Isthmiko-cervical insufficiency( ICI) in pregnancy - Causes, symptoms and treatment. MF.

Isthmicocervical insufficiency( ICI) is a pathological condition characterized by insufficiency of the isthmus and cervix of the uterus, leading to spontaneous termination of pregnancy in the II and III trimesters of pregnancy. In other words, it is a condition of the cervix during pregnancy, in which it begins to thin out, becoming soft, shortening and opening, losing the ability to retain the fetus in the uterus in terms of up to 36 weeks. ICN is a common cause of miscarriage in terms of 16 to 36 weeks.

Causes of the Nos.

Causes of the NIs are divided into:

- organic ICD - as a result of previous cervical injuries during labor( breaks), curettage( for abortion / miscarriage or for the diagnosis of certain diseases), in the treatment of diseases, for example,erosion or polyps of the cervix by the method of conization( excision of part of the neck) or diathermocoagulation( cauterization).As a result of the injury, normal muscle tissue in the neck is replaced with a scar, which is less elastic and more rigid( harder, stiffer, inelastic).As a result, the neck loses its ability to contract and stretch, and, accordingly, can not completely contract and retain the contents of the uterus inside.

- functional ICD , which develops for two reasons: due to a violation of the normal ratio of connective and muscle tissue in the cervix or a violation of its susceptibility to hormonal regulation. As a result of such changes, the cervix becomes too soft and supple during pregnancy and opens as the pressure from the growing fetus increases. Functional PTS can occur in women with ovarian failure or can be congenital. Unfortunately, the mechanism of development of this type of NIC has not been sufficiently studied. It is believed that in each individual case it is individual and there is a combination of several factors.

In either case, the cervix is ​​unable to resist the pressure of the growing fetus from within the uterus, which leads to its opening. The fetus descends into the lower part of the uterus, the fetal bladder protrudes into the cervical canal( prolapses), which is often accompanied by infection of the fetal membranes and the fetus itself. Sometimes as a result of infection, there is a discharge of amniotic fluid.

The fruit falls lower and further presses 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 ICD

There are no clinical manifestations of ICP during and outside pregnancy. The consequence of the NIH in the II and III trimesters is the spontaneous termination of pregnancy, which is often accompanied by premature discharge of amniotic fluid.

Out of pregnancy, ischemicocervical insufficiency does not threaten anything.

Diagnosis of ICI in pregnancy

The only reliable method of diagnosis is a vaginal examination and examination of the cervix in the mirrors. When vaginal examination, the following signs are detected( individually or in combination with each other): shortening of the cervix, in severe cases - sharp, softening and thinning;the external pharynx can be both closed( more often in primiparas), and gape;Cervical( cervical) canal can be closed or missing the tip of the finger, one finger or two, sometimes with breeding. When viewed in mirrors, the gaping of the external pharynx of the cervix with a prolapse( protruding) fetal bladder can be detected.

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

Complications of ICI during pregnancy

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

Treatment of ICI in pregnancy

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

Operative treatment of ICP

The operative method is to apply sutures to the cervix to narrow it, and is performed only in the hospital. There are different methods of suturing, their effectiveness is almost the same. Before treatment, ultrasound of the fetus is produced, its intrauterine status, the location of the placenta, and the condition of the internal pharynx are evaluated. Of laboratory tests, it is always necessary to analyze the smear on the flora and, in case of inflammatory changes in it, treat it. The operation is performed under local anesthesia, after the operation the patient is prescribed antispasmodic and pain medications for preventive purposes for several days.

After 2-3 days evaluate the consistency of the joints and if they are in a favorable condition, the patient is discharged under the supervision of a doctor of a woman's consultation. Complications of the procedure can be: increased uterus tone, prenatal outflow of amniotic fluid, infection of the sutures and intrauterine infection of the fetus.

In the absence of effect and progression of the NIC, prolongation of pregnancy is not recommended, as the sutures can erupt, causing bleeding.

Contraindications for suturing the uterus are:

- untreated infections of the genitourinary system;
- the presence in the past of pregnancy interruptions in the II and III trimesters( habitual miscarriage);
- presence of intrauterine malformations of the fetus, incompatible with life;
- uterine bleeding;
- severe concomitant diseases, which are contraindication for prolonging pregnancy( severe cardiovascular diseases, impaired renal and / or liver function, some mental illnesses, severe gestosis of the second half of pregnancy - nephropathy of II and III degrees, eclampsia and preeclampsia);
- an increase in the tone of the uterus, which is not amenable to drug treatment;
- progression of ICI - rapid shortening, softening of cervix, opening of internal pharynx.

Conservative treatment of the ICD

A non-operative method is to narrow the cervix and prevent its opening by installing a pessary. Pessary is a ring 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 be used only in cases where the cervical canal is closed, i.e., in the early stages of the NISC or if it is suspected, and may also be an addition to the suturing.

Every 2-3 days, the pessary is removed, disinfected and re-installed. The method has less efficiency, unlike the first one, but it has several advantages: bloodlessness, ease of implementation and the absence of the need for inpatient treatment.

Prognosis of pregnancy outcome with ICD

The prognosis depends on the stage and form of the NIC, on the presence of concomitant infectious diseases and on the duration of pregnancy. The less the gestation period and the more the cervix is ​​open, the worse the prognosis. As a rule, with early diagnosis, pregnancy can be prolonged in 2/3 of all patients.

Prevention of ICD

It consists in careful curettage, examination and suturing of cervical ruptures after childbirth, cervical plastic surgery in case of detection of old ruptures outside of pregnancy, treatment of hormonal disorders.

Doctor obstetrician-gynecologist Kondrashova DV