Screening for the first trimester of pregnancy is over, time passes, the belly grows, and new worries arise.
Have you heard or read somewhere about isthmic-cervical insufficiency (ICI), premature birth, ultrasound of the cervix and now you don’t know whether this threatens you and whether you need such a study, and if necessary, when?
In this article I will try to talk about such a pathology as ICI, modern methods of diagnosing it, the formation of a high-risk group for preterm birth and methods of treatment.

Premature births are those that occur during pregnancy from 22 to 37 weeks (259 days), starting from the first day of the last normal menstruation with regular menstrual cycle, while the fetal body weight ranges from 500 to 2500 g.

The frequency of premature births in the world in recent years is 5–10% and, despite the emergence of new technologies, is not decreasing. And in developed countries it increases, first of all, as a result of the use of new reproductive technologies.

Approximately 15% of pregnant women are at high risk for premature birth even at the stage of collecting anamnesis. These are women who have a history of late miscarriages or spontaneous premature births. There are about 3% of such pregnant women in the population. In these women, the risk of recurrence is inversely related to the gestational age of the previous preterm birth, i.e. The earlier the premature birth occurred in the previous pregnancy, the higher the risk of recurrence. In addition, this group can include women with uterine anomalies, such as a unicornuate uterus, a septum in the uterine cavity, or trauma, surgical treatment of the cervix.

The problem is that 85% of preterm births occur in 97% of women in the population for whom this is their first pregnancy, or whose previous pregnancies ended in birth at full term. Therefore, any strategy aimed at reducing the rate of preterm birth that targets only a group of women with a history of preterm birth will have very little impact on the overall rate of preterm birth.

The cervix plays a very important role in maintaining pregnancy and the normal course of labor. Its main task is to serve as a barrier that protects the fetus from being pushed out of the uterine cavity. In addition, the glands of the endocervix secrete special mucus, which, when accumulated, forms a mucus plug - a reliable biochemical barrier to microorganisms.

“Cervical ripening” is a term used to describe the rather complex changes that occur in the cervix related to the properties of the extracellular matrix and the amount of collagen. The result of these changes is the softening of the cervix, its shortening to the point of smoothing, and the expansion of the cervical canal. All these processes are normal during full-term pregnancy and are necessary for the normal course of labor.

For some pregnant women, due to various reasons“Cervical ripening” occurs ahead of time. Barrier function the cervix decreases sharply, which can lead to premature birth. It is worth noting that this process does not have clinical manifestations, not accompanied painful sensations or bloody discharge from the genital tract.

What is ICN?

Various authors have proposed a number of definitions for this condition. The most common is this: ICI is an insufficiency of the isthmus and cervix, leading to premature birth in the second or third trimester of pregnancy.
or something like that : ICI is a painless dilatation of the cervix in the absence of
uterine contractions, leading to spontaneous interruption
pregnancy.

But the diagnosis must be made even before the termination of pregnancy occurs, and we don’t know whether it will happen. Moreover, most pregnant women diagnosed with ICI will deliver at term.
In my opinion, ICI is a condition of the cervix in which the risk of preterm birth in a given pregnant woman is higher than the general population.

In modern medicine, the most reliable way to assess the cervix is transvaginal ultrasound with cervicometry - measuring the length of the closed part of the cervix.

Who is indicated for cervical ultrasound and how many times?

Here are the recommendations from https://www.fetalmedicine.org/ The Fetal Medicine Foundation:
If a pregnant woman is among those 15% with a high risk of preterm birth, then such women are shown an ultrasound of the cervix every 2 weeks from the 14th to the 24th week of pregnancy.
For all other pregnant women, a single ultrasound of the cervix is ​​recommended at 20-24 weeks of pregnancy.

Cervicometry technique

The woman empties her bladder and lies on her back with her knees bent (lithotomy position).
The ultrasound probe is carefully inserted into the vagina towards the anterior fornix so as not to place excessive pressure on the cervix, which could artificially increase the length.
A sagittal view of the cervix is ​​obtained. The mucous membrane of the endocervix (which can be either increased or decreased echogenicity compared to the cervix) serves as a good guide to determine the true position of the internal os and helps to avoid confusion with the lower segment of the uterus.
The closed part of the cervix is ​​measured from the external os to the V-shaped notch of the internal os.
The cervix is ​​often curved and in these cases the length of the cervix, considered as a straight line between the internal and external os, is inevitably shorter than the measurement taken along the cervical canal. From a clinical point of view, the measurement method is not important, because when the cervix is ​​short, it is always straight.

Each test should be completed within 2-3 minutes. In about 1% of cases, the length of the cervix may change depending on uterine contractions. In such cases, the lowest values ​​should be recorded. In addition, the length of the cervix in the second trimester may vary depending on the position of the fetus - closer to the fundus of the uterus or in the lower segment, in a transverse position.

You can evaluate the cervix transabdominally (through the abdomen), but this is a visual assessment, not cervicometry. The length of the cervix with transabdominal and transvaginal access differs significantly by more than 0.5 cm, both up and down.

Interpretation of research results

If the length of the cervix is ​​more than 30 mm, then the risk of premature birth is less than 1% and does not exceed the general population. Such women are not indicated for hospitalization, even in the presence of subjective clinical data: pain in the uterus and minor changes in the cervix, heavy vaginal discharge.

• If a shortening of the cervix of less than 15 mm is detected in a singleton pregnancy or 25 mm in a multiple pregnancy, urgent hospitalization and further management of the pregnancy in a hospital with the possibility of intensive care for newborns are indicated. The probability of delivery within 7 days in this case is 30%, and the probability of premature birth before 32 weeks of pregnancy is 50%.

• Shortening of the cervix to 30-25 mm during a singleton pregnancy is an indication for consultation with an obstetrician-gynecologist and weekly ultrasound control.

• If the length of the cervix is ​​less than 25 mm, a conclusion is issued: “ECHO signs of ICI” in the 2nd trimester, or: “Given the length of the closed part of the cervix, the risk of premature birth is high” in the 3rd trimester, and a consultation with an obstetrician-gynecologist is recommended for deciding whether to prescribe micronized progesterone, perform cervical cerclage or install an obstetric pessary.

Once again, I want to emphasize that the detection of a shortened cervix during cervicometry does not mean that you will definitely give birth ahead of time. We are talking about high risk.

A few words about the opening and shape of the internal pharynx. When performing an ultrasound of the cervix, you can find various shapes internal os: T, U, V, Y - shaped, moreover, it changes in the same woman throughout pregnancy.
With ICI, along with shortening and softening of the cervix, its dilatation occurs, i.e. expansion of the cervical canal, opening and changing the shape of the internal os is one process.
Conducted FMF large multicenter study showed that the shape of the internal os itself, without shortening the cervix, does not increase the statistical probability of premature birth.

Treatment options

Two methods of preventing premature birth have been proven effective:

• Cervical cerclage (suturing the cervix) reduces the risk of labor before 34 weeks by about 25% in women with a history of preterm labor. There are two approaches to treating patients with previous preterm birth. The first is to perform cerclage on all such women shortly after 11-13 weeks. The second is to measure the length of the cervix every two weeks from 14 to 24 weeks, and apply sutures only if the length of the cervix becomes less than 25 mm. The overall rate of preterm birth is similar with both approaches, but the second approach is preferred because it reduces the need for cerclage by approximately 50%.

If a short cervix (less than 15 mm) is detected at 20-24 weeks in women with a clear obstetric history, cerclage can reduce the risk of preterm birth by 15%.
Randomized studies have shown that in the case of multiple pregnancies, when the cervix is ​​shortened to 25 mm, cervical cerclage doubles the risk of preterm birth.

• Prescribing Progesterone from 20 to 34 weeks reduces the risk of childbirth before 34 weeks by approximately 25% in women with a history of premature birth, and by 45% in women with an uncomplicated history, but identified shortening of the cervix to 15 mm. A study was recently completed that showed that the only progesterone that can be used for a short cervix is ​​micronized vaginal progesterone at a dose of 200 mg per day.

• Multicenter studies of the effectiveness of using a vaginal pessary are currently ongoing. A pessary, which consists of flexible silicone, is used to support the cervix and change its direction towards the sacrum. This reduces the load on the cervix due to reduced pressure from the fertilized egg. You can read more about the obstetric pessary, as well as the results of the latest research in this area

The combination of cervical sutures and pessary does not improve effectiveness. Although the opinions of various authors differ on this matter.

After suturing the cervix or with an obstetric pessary in place, ultrasound of the cervix is ​​not advisable.

See you in two weeks!

ICN during pregnancy

Isthmic-cervical insufficiency during pregnancy (ICI) is a non-physiological process characterized by painless dilation of the cervix and its isthmus in response to an increasing load (increased 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).

• Occurrence of ICN
• Indirect causes of insufficiency of the isthmic-cervical canal
• Symptoms of ICI during pregnancy
• The mechanism of development of isthmic-cervical insufficiency of the cervix
• Methods for correcting ICI
• Application of circular sutures for isthmic-cervical insufficiency
• How is a pessary selected?
• Tactics of pregnancy management with ICI
• How many weeks is the pessary removed?

Occurrence of ICN

In the structure of late miscarriages and premature births, ICI plays a significant role. Isthmic-cervical insufficiency is common, according to various sources, from 1 to 13% of pregnant women. In women with a history of preterm birth, the incidence increases to 30–42%. If the previous pregnancy ended at term -, then the subsequent one in every fourth case will not last longer without correction and treatment of the causes.

ICNs are classified by origin:

• Congenital. Associated with developmental defects – . 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 pronounced uterine tone.

Indirect causes of isthmic-cervical insufficiency

Predisposing factors for cervical insufficiency birth canal are scar changes and defects formed after injuries in previous births or after surgical interventions on the cervix.

The causes of isthmic-cervical insufficiency are:

• birth of a large fetus;
• birth of a fetus with breech presentation;
• application of obstetric forceps during childbirth;
• abortions;
• diagnostic curettage;
• cervical 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 proper course of pregnancy. A shift in hormonal balance occurs as a result of:

• Hyperandrogenism is an excess of a group of male sex hormones. The mechanism involves fetal androgens. At week -27, it synthesizes male sex hormones, which, together with maternal androgens (they are produced normally), lead to structural transformations of the cervix due to its softening.
• Progesterone (ovarian) deficiency. – a hormone that prevents miscarriage.
• Pregnancy that occurs after induction (stimulation) of ovulation by gonadotropins.

Correction of isthmic-cervical insufficiency of a functional nature allows you to successfully maintain pregnancy through therapeutic means.

Isthmic-cervical insufficiency during pregnancy and symptoms

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

The only subjective symptom of ICI is an increase in the volume and change in the consistency of the discharge. In this case, it is necessary to exclude leakage of amniotic fluid. For this purpose, arborization smears and amniotests are used, 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 a vaginal examination performed during registration in the 1st trimester of pregnancy. The study determines:

• length, consistency of the cervix, location;
• the condition of the cervical canal (it allows a finger or its tip to pass through, normally the walls are tightly closed);
• location of the presenting part of the fetus (in later stages of pregnancy).

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

How does isthmic-cervical insufficiency develop?

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

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 ICI

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

Contraindications to suturing for isthmic-cervical insufficiency:

• suspicion of leakage of amniotic fluid;
• fetal malformations incompatible with life;
• pronounced tone;
• and bleeding;
• developed chorioamnionitis (with isthmic-cervical insufficiency, there is a high risk of infection of the membranes, fetus and uterus);
• suspicion of scar failure after cesarean section;
• extragenital pathology, in which prolongation of pregnancy is inappropriate.

What are the disadvantages of surgical sutures for ICI?

The disadvantages include:

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

Afterwards, the risk of complications when suturing increases many times over.

Unloading pessary for isthmic-cervical insufficiency

Conservative correction avoids most of the disadvantages of surgical treatment of ICI during pregnancy. In practice, pessaries that are used during pregnancy are often used for isthmic-cervical insufficiency. The first generation domestic pessary is made in the shape of a butterfly with a central hole for the cervix and an opening for the outflow of vaginal contents. Made from non-toxic plastic or similar materials.

The second generation of pessaries of the ASQ (Arabin) type is 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 os of the cervix in a closed state and redistribute fetal pressure on the pelvic floor (muscles, tendons and bones) and on the anterior wall of the uterus.

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

The absence of the need for anesthesia and cost-effectiveness are also advantages.

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

• prevention of suture failure during surgical correction and reducing the risk of suture cutting;
• group of patients who have no visual or ultrasound signs ICN, but there was a history of premature birth, miscarriages or;
• after prolonged infertility;
• cicatricial deformities of the cervix;
• aged and young pregnant women;
• dysfunction of the ovaries.

Contraindications to the use of a pessary for ICI:

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

It is not advisable to carry out unloading correction with a pessary in cases of severe ICI (with sagging of the amniotic sac).

How is a pessary selected for ICI?

When selecting 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 and the diameter of the vaginal vault.

Tactics of pregnancy management with isthmic-cervical insufficiency

When identifying the clinical picture and ECHO markers of ICI, taking into account medical history, doctors use a point assessment of isthmic-cervical insufficiency (6–7 points is a critical assessment that requires correction). Then, depending on the timing and causes of ICI, pregnancy management tactics are selected.

If the period is up to 23 weeks and there are indications for organic origin ICN is then assigned surgery or a combination - 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 the following every 2–3 weeks:

• Bacterioscopic control of smears - to assess the state of flora in the vagina. If the microflora changes and there is no 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 antibacterial therapy with re-use of the pessary for periods up to . After this period, only therapy aimed at restoring vaginal flora is carried out.
• – monitoring of cervical conditions, necessary for timely diagnosis of the threat of miscarriage, worsening dynamics, threat of premature birth and cutting of sutures.
• If necessary, tocolytic therapy is prescribed in parallel - medications, relieving uterine hypertonicity. Blockers are used depending on the indications calcium channels(Nifedipine), progesterone (Utrozhestan) at a dose of 200–400 mg, oxytocin receptor blockers (Atosiban, Tractocil).

When to remove the pessary

Early removal of sutures and pessaries is carried out in the event of the development of regular labor contractions, when bleeding from the genitals, effusion. The sutures and pessary are routinely removed at . At the same time, the pessary is also removed during a planned caesarean section.

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

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Transcript

1 ISTHMICO-CERVICAL INSUFFICIENCY. PREGNANCY MANAGEMENT TACTICS ICI is a painless dilatation of the cervix in the absence of uterine contractions, leading to spontaneous termination of pregnancy. Most often, the diagnosis is made retrospectively, since rapid and painless dilatation of the cervix in the 2nd or 3rd trimester ends in miscarriage or early premature birth. There are no objective criteria in the early stages. More often there is a combination causal factors, leading to ICN. Mechanism of abortion in ICI As a rule, due to an increase in mechanical load on the area of ​​the incompetent internal os, prolapse of the membranes into the cervical canal occurs, followed by infection of its membranes due to contact with the vaginal flora, rupture of the membranes and rupture of amniotic fluid. Classification of ICI According to etiology Functional (ovarian hypofunction, hyperandrogenism). Organic (traumatic) abortions, terminations of pregnancy, traumatic births, after cesarean section with full dilatation of the cervix, surgical interventions on the cervix. Congenital (abnormal uterine structure, hypoplasia). According to the shape of the cervix (sonographic classification) T-shaped internal os Y-shaped internal os V-shaped internal os U-shaped internal os the most unfavorable forms Risk groups for the development of ICI

2 History of cervical trauma. Hyperandrogenism. Malformations of the uterus. Connective tissue dysplasia (CTD). Genital infantilism. Pregnancy that occurs after induction of ovulation by gonadotropins. Multiple pregnancy. Increased load on the cervix during pregnancy (polyhydramnios, large fruit). Diagnosis of ICI Vaginal examination data Cervical length. Condition of the cervical canal. The location of the cervix in relation to the axis of the uterus. The consistency of the cervix, which can only be determined by vaginal examination. Location of the presenting part. Ultrasound data (transvaginal echography “gold standard”) Length of the cervix. The length of the closed part is assessed; shortening it to 25 mm requires more detailed observation and expansion of indications for correction. Cervical shortening of less than 20 mm is an absolute indication for cervical correction. Condition of the cervical canal. Condition of the internal os and cervical canal. In patients with an opening of the internal pharynx, its shape is assessed. Ultrasonographic criteria for changes in the cervix during pregnancy complicated by ICI (transvaginal technique) The length of the cervix, equal to 3 cm, is critical in first- and multi-pregnant women with a gestational age of less than 20 weeks and requires intensive monitoring of the woman, classifying her as a risk group. A cervical length of 2 cm or less is an absolute criterion for ICI and requires intensive treatment. In multiparous women

3 women on ICN indicates a shortening of the cervix in weeks up to 2.9 cm. The width of the cervical canal of 1 cm or more during pregnancy up to 21 weeks indicates cervical insufficiency. The ratio of the length to the diameter of the cervix at the level of the internal os is less than 1.6 is a criterion for ICI. Prolapse of the amniotic sac with deformation of the internal os is characteristic of ICN. The V and U-shape is considered the most unfavorable. Changes in the echostructure of the cervix (small liquid inclusions and bright line echoes) indicate hemodynamic changes in the vessels of the cervix and may be the initial signs of cervical insufficiency. When assessing the information content of the length of the cervix, it is necessary to take into account the method of its measurement. The results of a transabdominal ultrasound significantly differ from the results of a transvaginal ultrasound and exceed them by an average of 0.5 cm. Assessment of the ICN The assessment of the ICN is carried out using the Stember scale and with a score of 6-7 or more, correction of the cervix is ​​indicated. Methods for correcting ICI Conservative method (application of an obstetric pessary) Principles and mechanism of action of the pessary Closing the cervix with the walls of the central opening of the pessary. Formation of a shortened and partially open cervix. Reducing the load on the incompetent cervix due to the redistribution of pressure on the pelvic floor. Physiological sacralization of the cervix due to fixation in the central opening of the pessary displaced posteriorly. Partial transfer of intrauterine pressure to the anterior wall of the uterus due to the ventral oblique position of the pessary and sacralization of the cervix. Preserving the mucus plug and reducing sexual activity can reduce the likelihood of infection.

4 Protection of the lower pole of the ovum thanks to the combination of active components. Improving the psycho-emotional state of the patient. Indications for the use of obstetric pessary Isthmic-cervical insufficiency, including for the prevention of suture failure during surgical correction of ICI. Pregnant women potentially at risk of miscarriage. Women with a history of late miscarriages and premature births, suffering from recurrent miscarriage. Pregnancy after prolonged infertility. Old and young pregnant women. Women with ovarian dysfunction, suffering from genital infantilism. Women at risk of miscarriage current pregnancy in combination with progressive changes in the cervix. Patients with cicatricial deformity of the cervix. Women with multiple pregnancies. Women with a threat of termination of a current pregnancy and altered psychoadaptive reactions regarding the completion of pregnancy. As the main method of treating cervical insufficiency, an obstetric unloading pessary should not be used in cases of severe degrees of ICI (prolapse of the membranes). Advantages of the method: Simplicity and safety, possibility of application in outpatient setting, including for the prevention of suture failure. Possibility of use for periods longer than weeks. No anesthesia required. Economic efficiency. Disadvantages of the method Impossibility of using the method in case of severe ICI Types of obstetric pessaries

5 When choosing the size of a domestically produced unloading pessary, the size of the upper third of the vagina, the diameter of the cervix and the presence of a history of childbirth are taken into account. As a rule, a type 1 pessary is used for primiparous women, and a type 2 pessary for multiparous women. When choosing the size of a flexible silicone pessary with perforations type ASQ (Arabin), the width of the cervix (the inner diameter of the pessary corresponds to it), the diameter of the vaginal vault (the outer diameter of the pessary) and anatomical features (the height of the pessary) are taken into account. There are 17 types of Arabian Passaria. These are soft, flexible rings that are easy to insert without causing pain the patient and very rarely move. In some cases, after its removal, slight swelling is observed, which goes away within a few days and does not affect the birth process in any way. Surgical method Transabdominal cerclage (correction of ICI using abdominal access) Transvaginal cerclage Transvaginal cerclage is performed in a hospital setting under aseptic conditions using spinal anesthesia. A circular suture is placed on the cervix in a modification of the McDonald method using mersilene tape. The advantage of this suture material The point is that it is a flat wide tape that fits well into the fabrics and does not cut through. Contraindications to surgical and conservative correction of ICI Malformations of the fetus, in which prolongation of pregnancy is inappropriate. Suspicion of leakage of amniotic fluid. It is mandatory to use modern test systems for water leakage if there is a suspicion, since patients with ICI often have mucous discharge and need to be differentiated. Choriamnionitis. Stitching may be unsafe for the patient's life. Regular labor activity\pronounced uterine tone. Suturing can lead to miscarriage, so tocolytic therapy is mandatory in preparation for surgical correction.

6 Bloody discharge from the genital tract due to placental abruption. Suspicion of failure of the uterine scar. Conditions in which prolongation of pregnancy is inappropriate (severe extragenital pathology). Factors negatively affecting the effectiveness of surgical correction History of late spontaneous miscarriages. History of ICI. History of premature birth. Long-term threat of miscarriage. Infection. If pathogenic flora is detected, sanitation is recommended before and after correction. The length of the cervix according to ultrasound before suturing is less than 20 mm. Funnel-shaped expansion of the internal pharynx according to ultrasound is more than 9 mm. Disadvantages of surgical correction Invasiveness of the method. The need for anesthesia and complications associated with it. Complications associated with the method (damage to the membranes, induction of labor). There is a danger of suturing for more than a week due to the high risk of complications. The risk of sutures cutting through at the onset of labor. Tactics of pregnancy management in ICI Clinic of ICI, ultrasound markers, anamnesis data, score of ICI. At 1 week, an obstetric pessary is installed. For up to 23 weeks, the type of ICN (organic or functional) is determined. With organic ICI, surgical correction is indicated, or surgical correction together with the application of a pessary (in cases of severe ICI or multiple pregnancies). For functional ICI, an obstetric pessary is applied. After correction of the ICI, the following is carried out:

7 Bacterioscopic examination of smears (every 2-3 weeks); Ultrasound monitoring of the condition of the cervix (every 2-3 weeks); Tocolytic therapy (if indicated). Early removal of sutures and removal of the pessary is carried out according to indications in the presence of labor. Planned removal of sutures and removal of the pessary is carried out at 37 weeks. Management of patients after pessary insertion. Insertion of the pessary. Ultrasound monitoring of the condition of the cervix and bacterioscopic examination of smears. In the absence of pathology, the pessary is removed at 37 weeks, followed by sanitization of the genital tract. If there are changes according to ultrasound data Up to 20 weeks of hospitalization for suturing and pessary weeks of hospitalization with suturing and tocolytic therapy as indicated. More than 23 weeks of hospitalization with additional methods treatment. If there are changes in the microflora, sanitation is carried out against the background of a pessary during the day. If the treatment has a positive effect, the pessary is removed at 37 weeks. If the effect is negative, after 36 weeks the pessary is removed and the genital tract is sanitized. At up to 36 weeks, the pessary is removed, the genital tract is sanitized, followed by the introduction of a pessary. Correction of ICI using abdominal access was first performed in 1965 using laparotomy access. Today, cerclage is performed laparoscopically; sutures are placed at the level of the isthmus, which improves the obturator function. Stages The vesicouterine fold is opened Bladder moves downwards. Bifurcations of the accessory branches of the uterine arteries are visualized.

8 More medial uterine artery a “window” is created on each side by dissection broad ligament uterus. An injection is made through one “window”, the posterior portion of the cervix is ​​sutured at the level of the uterosacral ligaments. The injection is made through the second “window”. The ends of the thread are tied in front of the uterus with double knots. Peritonization is not performed. Indications Absence or sudden shortening of the cervix with a history of pregnancy loss. History of unsuccessful attempts at suturing via vaginal access. Advantages Correction can be carried out for those patients who cannot undergo correction through vaginal access. Sutures are placed in the isthmus area, which is more reliable. Disadvantages The patient undergoes two transabdominal correction surgeries and a cesarean section, since this is the only method of delivery for laparoscopic correction of ICI. Contraindications Prolapse or rupture of membranes Intrauterine infection Vaginal bleeding Antenatal fetal death Labor General contraindications to laparoscopic intervention % of laparoscopic correction procedures for ICI are performed during pregnancy, the rest preventively before pregnancy. This allows you to avoid surgery during pregnancy and reduce blood loss. Preventive sutures do not interfere with spontaneous pregnancy.

9 Sutures may be removed during caesarean section or left in place for subsequent pregnancies. During pregnancy, sutures can be removed laparoscopically if necessary. Questions about lecture 1. A pessary is foreign body, which is an excellent substrate for the development of pathogenic saprophytic flora. What to do in this situation? Following the recommendations given in today's webinar, indications for antibacterial therapy can be expanded when pathogenic flora is detected. 2. How to measure the vaginal vault to select an obstetric pessary? Manufacturers of imported pessaries offer special rings for measuring the vaginal vault. You can also use palpation data. 3. How can a pessary close the internal os? Sacralization is questionable; the central foramen is not displaced posteriorly. This directly concerns the domestic pessary. The opening is located ventro-sacral and actually fixes the neck posteriorly. It does not close the internal os, but it is important that it allows you to maintain the length and improve the psycho-emotional state of the patient. 4. It is recommended to carry out ultrasound control vaginally. What about the pessary? As for the soft pessary, no problems arise during the study. With a rigid pessary, you can start with a transabdominal examination. If necessary, we also perform vaginal. 5. During IVF, several embryos are often transferred; maybe preventive cerclage should be performed immediately? If we are talking about cervical correction during pregnancy, then when a multiple pregnancy occurs, the indications for one or another type of correction expand. If we are talking about patients with cervical defects, then transabdominal cerclage is recommended before transfer.

ICI is a painless dilatation of the cervix in the absence of uterine contractions, leading to spontaneous termination of pregnancy. Most often, the diagnosis is made retrospectively, since rapid

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

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

Symptoms of ICI are very scarce, since the disease is based on dilatation of the cervix, which occurs without pain or bleeding. A pregnant woman may be bothered by a feeling of heaviness in the lower abdomen, frequent urination, and copious mucous discharge from the genital tract. Therefore, it is very important to promptly report these symptoms to the obstetrician-gynecologist leading the pregnancy.

ICN: causes of occurrence

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

Organic ICN occurs after abortions, curettage of the uterine cavity. During these operations, the cervical canal is expanded with a special instrument, which can result in trauma to the cervix. Organic ICI can also result from cervical rupture during a previous birth. If the sutures heal poorly, scar tissue forms at the site of the ruptures, which cannot ensure complete closure of the cervix in the next pregnancy.

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

ICN: disease diagnosis

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

Most often, isthmic-cervical insufficiency is first diagnosed after spontaneous termination of the first pregnancy. The method for detecting ICI is vaginal examination. Normally, during pregnancy, the cervix is ​​long (up to 4 cm), dense, deviated posteriorly and its external opening (external os) is closed. With ICI, shortening of the cervix, its softening, as well as opening of the external and internal pharynx are observed. With severe ICI, when examining the cervix in the speculum, hanging membranes of the amniotic sac may be detected. The condition of the cervix can also be assessed by ultrasound. Using an ultrasound sensor, which the doctor inserts into the vagina, the length of the cervix is ​​measured and the condition of the internal os is assessed. The length of the cervix equal to 3 cm requires additional ultrasound examination in dynamics. And if the length of the cervix is
2 cm, then this is absolute sign isthmic-cervical insufficiency and requires appropriate surgical correction.

Isthmic-cervical insufficiency: treatment

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

There are two methods of treating ICI: conservative (non-surgical) and surgical.

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

Non-surgical correction of ICI is carried out using a pessary - an obstetric ring (this is a design of a special anatomical shape with a closing ring for the cervix). The pessary is placed on the cervix, thereby reducing the load and redistributing pressure on the cervix, i.e. it plays the role of a kind of bandage. The technique for placing a pessary is simple, does not require anesthesia and is well tolerated by the pregnant woman. When using this method, the patient is insured against technical errors that may occur during surgical treatment.

After the installation procedure, a pregnant woman should be under the dynamic supervision of a doctor. Every 3-4 weeks, smears are taken from the vagina for flora, and the condition of the cervix is ​​assessed using ultrasound. The pessary is removed at 37–38 weeks of pregnancy. Removal is easy and painless. If bleeding occurs or labor progresses, the pessary is removed ahead of schedule.

Currently developed various methods surgical treatment of ICN.

In case of gross anatomical changes in the cervix caused by old ruptures (if this is the only cause of miscarriage), it is necessary surgical treatment outside of pregnancy (cervical plastic surgery). A year after the operation, a woman can plan a pregnancy.

Indications for surgery during pregnancy are a history of spontaneous miscarriages, premature birth, as well as progressive insufficiency of the cervix: its flabbiness, shortening, increased gaping of the external pharynx or the entire cervical canal. Surgical correction of ICI is not performed in the presence of diseases for which pregnancy is contraindicated ( serious illnesses of cardio-vascular system, kidneys, liver, etc.); with detected fetal developmental defects; with repeated bloody discharge from the genital tract.

In most cases, with ICI, the uterine cavity is infected with microbes due to a violation of the obturator function of the cervix. Therefore, before surgical correction of the cervix, a vaginal smear for flora must be examined, as well as bacteriological culture or examination of genital tract discharge PCR method. If there is an infection or pathogenic flora, treatment is prescribed.

The surgical treatment method involves placing sutures made of a special material on the cervix. With their help, further dilatation of the cervix is ​​prevented, as a result it is able to cope with the growing load. Optimal time The time for suturing is 13–17 weeks of pregnancy, but the time of the operation is determined individually, depending on the time of occurrence and clinical manifestations of ICI. As the gestational age increases, due to cervical incompetence, the membranes descend and sag. This leads to the fact that its lower part becomes infected with microbes that are in the vagina, which can lead to premature rupture of the membranes and rupture of water. In addition, due to the pressure of the fetal bladder, the cervical canal expands even more. Thus, surgical intervention in more late dates pregnancy is less effective.

Sutures are placed on the cervix in a hospital under intravenous anesthesia. In this case, drugs are used that have minimal effect on the fetus. After suturing the cervix, the appointment is indicated medicines, reducing the tone of the uterus.

In some cases they use antibacterial drugs. In the first two days after surgery, the cervix and vagina are treated with antiseptic solutions. The length of hospital stay depends on the course of pregnancy and possible complications. Typically, a pregnant woman can be discharged from the hospital 5–7 days after surgery. In the future, it is carried out outpatient observation: Every 2 weeks the cervix is ​​examined in a speculum. According to indications or once every 2-3 months, the doctor takes a smear for flora. Sutures are usually removed at 37–38 weeks of pregnancy. The procedure is performed in a hospital without pain relief.

Labor may begin within 24 hours after the sutures are removed. If labor begins with “unremoved” sutures, the expectant mother needs to go to the nearest maternity hospital as quickly as possible. In the emergency room, you should immediately inform the staff that you have stitches on your cervix. Sutures are removed regardless of the stage of pregnancy, since during contractions they can cut through and thereby injure the cervix.

Prevention of ICN

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

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

If you have been diagnosed with isthmic-cervical insufficiency, do not despair. Timely diagnosis, correctly chosen pregnancy management tactics, a therapeutic and protective regime, as well as a favorable psychological attitude will allow you to carry your pregnancy to the due date and give birth to a healthy baby.

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

Causes of ICN

In accordance with the reasons, ICNs are divided into:

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

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

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

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

Symptoms of ICN

There are no clinical manifestations of ICI during or outside of pregnancy. The consequence of ICI in the second and third trimesters is spontaneous termination of pregnancy, which is often accompanied by premature rupture of amniotic fluid.

Outside of pregnancy, isthmicocervical insufficiency does not threaten anything.

Diagnosis of ICI during pregnancy

The only reliable method of diagnosis is vaginal examination and examination of the cervix in speculums. A vaginal examination reveals the following signs (individually or in combination with each other): shortening of the cervix, in severe cases - sharp, softening and thinning; the external pharynx can be either closed (more often in primigravidas) or gaping; the cervical (cervical) canal may be closed or allow the tip of a finger, one finger or two to pass through, sometimes with separation. When examined in the speculum, a gaping of the external os of the cervix with a prolapsed (protruding) amniotic sac may be detected.

Sometimes, if there is questionable data from a vaginal examination in the early stages of development, ultrasound helps diagnose ICI, which can detect an expansion of the internal os.

Complications of ICI during pregnancy

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

Treatment of ICI during pregnancy

Treatment methods are divided into operative and non-operative/conservative.

Surgical treatment of ICI

The surgical method involves placing sutures on the cervix to narrow it, and is carried out only in a hospital. There are various methods of suturing, their effectiveness is almost the same. Before treatment, an ultrasound of the fetus is performed, its intrauterine condition, the location of the placenta, and the condition of the internal os are assessed. From laboratory tests A smear analysis of the flora must be prescribed and, if inflammatory changes are detected in it, treatment is carried out. The operation is performed under local anesthesia; after the operation, the patient is prescribed antispasmodic and painkillers with for preventive purposes within a few days.

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

If there is no effect and ICI progresses, it is not recommended to prolong pregnancy, since the sutures can cut through, causing bleeding.

Contraindications for suturing the uterus are:

Untreated genitourinary tract infections;
- history of pregnancy terminations in the second and third trimesters (recurrent miscarriage);
- the presence of intrauterine fetal malformations incompatible with life;
- uterine bleeding ;
- heavy accompanying illnesses, which are a contraindication for prolonging pregnancy (severe cardiovascular diseases, impaired renal and/or liver function, some mental illnesses, severe gestosis in the second half of pregnancy - nephropathy of degrees II and III, eclampsia and preeclampsia);
- increased uterine tone that cannot be treated with medication;
- progression of ICN - rapid shortening, softening of the cervix, opening of the internal pharynx.

Conservative treatment of ICI

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

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

Prediction of pregnancy outcome with ICI

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

Prevention of ICN

It consists of careful curettage, examination and suturing of cervical ruptures after childbirth, cervical plastic surgery when old ruptures are detected outside of pregnancy, and treatment of hormonal disorders.

Obstetrician-gynecologist Kondrashova D.V.