a wound on the cervix is ​​carried out by washing the wound with dioxidine using tampons with antiseptic ointments. If necessary, antibiotic therapy is prescribed.

Currently, non-surgical methods of correction are widely used - the use of various pessaries.

Non-surgical methods have a number of advantages: they are bloodless, simple, applicable in an outpatient setting. The treatment of the vagina and pessary should be done with antiseptic solutions every 2 to 3 weeks to prevent infection. These methods are more often used in functional CI, when there is only softening and shortening of the cervix, but the canal is closed or when CI is suspected to prevent cervical dilatation. With severe ICI, these methods are not very effective. Pessaries can also be used after surgical correction to reduce pressure on the cervix and prevent the consequences of CCI (fistulas, ruptures of the cervix).

ICI during pregnancy

Isthmic-cervical insufficiency during pregnancy (ICN) is a non-physiological process characterized by painless opening of the cervix and its isthmus in response to an increasing load (an increase in the volume of amniotic fluid and fetal weight). If the condition is not corrected therapeutically or surgically, then this is fraught with late miscarriages (before) or premature birth (after 21 weeks).

• The incidence of CCI
• Indirect causes of insufficiency of the isthmic-cervical canal
• Symptoms of CI during pregnancy
• The mechanism of development of isthmic-cervical insufficiency of the cervix
• ICI correction methods
• The imposition of circular sutures in isthmic-cervical insufficiency
• How is a pessary selected?
• Management of pregnancy in ICI
• How many weeks is the pessary removed?

The incidence of CCI

In the structure of late miscarriages and premature births, ICI occupies a significant role. Isthmic-cervical insufficiency is common according to data from various sources from 1 to 13% of pregnant women. In women who have had a preterm birth in the past, the frequency increases to 30-42%. If the previous pregnancy ended on time -, then the next one in every fourth case will not last longer without correction and treatment of the causes.

CCI is classified by origin:

• Congenital. Associated with malformations -. Requires careful diagnosis and surgical treatment at the stage of conception planning.
• Acquired
• Post-traumatic
• Functional.

Often, cervical insufficiency is combined with the threat of interruption and a pronounced tone of the uterus.

Indirect causes of isthmic-cervical insufficiency

Predisposing factors for insufficiency of the cervical part of the birth canal are cicatricial changes and defects that form after injuries in previous births or after surgical interventions on the cervix.

Causes of isthmic-cervical insufficiency are:

• the birth of a large fetus;
• the birth of a fetus with a breech presentation;
• the imposition of obstetric forceps during childbirth;
• abortions;
• diagnostic curettage;
• neck surgery;
• connective tissue dysplasia;
• genital infantilism;

The identified cause must be treated surgically at the stage of pregnancy planning.

The functional cause of ICI is a violation of the hormonal balance necessary for the correct course of pregnancy. A shift in hormonal balance occurs as a result of:

• Hyperandrogenism is an excess of a group of male sex hormones. Fetal androgens are involved in the mechanism. At -27 weeks, he synthesizes male sex hormones, which, together with maternal androgens (they are normally produced), lead to structural transformations of the cervix due to its softening.
• Progesterone (ovarian) insufficiency. A hormone that prevents miscarriage.
• Pregnancy that occurred after induction (stimulation) of ovulation by gonadotropins.

Correction of isthmic-cervical insufficiency of a functional nature makes it possible to successfully maintain pregnancy in a therapeutic way.

Isthmic-cervical insufficiency during pregnancy and symptoms

It is precisely because of the absence of pronounced symptoms that cervical insufficiency is often diagnosed after the fact - after a miscarriage or premature termination of pregnancy. The opening of the cervical canal proceeds almost painlessly or with mild pain.

The only subjective symptom of ICI is an increase in volume and a change in the consistency of secretions. In this case, it is necessary to exclude leakage of amniotic fluid. For this purpose, a smear for arborization is used, an amniotest, which can give false results. More reliable is the Amnishur test, which allows you to determine the proteins of amniotic fluid. Violation of the integrity of the membranes and leakage of water during pregnancy is dangerous for the development of infection of the fetus.

Signs of isthmic-cervical insufficiency are visible during vaginal examination, carried out during registration in the 1st trimester of pregnancy. The study determines:

• length, consistency of the cervix, location;
• the state of the cervical canal (passes a finger or its tip, normal - the walls are tightly closed);
• the location of the presenting part of the fetus (at later stages of pregnancy).

The gold standard for diagnosing CI is transvaginal echography (ultrasound). In addition to changes in the length of the neck on ultrasound with isthmic-cervical insufficiency, the shape of the internal os is determined. The most unfavorable prognostic sign of ICI are V- and Y-shaped forms.

How does cervical insufficiency develop?

The trigger mechanism for the development of ICI during pregnancy is an increase in the load on the area of ​​\u200b\u200bthe internal pharynx - the muscular sphincter, which, under the influence of pressure, becomes insolvent and begins to open slightly. The next stage is the prolapse (sagging) of the fetal bladder into the expanding cervical canal.

Methods for correcting insufficiency of the isthmic-cervical canal

There are two main types of correction of isthmic-cervical insufficiency:

• conservative method;
• surgical.

Suturing for isthmic-cervical insufficiency of CCI

Surgical correction of ICI occurs by applying a circular suture. For this purpose, mersilene tape is used - a flat thread (this form reduces the risk of seam cutting) with two needles at the ends.

Contraindications to suturing in isthmic-cervical insufficiency:

• suspicion of leakage of amniotic fluid;
• malformations of the fetus incompatible with life;
• pronounced tone;
• and bleeding;
• developed chorioamnionitis (with isthmic-cervical insufficiency, there are high risks of infection of the membranes, fetus and uterus);
• suspicion of insolvency of the scar after caesarean section;
• extragenital pathology, in which prolongation of pregnancy is impractical.

What are the disadvantages of surgical sutures for CCI?

The disadvantages include:

• invasiveness of the method;
• possible complications of anesthesia (spinal anesthesia);
• the possibility of damage to the fetal bladder and induction of labor;
• the risk of additional trauma to the cervix when cutting the sutures at the beginning of labor.

Thereafter, the risk of complications with suturing increases many times over.

Unloading pessary for isthmic-cervical insufficiency

Most of the disadvantages of surgical treatment of CI during pregnancy are deprived of conservative correction. In practice, pessaries, which are used during pregnancy, are often used for isthmic-cervical insufficiency. Domestic pessary of the first generation is made in the form of a butterfly with a central hole for the cervix and a hole for the outflow of vaginal contents. Manufactured from non-toxic plastic or similar materials.

The second generation of ASQ (Arabin) type pessaries are made of silicone. There are 13 types of silicone pessaries with perforations for fluid drainage. Outwardly, they resemble a cap with a central hole. Its advantage is that the moment of its introduction is absolutely painless. Its use is easily tolerated by a woman, and it is devoid of the elements of discomfort inherent in domestic pessaries. Pessaries allow you to maintain the internal and external cervical os in a closed state and redistribute the pressure of the fetus on the pelvic floor (muscles, tendons and bones) and on the anterior wall of the uterus.

Pessaries during pregnancy with ICI allow you to save in the cervix - a natural barrier against ascending infection. They can be used at those stages of pregnancy when suturing is contraindicated (after 23 weeks).

The advantage is also the absence of the need for anesthesia and cost-effectiveness.

Indications for the use of a pessary for isthmic-cervical insufficiency:

• prevention of suture failure during surgical correction and reducing the risk of suture eruption;
• a group of patients who do not have visual or ultrasound signs of CCI, but have a history of premature birth, miscarriage or;
• after prolonged infertility;
• cicatricial deformities of the neck;
• age and young pregnant women;
• dysfunction of the ovaries.

Contraindications to the use of a pessary for CCI:

• diseases in which prolongation of pregnancy is not indicated;
• recurring spotting in the 2nd - 3rd trimesters;
• inflammatory processes in the internal and external genital organs (is a contraindication until the completion of treatment and bacterioscopic confirmation of the cured infection).

It is not advisable to carry out an unloading correction with a pessary for severe CCI (with sagging of the fetal bladder).

How is a pessary selected for ICI?

When choosing a pessary, the approach is individual, depending on the anatomical structure of the internal genital organs. The type of pessary is determined based on the internal diameter of the pharynx, the diameter of the vaginal fornix.

Management of pregnancy in isthmic-cervical insufficiency

When identifying a clinic, ECHO-markers of CI, taking into account the data of anamnesis, doctors use a scoring of isthmic-cervical insufficiency (6–7 points is a critical assessment that requires correction). Then, depending on the timing and causes of ICI, a pregnancy management strategy is chosen.

If the period is up to 23 weeks and there are indications of the organic origin of the CCI, then surgical treatment or a combination is prescribed - the imposition of a circular suture and a pessary. When indicating the functional type of the pathological process, you can immediately use an obstetric pessary.

In periods exceeding 23 weeks, as a rule, only an obstetric pessary is used for correction.

In the future, be sure to do every 2-3 weeks:

• Bacterioscopic control of smears - to assess the state of the flora in the vagina. With a change in the microflora and the absence of progression of isthmic-cervical insufficiency, sanitation is carried out against the background of a pessary. If there is no effect, it is possible to remove the pessary, sanitation and antibiotic therapy with reuse of the pessary for periods up to. After the specified period, only therapy is carried out aimed at restoring the vaginal flora.
• - control of the state of the cervix, necessary for the timely diagnosis of the threat of termination of pregnancy, deterioration of dynamics, the threat of premature birth and eruption of sutures.
• If necessary, tocolytic therapy is prescribed in parallel - drugs that relieve uterine hypertonicity. Depending on the indications, calcium channel blockers (Nifedipine), progesterone (Utrozhestan) at a dose of 200–400 mg, and oxytocin receptor blockers (Atosiban, Traktocil) are used.

When is the pessary removed?

Early removal of sutures and pessaries is carried out in the event of the development of regular labor pains, with the appearance of blood discharge from the genitals, outflow. In a planned manner, the sutures and the pessary are removed at. At the same time, the pessary is also removed during a planned caesarean section.

With negative dynamics of isthmic-cervical insufficiency, hospitalization and tocolytic therapy are recommended.