Isthmic-cervical insufficiency: is there a chance to carry the pregnancy to term? Rules for planning and pregnant women with ICN - how to get pregnant and carry a child to term

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

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

ICI during pregnancy: what is it.

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

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

Isthmic-cervical insufficiency: causes.

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

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

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

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

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

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

Isthmic-cervical insufficiency: symptoms.

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

ICI can be determined using ultrasound; first of all, the length of the cervix is ​​taken into account, as well as whether the internal os is closed. The normal length of the cervix during pregnancy is 2.5 centimeters or more. The size of the internal os of the cervix should be up to 10 mm.

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

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

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

Isthmic-cervical insufficiency: treatment.

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

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

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

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

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

In addition, a pessary is foreign body, which irritates the cervix and can even provoke labor. Abroad, the application of pessaries has practically not been used recently.

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

Drug treatment of isthmic-cervical insufficiency is very limited. On later When suturing is not possible, progesterone suppositories are used in the vagina. This treatment has little effectiveness compared to surgery and is used from 24 to 32 weeks.

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

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

Among various reasons In cases of miscarriage, isthmic-cervical insufficiency (ICI) occupies an important place. If it is present, the risk of miscarriage increases almost 16 times.

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

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

Definition of the concept and risk factors

Isthmic-cervical insufficiency is a pathological premature shortening of the cervix, as well as expansion of its internal os (muscular “obturator” ring) and the cervical canal as a result of increase during pregnancy intrauterine pressure. This can cause prolapse of the membranes in the vagina, their rupture and loss of pregnancy.

Reasons for the development of ICN

In accordance with modern ideas, the main causes of cervical inferiority are three groups of factors:

1. Organic - formation of scar changes after traumatic injury cervix.
2. Functional.
3. Congenital - genital infantilism and uterine malformations.

The most common provoking factors are organic (anatomical and structural) changes. They may arise as a result of:

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

The functional factor is presented:

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

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

In this regard, it should be noted that the prevention of ICI consists of correcting the existing pathology and excluding (if possible) the causes of organic changes in the cervix.

Clinical manifestations and diagnostic possibilities

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

Most authors consider a decrease in the length of the cervix to be the main diagnostic sign. During a vaginal examination in the speculum, this sign is characterized by flaccid edges of the external pharynx and gaping of the latter, and the internal pharynx freely allows the gynecologist’s finger to pass through.

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

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

IN in rare cases Possible indirect symptoms of ICN are:

• sensations of discomfort, “bloating” and pressure in lower sections belly;
• stabbing pains in the vaginal area;
• discharge from the genital tract of a mucous or sanguineous nature.

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

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

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

1. Anamnesis data on the presence in the past of low-painful miscarriages in late gestation or rapid premature births.
2. . It is taken into account that each subsequent pregnancy ended in premature birth at increasingly earlier gestational stages.
3. The onset of pregnancy after a long period of infertility and use.
4. The presence of prolapse of the membranes in the cervical canal at the end of the previous pregnancy, which is established according to the anamnesis or from the dispensary registration card located in the antenatal clinic.
5. Data from vaginal examination and speculum examination, during which signs of softening of the vaginal cervix and its shortening, as well as prolapse of the amniotic sac in the vagina are determined.

However, in most cases, even a pronounced degree of prolapse of the amniotic sac occurs without clinical signs, especially in primigravidas, due to a closed external pharynx, and risk factors cannot be identified until the onset of labor activity.

In this regard, ultrasound for isthmic-cervical insufficiency with determination of the length of the cervix and the width of its internal pharynx (cervicometry) becomes highly diagnostic value. A more reliable method is an echographic examination using a transvaginal sensor.

How often should cervicometry be done for ICI?

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

The criteria for assessing echographic examination data, primarily on the basis of which the final diagnosis is made and treatment of ICI during pregnancy is selected, are:

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

At the same time, the variability of all these parameters is influenced by the tone of the uterus and its contractile activity, low placental attachment and the degree of intrauterine pressure, which creates certain difficulties in interpreting the results in terms of differential diagnosis reasons for the threat of miscarriage.

Ways to maintain and prolong pregnancy

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

These methods are:

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

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

Is it possible to sit with ICN?

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

How to lie down correctly during ICN?

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

Drug therapy

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

To reduce and, accordingly, intrauterine pressure, the following are prescribed: antispasmodics, like Papaverine orally or in suppositories, No-shpa orally, intramuscularly or intravenously. If they are insufficiently effective, tocolytic therapy is used, which contributes to a significant decrease in uterine contractility. The optimal tocolytic is Nifedipine, which has the lowest number side effects and their insignificant expression.

In addition, in case of ICN, it is recommended to strengthen the cervix with Utrozhestan of organic origin up to 34 weeks of pregnancy, and in the case of a functional form with the drug Proginova up to 5-6 weeks, after which Utrozhestan is prescribed up to 34 weeks. Instead of Utrozhestan, the active component of which is progesterone, analogues of the latter (Duphaston, or dydrogesterone) can be prescribed. In cases of hyperandrogenism, the basic drugs in the treatment program are glucocorticoids (Metypred).

Surgical and conservative methods for correcting ICI

Can the cervix lengthen with ICI?

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

What is better - sutures or a pessary for ICI?

The procedure for installing a pessary, unlike surgical technique suturing, is relatively simple in terms of technical implementation, does not require the use of anesthesia, is easily tolerated by a woman and, most importantly, does not cause circulatory problems in the tissues. Its function is to reduce pressure ovum on an incompetent cervix, preserving the mucus plug and reducing the risk of infection.

Obstetric relief pessary

However, the use of any technique requires a differentiated approach. With the organic form of ICI, the application of circular or U-shaped (better) sutures is advisable during 14-22 weeks of pregnancy. If a woman has a functional form of pathology obstetric pessary can be installed in periods from 14 to 34 weeks. In case of progression of shortening of the cervix to 2.5 cm (or less) or an increase in the diameter of the internal pharynx to 8 mm (or more), in addition to the pessary, surgical sutures. Removal of the pessary and removal of sutures for PCN is carried out in a hospital setting at the 37th – 38th weeks of pregnancy.

Thus, ICI is one of the most common causes of abortion before 33 weeks. This problem has been sufficiently studied and adequately corrected ICI in 87% or more allows achieving desired results. At the same time, correction methods, methods of monitoring their effectiveness, as well as the question of optimal timing surgical treatment remains controversial to this day.

For many reasons, the muscles of the uterus become weakened, the cervix shortens and softens, this indicates that isthmic-cervical insufficiency develops during pregnancy. The pathology is characterized by the inability to hold the fetus inside the womb; the cervix cannot function fully.

Symptoms of isthmic-cervical insufficiency during pregnancy

The body of the uterus, where the fetus develops over 9 months, narrows towards the bottom, forming a cone-shaped passage consisting of an internal part (cervix) and an external part (vagina). Between the cervix and the cavity there is a restriction in the form of a pharynx (muscle ring) and a mucous plug, which hold the baby inside the womb and prevent the penetration of infections.

Isthmic-cervical insufficiency (ICI) during pregnancy is caused by the inability to hold the developing embryo in the cavity. Symptoms for this pathology are often absent or mild:

• There is a feeling of pressure in the vaginal area, a slight pain syndrome;
• discomfort in the lower abdomen;
• discharge interspersed with blood.

Due to practically asymptomatic, with such a pathology, additional tests and measurements are required to establish accurate diagnosis and start timely treatment.

Signs and sensations of cervical insufficiency during pregnancy

Signs of ICI during pregnancy are determined using indirect indicators. Ultrasonography together with a medical examination, they make it possible to clarify the length, opening and density of the cervix. If the size is less than 20 mm, and the organ is very soft, then this becomes a risk factor for premature labor.

Until the 20th week of gestation, this indicator is not an indicative criterion, since the cervix is ​​not yet sufficiently formed and can be variable.

The causes of ICI are divided into functional and traumatic. The latter appear due to frequent abortions, miscarriages or as a result of trauma during previous births. Injured tissues of the pharynx form adhesions that are unable to stretch and contract.

The main cause of functional pathology is hormonal disbalance, which manifests itself in a lack of progesterone or an excess of androgens. Often, infection of the fetal membrane becomes a decisive factor in diagnosing ICI. Harmful bacteria thin the tissues, the growing fetus exerts pressure, thus opening the pharynx, and premature labor begins.

The formation of pathology is influenced by the presence of uterine malformations, polyhydramnios, or fertilization of more than one egg.

Treatment of isthmic-cervical insufficiency

Treatment caused by hormonal changes involves the use of drug therapy in order to normalize progesterone or androgens. Also, they may recommend installing a unloading pessary (Meyer ring) to continue pregnancy until 37 weeks. This method works as a support for the internal os, distributing the main weight of the uterus around the entire perimeter.

In case of diagnosing progressive ICI, use surgery when the neck is sutured. The procedure lasts no more than 15-20 minutes under general anesthesia and no later than 25 weeks.

At around 36-37 weeks, the sutures are removed as the baby and his internal organs already formed and will be able to function independently.

It is worth remembering that isthmic-cervical insufficiency is very dangerous pathology during pregnancy. Therefore, absolute rest is necessary, sitting as little as possible and eliminating sex life to keep the fetus healthy until birth.

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

Risk factors for ICI are listed below.

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

DIAGNOSTICS ICN

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

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

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

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

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

PREPARATION FOR PREGNANCY

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

CLINICAL PICTURE (SYMPTOMS) ICI

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

TREATMENT OF ICI

Treatment of ICI depends on the presence of pregnancy.

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

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

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

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

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

Activities required in postoperative period, are given below:

– bacterioscopy of vaginal discharge;

– correction of microbiocenosis;

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

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

Indications for removing sutures from the cervix are listed below:

– gestational age 37 weeks;

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

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

IN last years V clinical practice received wide use the least traumatic method of correcting ICI using a pessary - a Meyer ring, placed on the cervix.

ICI during pregnancy has absolutely different reasons. All causes form two types of failure, traumatic and functional. Let's look at the main causes of these two types of deficiency.

1. The traumatic type of ICI, as the name implies, is caused by various types cervical injuries. They arise due to any expansion of the uterus, this can include abortion, miscarriage, diagnosis of fetal curettage in case of miscarriage. Injuries can also occur after childbirth due to artificial insemination.
2. At the site of injury, a scar develops, which consists of connective tissue. Connective tissue does not stretch, which leads to the cause of the appearance of ICN.
3. With functional insufficiency the situation is worse. Various factors may be the cause here. In most cases this is a failure hormonal levels. This includes excess male hormones– androgens, or lack of progesterone. develop this problem maybe around the 11th week of pregnancy, as a result of which the cervical muscle becomes weak and opens.
4. More serious causes of the development of this disease may be polyhydramnios, especially if the pregnancy is multiple. In this case, the load on the uterus is doubly large, which leads to insufficiency.
5. Pathologies in the development of the uterus may also be the cause.

At an appointment with an obstetrician-gynecologist All tips Treatment
doctor on monitor studying
care during pregnancy pain

How to recognize the problem and its signs

It is quite difficult to independently recognize ICI during pregnancy; in particular, in the early stages, its symptoms are almost invisible or completely absent. More noticeable signs may appear after the second trimester; it is very important to see them in time to prevent miscarriage.

To do this, it is advisable to check with your obstetrician-gynecologist in a timely manner. The doctor conducts an examination using a speculum, ultrasound, or digital vaginal examination.

At an appointment with an obstetrician-gynecologist

Possible signs.

1. The appearance of bloody discharge streaked with blood.
2. Severe pain in the lower abdomen or lower back.
3. A feeling of “fullness” in the vaginal area or strong pressure to this area.
4. Shortening or softening of the cervix.
5. During the examination it will be visible amniotic sac and opening of the channel, which is also a sign of ICN.
6. When performing an ultrasound, ICI can be determined by such criteria as the length of the cervix, it should be from 36 to 46 mm, and closer to childbirth - 29-36 mm. If the length is less than these indicators, then the doctor diagnoses ICI.
7. Ultrasound will also help identify another reason - this is a V-shaped opening of the pharynx. It is detected by applying pressure to the fundus of the uterus.

If the doctor confirms the presence of one of the signs, he will immediately prescribe treatment and correction, and in more difficult situations sends the pregnant woman for safekeeping. Also find out.

What to do if you notice signs

Only your gynecologist can diagnose ICI during pregnancy, but if you notice signs of this disease, you should immediately seek help from a doctor. Do not delay your appointment with the doctor under any circumstances, otherwise this could result in miscarriage or premature birth. This problem is very serious consequences, you should start treatment immediately.

1. The first thing to do is see a doctor.
2. Next, the doctor will conduct a diagnosis and accurately establish the diagnosis, its presence or absence.
3. After which the pregnant woman should lead a quiet lifestyle, limit activity to the maximum, physical exercise.
4. If you have ICN, you should not engage in sports while carrying a child; you should abstain from sexual activity during the entire period.
5. This problem also requires the use of special medications that will reduce tone.
6. When hormonal disorders, which subsequently led to the appearance of ICI, a qualitative correction is necessary to balance the level of hormones in the body.

The most important thing is to see a doctor in time. With constant examination and supervision by a doctor, this problem can be avoided. Protect yourself and your baby, ICN is serious problem, which cannot be delayed.

Medical treatment

On this moment There are two ways to treat ICI. These include:

• standard conservative method correction and treatment that does not require surgical intervention;
• an operable method that requires the intervention of a surgeon, as well as an operation.

Conservative treatment is safer for the mother and baby. It is performed on an outpatient basis and is completely safe at any stage of pregnancy. But, unfortunately, this option is suitable only in the case of an uncomplicated course of the disease, with minor changes in the cervical area.

Correction in the case of non-surgical treatment is carried out using a pessary. This device is an obstetric ring that is placed on the cervix and reduces the load by redistributing the pressure evenly, acting as a kind of bandage.

All advice given by the obstetrician-gynecologist should be carefully followed.

You should not be afraid of the installation process of this device; it is painless, even without painkillers. After this, the pregnant woman should be constantly under the supervision of a doctor.

Remove the device last weeks pregnancy, the process is also harmless and painless. If a woman in labor suddenly experiences bleeding, the device is immediately removed before the end of the wearing period.

Surgical methods of treating the problem

If ICN is detected for more than late stages it cannot be done without surgical intervention. At the moment there are many proven operational methods treatment of ICN during pregnancy. If happened anatomical changes in the uterus, it is carried out surgical treatment, but only after pregnancy. In this case, the necessary plastic surgery is performed.

During pregnancy, indications for the need for surgical treatment are as follows:

• the woman’s experience of miscarriages;
• previous pregnancy ended prematurely;
• there is uterine insufficiency.

In addition, surgical intervention is required for shortening, laxity of the pharynx and the entire cervical canal.

Surgical treatment of ICI during pregnancy cannot be performed if the woman in labor:

• malformation of the fetus;
• bloody issues;
• chronic diseases.

This disease also provokes infection of the cervical area. Therefore, it is necessary to take smears for analysis and conduct research in order to prescribe additional treatment.

How does surgical treatment occur?

At surgical treatment During pregnancy, ICN is sutured from a special material on the cervix. The sutures block the opening of the cervix, which becomes easier to cope with the load. It is best to apply stitches at the 17th week of pregnancy, but this decision is chosen entirely individually.

Surgery in later stages of pregnancy is less effective, so it is worth solving this problem as quickly as possible. Sutures are placed under internal anesthesia. Are used special drugs, which cause minimal risk to the fetus, as well as to the woman in labor. After the procedure, medications are prescribed that reduce tone.

In the first days after surgery you should take antibacterial drugs and treat the sutures and cervix with special antiseptics. About a week after the operation, the pregnant woman can be discharged from the hospital. But every two weeks there is a mandatory examination by a doctor. Sutures are removed at approximately 38 weeks of pregnancy.

Labor may begin a day after the stitches are removed, but if contractions begin while stitches are present, you should go to the hospital immediately and tell your doctor that you have stitches. Sutures can be removed at any stage of pregnancy, but if premature birth they can rupture and injure the uterus.

Why you shouldn't ignore the problem

The threat of ICI during pregnancy cannot be ignored categorically. Due to the dilation of the cervix, the fetal bladder descends, the fetal membrane becomes infected and its premature opening occurs. These consequences lead to:

• the onset of premature birth;
• the birth of a premature baby.

For more early stages late miscarriage occurs during pregnancy.

Installation of a special device

Ignoring the problem can lead to:

• inflammation of the amniotic sac;
• the occurrence of bleeding;
• rupture of the amniotic sac;
• cervical injury;
• congenital anomalies in the development of your baby.

Isthmic-cervical insufficiency can lead to functional disorders connective tissue, dysplasia and hyperandrogenism.

Such a threat is a significant factor in order to undergo high-quality and competent, and, most importantly, timely treatment for ICN. In addition to miscarriage and premature pregnancy, this problem will bring a lot of trouble to the mother in labor and after childbirth. Immediate surgical intervention will be required to restore the condition of the uterus, and it will also appear serious injury this area.

Disease prevention

As with any disease, after treatment with ICI during pregnancy, high-quality prevention is required, which includes the following measures.

1. If you are planning a second pregnancy, abortion must be excluded.
2. Before becoming pregnant, it is best to get examined by a doctor to identify the presence of all possible chronic gynecological diseases and cure them before pregnancy.
3. In order to exclude possible appearance problems, you should immediately register with the antenatal clinic at the beginning of pregnancy. This should be done before week 11.
4. You should see your healthcare provider regularly for check-ups. And pregnant women who are at risk should visit the doctor much more often and monitor the condition of the reproductive organ.
5. It is best to perform an ultrasound assessment of the uterus if there is a risk of ICI during pregnancy.

If you were diagnosed with ICI during pregnancy and treated, do not forget that after childbirth you also need additional care. This includes examining cervical ruptures, performing cervical plastic surgery if necessary, as well as treating hormonal disorders.

Don’t forget to follow a routine, avoid physical activity and get plenty of rest. Also find out about and.