The article discusses a number of publications regarding complicatedcourse of pregnancy. The leading background of early premature birth is isthmic-cervical insufficiency.
Application prospects are covered in detail modern methods prevention and treatment of this pathology.
Modifications of the surgical method for correcting isthmic-cervical insufficiency in recurrent miscarriage are presented.
Key words: isthmic-cervical insufficiency, early premature birth, miscarriage, transvaginal and transabdominal cerclage.
Isthmic-cervical insufficiency (ICI) (lat. insufficientia isthmicocervicalis: isthmus - isthmus of the uterus + cer-vix - cervix) is pathological condition isthmus and cervix (cervix) during pregnancy, in which they are not able to withstand intrauterine pressure and hold the enlarging fetus in the uterine cavity until timely birth.
The state of the CMM plays one of the key roles for normal course pregnancy. Among the factors leading to miscarriage, ICI occupies a significant place. It accounts for 25 to 40% of cases of miscarriage in II- III trimester gestation [,]. There are multiple (2 or more) cases of termination of pregnancy caused by ICI, which are regarded as recurrent miscarriage. ICI is the leading cause of termination of pregnancy at 22-27 weeks, while the fetal body weight is 500-1000 g, and the pregnancy outcome for the child is extremely unfavorable due to extreme 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, clinically manifested by its failure, are an important diagnostic and therapeutic problem and the subject of lively discussion among practitioners.
In this period of time, the mechanisms, causes and conditions for the occurrence of ICI have been quite well studied, among which are cervical injuries, as well as anatomical and functional congenital defects. Based on the root cause of ICI, organic and functional cervical insufficiency are distinguished.
Diagnosis of ICI 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. Score of the degree of ICI according to the Stember scale
|
Clinical signs |
Score in points |
||
|
Length of the vaginal part of the cervix |
Shortened |
||
|
BL channel status |
Partially passable |
Misses a finger |
|
|
CMM location |
Sacred |
Central |
Directed anteriorly |
|
Consistency of CMM |
Softened |
||
|
Localization of the adjacent part of the fetus |
Above the entrance to the pelvis |
Pressed against the entrance to the pelvis |
At the entrance to the pelvis |
However, the most information about the presence of ICI is obtained using ultrasound. With transvaginal scanning of the cervix, one can visualize the smoothness (or shortening) of the cervix, dynamic changes in its structure, changes in the anatomy of the internal pharynx, expansion of the cervical canal with prolapse of the membranes into its lumen (funnel-shaped formation).
Ultrasound monitoring of the condition of the cervix should begin in the first trimester of pregnancy. The length of the CMM, equal to 30 mm, is critical at 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 cervical funnels during ultrasound The letters T, Y, V, U display the relationship between the lower segment of the uterus and the cervical canal. Gray the configuration of the cervix is indicated, blue is the fetal head, orange is the cervix, red is the modified cervix.
M. Zilianti et al. described various shapes of the CMM funnel - T-, Y-, V- and U-shaped types. The acoustic window was obtained using transperineal ultrasound scanning (Fig. 1).
The T shape represents the absence of a funnel, the Y represents the first stage of the funnel, and the U and V represent the expansion of the funnel (Fig. 2).
With the V-shaped type, the membranes prolapse into the cervical canal to form a triangular-shaped funnel. With the U-shaped type, the pole of the prolapsed membranes has a rounded shape.
N. Tetruashvili et al. We have developed an algorithm for the management of patients with prolapse of the membranes 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 incompetent 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 inappropriate.
The same researchers, in 17 patients with ICI complicated by prolapse of the membranes into the cervical canal or upper third of the vagina at 24-26 weeks of gestation, after taking into account all contraindications, initiated tocolysis with the drug atosiban and antibacterial therapy. Then, surgical correction of the ICI was performed with “tucking” the amniotic sac behind the area of the internal os. Tocolysis with atosiban was continued for 48 hours, prophylaxis was carried out respiratory distress syndrome fetus In 14 (82.4%) of 17 cases, pregnancy ended in timely birth at 37-39 weeks. In three cases, premature birth occurred (at 29, 32, 34 weeks), after which the babies underwent treatment and rehabilitation. Use of atosiban in complex treatment complicated ICI at 24-26 weeks may be one of the possibilities for preventing very early preterm birth.
E. Guzman et al. It is recommended to perform a cervical stress test during ultrasound. This study aims to early identify women with high risk development of ICN during ultrasonography. The technique is as follows: apply moderate pressure with your hand on the anterior abdominal wall along the axis of the uterus in the direction of the vagina for 15-30 s. The test result is considered positive if the length of the cervix decreases and the internal pharynx expands by ≥ 5 mm.
Rice. 3. Transvaginal scanning of the cervix. The presence of a funnel-shaped expansion of the internal os and amniotic sludge
Before deciding on the need and possibility of surgical correction of ICI, it is advisable to exclude the presence of chorioamnionitis, which, as noted above, is a contraindication to the operation. As reported by 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 - an accumulation of an echogenic suspension of cells in the amniotic fluid in the area of the internal os (Fig. 3).
As it turned out, with 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 by transvaginal ultrasound is an important manifestation of microbial invasion, inflammatory process and a predictor of spontaneous preterm birth.
In a sample of amniotic fluid aspirated close to the amniotic sludge in the area of the internal cervical os, the authors found prostaglandins and cytokines/chemokines in higher concentrations compared to samples of amniotic fluid obtained from the fundus of the uterus. A study of amniotic sludge cell cultures revealed 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 between 15 and 22 weeks. This marker was associated with cervical shortening, increased body mass index, and the risk of cervical cerclage and preterm birth before 28 weeks. Researchers noted that the administration of azithromycin to pregnant women with amniotic sludge significantly reduced the risk of preterm birth before 24 weeks of pregnancy.
At the same time, L. Gorski et al. when studying clinical cases 177 pregnant women who underwent cervical cerclage according to McDonald (from 14 to 28 weeks of gestation) did not find a significant difference in the timing of labor in 60 pregnant women who had amniotic sludge (36.4 ± 4.0 weeks), compared with 117 women without it (36.8 ± 2.9 weeks; p = 0.53). There were also no statistical differences in the incidence of preterm birth before 28, 32 and 36 weeks in these patients.
Ultrasound dynamic monitoring of the condition of the cervix up to 20 weeks of pregnancy allows for timely diagnosis and surgical correction of ICI in the most favorable terms. But at the same time, when diagnosing ICI, ultrasound data alone is not enough, since the cervix may be short but dense. For a more accurate diagnosis, a visual examination of the cervix in the mirrors and a bimanual examination are necessary to identify a short and soft cervix.
Surgical correction ICN is performed in a hospital setting. Previously, bacterioscopic and bacteriological examinations of vaginal contents are carried out, sensitivity to antibiotics is determined, and tests are performed for sexually transmitted infections. Other causative factors for miscarriage should also be identified and eliminated. Then, after discharge from the hospital, every 2 weeks, on an outpatient basis, a visual examination of the cervical cavity is carried out using mirrors. Sutures are removed at 37-39 weeks of pregnancy in each case individually.
The practitioner must remember that with the surgical treatment of ICI, complications such as cervical rupture, amniotic sac injury, stimulation of labor due to the inevitable release of prostaglandins during manipulation, sepsis, cervical stenosis, cutting of sutures, complications of anesthesia and maternal death can develop, which determines ambiguous attitude of obstetricians and gynecologists to the advisability of surgical correction of this disorder in pregnant women.
It is known that non-surgical cerclage using supportive 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 be used both on an outpatient basis and in a hospital setting at any stage of gestation. At the same time, the effectiveness of this method is slightly lower than that of surgery. Nevertheless, scientists note that when a pessary was introduced at the beginning of the second trimester (15-16 weeks) to patients at high risk of miscarriage to prevent the progression of ICI, the effectiveness of the method increased to 97%.
As is known, the mechanism of action of pessaries is to reduce the pressure of the fertilized egg on the incompetent cervical cavity. Due to the redistribution of intrauterine pressure, the cervical cavity is closed by the central opening of the pessary, a shortened and partially open cervical cavity is formed, and it is unloaded. All this together provides protection for the lower pole of the fertilized egg. Preserving the mucus plug reduces the risk of infection. The indication for the use of an obstetric pessary is mild to moderate ICI of both traumatic and functional origin, a high risk of developing ICI at any stage of pregnancy.
In the last decade, the silicone ring pessary R. Arabin (“Doctor Arabin”, Germany) has gained the greatest popularity. Its peculiarity is the absence of a steel spring and large area surface, which reduces the risk of necrosis of the vaginal wall.
M. Cannie et al. , having performed 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, they 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, they also found quite wide application obstetric unloading pessaries “Juno” produced by the medical enterprise “Simurg” (Republic of Belarus), made of soft medical plastic.
Publications note that the outcomes of various methods of correction of ICI are not the same: after surgical correction, the threat of miscarriage more often develops, and after conservative correction, colpitis develops. According to I. Kokh, I. Satysheva, when using both methods of correction of ICI, pregnancy carrying to term is 93.3%. In a multicenter retrospective cohort study, A. Gimovsky et al. with the participation of patients with a singleton asymptomatic pregnancy at 15-24 weeks and a cervical opening > 2 cm, the effectiveness of using a pessary, the technique of cervical suture, and expectant management were compared. The results showed that applying a suture to the CMM - best method treatment for the purpose of prolonging pregnancy in patients with a singleton pregnancy and opened 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 applying a suture to the cervical cervix with those when using a vaginal pessary in patients with a shortened cervical 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 later gestation and are associated with fewer complications such as chorioamnionitis and vaginal bleeding.
J. Harger reports that the effectiveness of the Shirodkar and McDonald methods exceeds 70-90% due to the creation of conditions for calendar prolongation of pregnancy after correction of ICI. At the same time, the author points out that the Shirodkar cerclage applied more distally through 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 distinguish the category of patients who have undergone surgical interventions on the cervical mass, in whom there is a significant shortening of its length and the absence of its vaginal portion. In such a situation, performing vaginal cerclage during pregnancy is technically difficult.
Therefore, in 1965, R. Benson and R. Durfee, to solve this problem, proposed a method of performing cerclage using the abdominal approach (TAC). For the stages 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 cervical cerclage has the highest efficiency. A cohort study found that premature birth in this category of patients was observed in 5.7% of cases, complications - up to 4.5%.
At this time, cervical cerclage is increasingly performed laparoscopically 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 transabdominal cerclage of the CMM, a technique for transvaginal cervico-isthmic cerclage (TV CIC) has been developed. This method of surgical correction means performing an intervention through vaginal access for the purpose of correcting ICI both during pregnancy and at the planning stage. After preliminary tissue dissection, the synthetic prosthesis is located at the level of the cardinal and uterosacral ligaments.
In a systematic review by V. Zaveri et al. compared the effectiveness of TV CIC and TAC in women who had previously undergone unsuccessful vaginal cerclage complicated by perinatal losses. According to the results, the number of cases of abortion in the group with abdominal access was 6 versus 12.5% in the group with vaginal access, which indicates a higher efficiency of the overlying 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 technical capabilities are available, the operation of choice in patients with a preserved vaginal portion of the cervical mucus when previously performed vaginal cerclage is ineffective is transvaginal cervico-isthmic cerclage.
Researchers studying this problem indicate that special attention attention should be paid to the problem of pregnancy in patients who have undergone radical organ-preserving treatment for cervical cancer. According to these publications, at present, gynecological oncologists in practice abroad carry out organ-preserving operations for some forms of precancerous diseases and cervical cancer in a volume that leaves the woman the opportunity to realize reproductive function (high knife amputation of the cervical tumor, radical abdominal [RAT] or vaginal trachelectomy, performed by laparotomy or laparoscopic approach).
When studying the outcomes of both abdominal and vaginal trachelectomies, the high effectiveness of this method of organ-preserving treatment was discovered, which preserves the conditions for childbearing.
Despite the success surgical technique, 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 cervix, the progression of pregnancy creates an increasing load on the uterovaginal anastomosis, which often leads to its loss in the second and third trimesters of gestation.
C. Kohler et al. report that during pregnancy after vaginal trachelectomy, 50% of patients have children born prematurely, mainly due to rupture of the membranes and premature rupture of amniotic fluid.
Recently, publications have appeared in the literature on the method of performing trachelectomy with the addition of the operation by simultaneous fixation of the anastomosis with a synthetic prosthesis or circular ligatures, at the same time, many oncologists do not perform this technical element.
Rice. 4. Features of performing cerclage in patients who have undergone trachelectomy for cervical cancer
J. Persson et al. conducted an in-depth study of the features of performing cerclage of the uterus. They reported that in the group of women who underwent trachelectomy using robot-assisted laparoscopy, the level of the uterine suture was 2 mm higher than in the group of patients using a vaginal approach (Fig. 4).
Abroad, in patients with preserved length of the cervical cervix and a history of miscarriage, the operation of applying a vaginal cerclage to the cervical cervix is often performed using a laparoscopic approach. When performing 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 advisable to note that performing cerclage of the uterus after RAT is a technically difficult procedure due to the pronounced adhesive process in the abdominal and 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, requires further careful monitoring and the need for surgical preparation for subsequent pregnancy. Thus, based on the findings presented in multiple publications, a thorough examination of the cervix at the stage of preconception preparation (especially among patients with recurrent miscarriage) is necessary to determine the risk group for the development of ICI.
For patients with a pronounced degree of traumatic ICI, it is advisable to carry out correction before pregnancy using both transvaginal and transabdominal techniques.
Obstetricians and gynecologists of Ukraine should adhere to the principles clinical protocol“Miscarriage”, regulated by order of the Ministry of Health of Ukraine dated November 3, 2008 No. 624. According to this document, treatment of ICN consists of applying a preventive or therapeutic suture to the cervical tumor. At the same time, further research into this problem may help answer the questions of modern obstetrics regarding the choice of optimal tactics for managing pregnant women with ICI and preventing very early preterm birth.
Sidelnikova V. M. Nevynashivanie beremennosti. . Moscow: Meditsina. 1986; 176. (In Russ.).
Lee S. E., Romero R., Park C. W., Jun J. K., Yoon B. H. The frequency and significance of intraamniotic inflammation in patients with cervical insufficiency //Am. J. Obstet. Gynecol. 2008; 198 (6): 633. e.1-8.
Baskakov P. N., Torsuev A. N., Tarkhan M. O., Tatarinova L. A. Korrektsiya istmiko-tservikovalnoi nedostatochnosti akusherskim razgruzhayushehim pessariem. . 2008; http://sinteth.com.ua/index.php?p=163. (In Russ.).
Eggert-Kruse W., Mildenberger-Sandbrink B., Schnitzler P., Rohr G., Strowitzki T., Petzoldt D. Herpes simplex virus infection of the uterine cervix-relationship with a cervical factor? // Fertil Steril. 2000; 73:2:248-257.
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 Gynecologists 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. Oct 2010; 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 isthmic-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.
Köhler C., Schneider A., Speiser D., Mangler M. Radical vaginal trachelectomy: a fertility-preserving procedure in early cervical cancer in young women. Fertil Steril. 2011; 95:7: 2431 e5-2437.
Clinical protocol for obstetric care “Non-vagity”, approved by order of the Ministry of Health of Ukraine dated 03.11.2008. No. 624.
M. P. Veropotvelyan, I. S. Tsekhmistrenko, P. M. Veropotvelyan, P. S. Goruk
The article looks at a number of publications that are completely comprehensive in their analysis of the importance. The main background of early frontal symptoms is isthmic-cervical insufficiency.
The prospects for the stagnation of current methods of prevention and treatment of this pathology are being reported.
A modification of the surgical method for correcting esthmic-cervical insufficiency in cases of primary non-immature vaginosis is presented.
Key words: isthmic-cervical insufficiency, early anterior ruptures, unexplained vaginosis, transvaginal and transabdominal cerclage.
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.
A violation of the obturator ability of the uterine sphincter (isthmic-cervical insufficiency) carries with it, but the pathology does not have characteristic pronounced symptoms.
Therefore, women with this diagnosis should be especially attentive to their health and report to the doctor about any alarming sensations.
Normally, the cervix is represented by an elastic and dense muscular tube. It is able to withstand the growing load of the fetus and amniotic fluid during pregnancy, reliably protects the amniotic sac from infections and keeps it inside the uterine cavity.
Pathology is a situation when the cervical canal is too short, or its walls are weakened or cannot close securely due to the presence of sutures or scars. This is organic isthmic-cervical insufficiency.
The reason for the non-closure of the internal and external pharynx may be an insufficiently developed mucous membrane. In this case, a diagnosis of “functional ICI” is made.
The types of isthmic-cervical insufficiency are determined based on the causes that cause it.
During these procedures, the cervix is dilated with the help of special medical instruments, and the walls are injured. The connective tissue that subsequently appears in the injured areas is not as elastic as the muscles of the cervical canal, so the previous tightness of closure can no longer be achieved.
They also lead to the formation of scar tissue, which is rougher in nature and disrupts the elasticity and barrier functions of the cervix.
These include insufficient (hormone to maintain pregnancy) or increased production of androgens. Male sex hormones cause the walls of the cervical canal to soften and shorten.
Violations of its structure or location, which do not allow the muscle ring to close tightly).
Situations when the load on the walls of the cervix is higher than the natural “margin of safety”, and the muscle simply physically cannot cope with its functions.
During pregnancy, isthmic-cervical insufficiency of the cervix occurs. Typically, termination of pregnancy occurs in the second trimester or early third.
Partial opening of the external pharynx occurs without any noticeable symptoms. This is another danger of this pathology. Against the background of a relatively prosperous pregnancy, water infection and miscarriage suddenly occur, but perhaps the tragedy could have been prevented if we had known about the diagnosis earlier.
Unfortunately, the diagnosis is often made only after a failed pregnancy, since in non-pregnant women, due to the lack of significant load on the cervix, it is difficult to assess the degree of its damage and plasticity.
A woman can pay attention to some signs and should report them to the doctor in a timely manner, especially if there has been a history of abortion or functional curettage.
You should be wary:
The doctor will conduct an examination and prescribe additional tests to make a diagnosis. If isthmic-cervical insufficiency is confirmed, medications or therapeutic procedures will help preserve the pregnancy and the health of the unborn baby.
In the diagnosis of isthmic-cervical insufficiency plays an important role gynecological examination And detailed fee anamnesis.
A woman must inform the doctor leading the pregnancy about previous abortions or other injuries (if any), about congenital and systemic diseases. In this case, the doctor will be more attentive to the patient and will not attribute minor disturbing symptoms to the usual suspiciousness inherent in all expectant mothers.
Gynecological examination using vaginal speculum will allow you to assess the size of the cervical canal (normally about 4 cm), the density of the uterine closure.
In the case of cervical insufficiency, due to loose closure of the canal, the membranes of the amniotic sac may be visible in the mirror and have fallen out. They can also be detected by manual examination.
Ultrasound allows you to more accurately measure the length of the cervical canal. The length is determined using a vaginal sensor. A cervix measuring 3 cm will require repeated studies to assess the dynamics of the process, and with a canal size of 2 cm, the diagnosis of ICI is made unconditionally and surgical correction is prescribed.
If the examination is carried out before pregnancy, X-ray methods with a contrast agent (hysterosalpingography) can be used for diagnosis.
Pressure on weak muscles of the external os can lead to mechanical miscarriage.
The “trigger mechanism” can be sneezing, lifting heavy objects, or sudden movements of the fetus. But the main danger when the sphincter is not tightly closed is infection of the amniotic membranes.
As the process progresses, the cause of termination of pregnancy is the bacterial infection itself, leading to a violation of the integrity of the bladder. The result will be a miscarriage or premature birth (depending on the period).
Medical measures depend on the general condition of the woman, the duration of pregnancy and the cause of cervical insufficiency. Appointed drug therapy or surgical correction is performed. Both treatment methods can take place simultaneously.
The procedure gives a good effect when carried out for a period of 13-17 weeks. This measure allows you to mechanically cope with the growing pressure and prevent prolapse of the membranes.
Sutures are placed in a hospital setting, short-term intravenous anesthesia is used, which is not dangerous to the fetus. Sutures are combined with preventive antibacterial therapy and drugs to reduce uterine tone. The stitches are removed in the hospital on the eve of the planned date of birth.
In the presence of gross cicatricial changes in the cervical canal or its anatomical shortening and muscle flabbiness, cervical plastic surgery can be performed.
This operation is performed a year before the planned pregnancy and only if there are no other contraindications for conception (chronic illness of the mother, age, etc.)
Its purpose, as with suturing, is to mechanically hold the uterine sphincter in a closed state.
For this purpose, a special obstetric design with a closing ring is used. It is made of safe plastic or silicone.
Thanks to its anatomical shape, the pessary not only closes the walls of the cervix, but also redistributes the load on the canal, that is, it simultaneously acts as a bandage. Its use is possible with minor changes in the muscular system of the cervical canal.
Installation of a pessary, as opposed to surgical procedures, is quite easy and does not require anesthesia.
If the pregnancy progresses well, the ring is removed at 37-38 weeks. If other pregnancy complications arise, the device can be removed earlier.
If the cause of the pathology is anatomical features the structure and location of the uterus, timely application of sutures or a pessary and adherence to the prescribed regimen will allow you to successfully carry the pregnancy to term.
Despite the seriousness of the pathology and the real threat of miscarriage with isthmic-cervical insufficiency, this diagnosis is not a death sentence.
Modern methods of medical care, support from loved ones and strict implementation of all recommendations make it possible to carry a pregnancy to term without threats to health. expectant mother and her baby.
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 premature births should be recommended to be examined before pregnancy to identify the causes, correct disorders and prevent subsequent complications.
Genetic causes of recurrent miscarriage (3-6%):
hereditary diseases in family members;
presence of congenital anomalies in the family;
birth of children with mental retardation;
the presence of infertility or miscarriage of unknown origin in the couple and relatives;
presence of cases of perinatal mortality;
study of the parents' karyotype;
cytogenetic analysis of abortion;
genetic consultation.
During pregnancy:
prenatal diagnosis: chorionic villus biopsy, cordocentesis.
Anatomical causes of recurrent miscarriage (10-16%):
acquired anatomical defects:
intrauterine synechiae;
submucous fibroid uterus;
Isthmic-cervical insufficiency (ICI).
medical history (usually late termination of pregnancy);
hysterosalpingography (7-9 days of the cycle). To diagnose ICI, HSG on days 18-20 of the cycle;
hysteroscopy;
Ultrasound in the first phase of the cycle: submucous fibroids, intrauterine synechiae; in phase II of the cycle: bicornuate uterus, intrauterine septum;
MRI – pelvic organs.
hysteroresectoscopy: intrauterine septum, submucous uterine fibroids, synechiae;
drug treatment: cyclic hormonal therapy 3 cycles
14 days 17β – estradiol 2 mg
14 days 17β – estradiol 2 mg + Dydrogesterone 20 mg
Features of pregnancy (with a bicornuate uterus):
in the early stages – bleeding from the “empty” horn: antispasmodics and hemostatic drugs;
threat of miscarriage throughout the entire gestation period;
development of ICN;
IUGR against the background of chronic placental insufficiency.
Duphaston from early gestation 20-40 mg until 16-18 weeks of gestation.
No-spa 3-6 tablets/day in courses.
Isthmic-cervical insufficiency (ICI): risk factors for ICI
history of cervical trauma:
damage to the cervix during childbirth,
invasive methods of treating cervical pathology,
induced abortions, late pregnancy terminations;
congenital anomalies development of the uterus;
functional disorders
hyperandrogenism,
connective tissue dysplasia,
increased stress on the cervix during pregnancy
multiple births,
polyhydramnios,
large fruit;
anamnestic indications of low-painful rapid terminations of pregnancy in the second trimester.
Cervical assessment outside of pregnancy:
Hysterosalpingography on days 18-20 of the cycle.
Cervical plastic surgery according to Eltsov-Strelkov. Cervical plastic surgery does not exclude the formation of ICI during pregnancy. Childbirth only by caesarean section.
Preparing for pregnancy:
treatment of chronic endometritis, normalization of vaginal microflora.
Monitoring the condition of the cervix during pregnancy.
monitoring includes:
examination of the cervix in the mirrors;
vaginal examination;
Ultrasound – neck length and condition of the internal pharynx;
monitoring is carried out from 12 weeks.
Clinical manifestation of ICI:
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 bleeding from the genital tract;
measuring cervical length:
24-28 weeks – cervical length 45-35 mm,
32 weeks or more – 30-35 mm;
shortening of the cervix by up to 25 mm at 20-30 weeks is a risk factor for premature birth.
Criteria for diagnosing ICI during pregnancy:
prolapse of the membranes,
shortening of the cervix less than 25-20 mm,
opening of the internal pharynx,
softening and shortening of the vaginal part of the cervix.
Conditions for surgical correction of ICI:
a living fetus without developmental defects;
pregnancy period is not more than 25 weeks of gestation;
whole amniotic sac;
normal uterine tone;
no signs of chorioamnionitis;
absence of vulvovaginitis;
no bleeding.
After suturing:
bacterioscopy and inspection of the condition of the sutures every 2 weeks.
Indications for suture removal:
gestational age 37 weeks,
leakage, outpouring of water,
bleeding,
cutting seams.
3. Endocrine causes of recurrent miscarriage (8-20%).
Diagnosis. Luteal phase deficiency
medical history (late menarche, irregular cycles, weight gain, infertility, recurrent miscarriages early dates);
examination: hirsutism, stretch marks, galactorrhea;
functional diagnostic tests 3 cycles;
hormonal examination:
7-8 days FSH, LH, prolactin, TSH, testosterone, DHAS, 17OP;
on days 21-22 – progesterone;
Ultrasound: 7-8 days – endometrial pathology, polycystic ovary syndrome
20-21 days – change in endometrial thickness (No. 10-11 mm)
endometrial biopsy: 2 days before menstruation.
Luteal phase deficiency:
for NLF and hyperprolactinemia, an MRI of the brain is performed
Bromocriptine 1.25 mg/day – 2 weeks, then up to 2.5 mg/day. If pregnancy occurs, Bromocriptine is discontinued;
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 tablet;
ICN monitoring.
Adrenal hyperandrogenism:
increase in blood plasma 17OP
Treatment: Dexamethasone 0.25 mg before pregnancy. During pregnancy from 0.25 mg to 1 mg - throughout the entire gestation period. Reduce the dose from the 3rd day after birth 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 pregnancy
ICN monitoring.
Antiphospholipid syndrome:
From early gestation:
BA, antiphospholipid antibodies
anticardiolipin antibodies
hemostasiogram
individual selection of doses of anticoagulants, antiplatelet agents.
every week - platelet count, general blood test, from the second trimester 1 time - every 2 weeks;
Ultrasound from 16 weeks every 3-4 weeks;
II – III trimesters – examination of liver and kidney function;
Ultrasound + Dopplerometry from 24 weeks of pregnancy;
CTG from 33 weeks of pregnancy;
control of hemostasiogram before and during childbirth;
control of the hemostatic system on days 3 and 5 after birth.
Medicines used for miscarriage:
Drotaverine hydrochloride – in the first trimester (No-spa)
Magne B6, Magnerat - in the first trimester
Magnesium sulfate 25% - in the II-III trimester
β-adrenergic agonists – from 26-27 weeks
(Partusisten, Ginipral) in the third 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 intramuscularly once a week for chorionic hypoplasia
Etamzilat – I trimester of pregnancy
Aspirin - II trimester of pregnancy.
A cervical length of 3 cm is critical for the threat of miscarriage in primigravidas and in multigravidas at less than 20 weeks and requires intensive monitoring of the woman and classifying her as a risk group.
A cervical length of 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 the 10th to the 36th week from 2.58 to 4.02 cm.
A prognostic sign of the threat of 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, while the norm is 1.53±0.03.
Treatment of pregnant women with ICI. Methods and modifications of surgical treatment of ICI during pregnancy can be divided into three groups:
1) mechanical narrowing of the functionally defective internal os of the cervix;
2) suturing the external os of the cervix;
3) narrowing of the cervix by creating muscle duplication along the lateral walls of the cervix.
The method of narrowing the cervical canal by creating muscle duplication along its side walls is the most pathogenetically justified. However, it has not found application due to its 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 pharynx are more favorable, since during these operations a drainage hole remains. When suturing the external pharynx, a closed space is formed in the uterine cavity, which is unfavorable if there is a hidden infection in the uterus. Among the operations that eliminate the inferiority of the internal os of the cervix, the most widely used are modifications of the Shirodkar method: the MacDonald method, a circular suture according to the Lyubimova method, U-shaped sutures according to the Lyubimova and Mamedalieva method.
Indications for surgical correction of ICI:
A history of spontaneous miscarriages and premature births (in the 2nd – 3rd trimester of pregnancy);
Progressive, according to data clinical examination, insufficiency of the cervix: change in consistency, appearance of flabbiness, shortening, gradual increase in the “gaping” of the external pharynx and the entire canal of the cervix and opening of the internal pharynx.
Contraindications to surgical correction of ICI are:
Diseases and pathological conditions that are a contraindication to continuing 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 a non-developing pregnancy;
III – IV degree of purity of the vaginal flora and the presence pathogenic flora in the discharge of the cervical canal. Cervical erosion is not a contraindication to surgical treatment ICN, if pathogenic microflora is not released.
Surgical correction of ICI is usually performed between 13 and 27 weeks of pregnancy. The timing of surgical correction should be determined individually depending on the time of occurrence clinical manifestations ICN. In order to prevent intrauterine infection, it is advisable to perform the operation at 13–17 weeks, when there is no significant shortening and dilatation of the cervix. With increasing gestational age, insufficiency of the “obturator” function of the isthmus leads to mechanical descent and prolapse of the amniotic sac. This creates conditions for infection of the lower pole through its ascending route.
Management of the operational period for ICN.
You are allowed to stand up and walk immediately after surgery. During the first 2–3 days, antispasmodics are prescribed for preventive purposes: suppositories with papaverine, no-spa 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 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% hydrogen peroxide rum or other antiseptics.
Antibacterial therapy is prescribed for extensive erosion and the appearance of a band shift in the blood. At the same time, antimycotic drugs are prescribed. 5–7 days after the operation, the patient can be discharged for outpatient observation. The suture is removed at 37–38 weeks of pregnancy.
Most a common complication After surgical correction of ICI, the cervix is cut through with a thread. This can occur if contractile activity of the uterus occurs and the sutures are not removed; if the operation was technically incorrect and the cervix is tied with sutures; if the cervical tissue is affected by an inflammatory process. In these cases, when applying circular sutures, bedsores may form, and subsequently fistulas, transverse or circular avulsions of the cervix. If eruption occurs, 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, antibacterial therapy is prescribed.
Currently, non-surgical correction methods are widely used - the use of various pessaries.
Non-surgical methods have a number of advantages: they are bloodless, simple, and applicable on an outpatient basis. The vagina and pessary must be treated with antiseptic solutions every 2 to 3 weeks to prevent infection. These methods are more often used in functional ICI, when only softening and shortening of the cervix is observed, but the canal is closed, or when ICI 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 ICI (fistulas, cervical ruptures).
– a disorder associated with the opening of the cervix during embryogenesis, which leads to spontaneous abortion or premature birth. Clinically, this pathology usually does not manifest itself in any way; sometimes minor pain and a feeling of fullness, and the release of mucus and blood are possible. Ultrasound scanning is used to determine pathological changes and confirm the diagnosis. Medical assistance consists of installing a Meyer ring (special pessary) in the vagina or surgical suturing. Drug therapy is also indicated.
Isthmic-cervical insufficiency (ICI) is a pregnancy pathology that develops as a result of weakening of the muscle ring located in the area of the internal os 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 experiences recurrent miscarriage, in about a quarter of clinical cases the cause of this condition is ICI.
With isthmic-cervical insufficiency, there is a decrease in muscle tone in 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 amniotic sac, subsequent premature birth or fetal death. In addition, with ICI, infection can be transmitted to the fetus, since a certain microflora is always present in the genital tract.
The etiology of isthmic-cervical insufficiency is a decrease in the tone of the muscle fibers that form the uterine sphincter. Its main role is to maintain the cervix closed until labor occurs. 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 history of cervix. The likelihood of developing isthmic-cervical insufficiency increases in women who have suffered late abortions, ruptures, or surgical births (application of obstetric forceps).
Isthmic-cervical insufficiency often occurs after fetal destruction operations, breech birth and surgical interventions on the cervix. All these factors cause trauma to the cervix and possible disruption of the location of 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 abnormal structure of organs reproductive system pregnant woman. Congenital ICI is quite rare, and can be determined even in the absence of conception - in such a case, at the time of ovulation, the cervical canal will dilate by more than 0.8 cm.
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 observed when this problem is combined with a deficiency of progesterone production. An aggravating factor for isthmic-cervical insufficiency is multiple births. Along with increased pressure on the cervix, in such cases there is often an increase in the production of the hormone relaxin. For the same reason, isthmic-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 performing heavy physical work during gestation.
Taking into account the etiology, two types of isthmic-cervical insufficiency can be distinguished:
Clinically, isthmic-cervical insufficiency, as a rule, does not manifest itself in any way. If symptoms are present, the signs of pathology depend on the period at which the changes occurred. In the first trimester, isthmic-cervical insufficiency may be indicated by bleeding, 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. Bleeding occurs and discomfort in the lower back and abdomen is possible.
The peculiarity of isthmic-cervical insufficiency is 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 an objective gynecological examination is not routinely performed during each consultation in order to reduce the likelihood of pathogenic microflora. However, even during a gynecological examination, it is not always possible to suspect manifestations of isthmic-cervical insufficiency. The reason for holding instrumental diagnostics may cause excessive softening or reduction in the length of the neck. It is these symptoms that often indicate the onset of isthmic-cervical insufficiency.
Ultrasound scanning is the most informative method in identifying isthmic-cervical insufficiency. A sign of pathology is shortening of the cervix. Normally, this indicator varies and depends on the stage of embryogenesis: before 6 months of pregnancy it is 3.5-4.5 cm, in later stages - 3-3.5 cm. With isthmic-cervical insufficiency, these parameters change to a lesser extent. About the threat of interruption or premature appearance The birth of a baby is indicated by a shortening of the canal to 25 mm.
A V-shaped opening of the cervix is a characteristic sign of isthmic-cervical insufficiency, which is observed in both parous and nulliparous patients. This symptom can be detected by ultrasound monitoring. Sometimes, to confirm the diagnosis during scanning, a test with increasing load is performed - the patient is asked to cough or lightly presses on the bottom of the uterine cavity. In women who have given birth, isthmic-cervical insufficiency is sometimes accompanied by an increase in the lumen of the cervix along its entire length. If a woman is at risk or has indirect signs of ICI, monitoring should be carried out twice a month.
In case of isthmic-cervical insufficiency, complete rest is indicated. It is important to protect a pregnant woman from negative factors: stress, harmful conditions labor intensive physical activity. The question of the conditions for subsequent pregnancy management 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 installing a Meyer ring in the vagina, which reduces fetal pressure on the cervix. The procedure is recommended to be carried out during the embryogenesis period of 28 weeks or more with a slight opening of the pharynx.
Surgical intervention for isthmic-cervical insufficiency allows high probability bring the baby to term. The manipulation involves placing a suture on the neck to prevent its premature opening. The operation is carried out under anesthesia, the following conditions are necessary for its implementation: signs of integrity of the membranes and fetal activity, gestational age up to 28 weeks, absence pathological discharge And infectious processes from the genitals. Sutures and pessaries for isthmic-cervical insufficiency are removed upon reaching the embryogenesis period of 37 weeks, as well as in the event of labor, opening of the amniotic sac, formation of a fistula, or bleeding.
During conservative therapy and postoperative period Patients with isthmic-cervical insufficiency are prescribed antibacterial drugs to prevent the development of infection. The use of antispasmodics is also indicated, and tocolytics for hypertonicity of the uterus. In the functional form of isthmic-cervical insufficiency, hormonal agents can be additionally used. Delivery is possible through the vaginal genital tract.
With isthmic-cervical insufficiency, a woman can carry the baby to the expected date of birth. Due to a weak muscular sphincter, the risk of rapid labor increases; if there is a possibility 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 stage of planning conception. After fertilization, the patient must normalize her work and rest schedule. It is important to exclude stress factors and hard work. Specialists should closely monitor the woman’s condition and determine as early as possible whether she is at risk for developing ICI.
