Pregnancy preparation tactics for patients with uterine malformations

Preparation of women with uterine malformations for pregnancy should be carried out taking into account the anamnesis and the type of uterine malformation. Very often a woman has normal reproductive function and does not suspect that she has an underdeveloped uterus. According to Simon C. et al. (1991), uterine malformations were detected during sterilization in 3.2% of women with normal reproductive function. According to Stampe Sorensen S. (1988), unsuspected bicornuate uterus was detected during laparoscopy for sterilization in 1.2% of patients, intrauterine septum in 3.2% of fertile women and saddle-shaped uterus in 15.3% of patients.

In addition to uterine malformations, patients with habitual pregnancy loss experience uterine fibroids, isthmic-cervical insufficiency, and chronic endometritis.

When preparing for pregnancy, it is necessary to exclude the presence of bacterial and/or viral infection, hormonal disorders. If the functional diagnostic tests do not correspond to the hormonal parameters, it is necessary to exclude damage to the receptor apparatus of the endometrium.

Preparation for pregnancy consists of the results of examination. This may include antibacterial, antiviral, immunomodulatory therapy. Normalization of the second phase of the cycle by using cyclic hormonal therapy in combination with physiotherapy (electrophoresis Ca), sea flexotherapy.

If conservative methods of pregnancy preparation and pregnancy management do not allow the pregnancy to be successfully completed, surgical treatment of the uterine malformation may be recommended. Particularly good results are observed when removing the intrauterine septum during hysteroscopy. Most researchers recommend inserting an IUD or Foley catheter after removing the septum and prescribing cyclic hormonal therapy for 2-3 cycles, then removing the IUD and using cyclic hormonal therapy for another 2-3 cycles.

In case of malformations in the form of a bicornuate uterus, metroplasty according to the Strassmann method is recommended. The operation consists of dissecting the uterine horns, excising the upper part of the uterine horns, and forming the uterus. After the operation on the uterus, an IUD is inserted into the cavity for 3 months to prevent the formation of adhesions and cyclic hormonal therapy is performed. If the postoperative period is favorable, the IUD is removed after 3 months, and a control hysterosalpingography is performed. After 6-7 months, hormone levels are assessed, and functional diagnostic tests are performed. If all parameters are within normal limits, then pregnancy is allowed after 5-9 months.

When assessing the significance of surgical treatment and conservative, many researchers have obtained data that surgical treatment does not provide great advantages. Thus, according to research data, in groups of women with a bicornuate uterus and with a septum in the uterus, the pregnancy outcome was favorable in 52% and 53% of women before surgical treatment and 58% and 65% after surgical treatment in the same patients.

If conservative methods of preparation and pregnancy management in women with uterine malformations are ineffective, it is necessary to clarify the form of the malformation and accompanying changes in the malformation architecture and the condition of adjacent organs. Magnetic resonance imaging (MRI) can be performed for these purposes, during which the form of the uterine malformation and, possibly, the accompanying pathology are clarified. After clarification of the clinical situation, reconstructive plastic surgery can be proposed in each specific case. The use of endoscopic access allows these operations to be performed in full, as well as to perform a one-time correction of concomitant gynecological pathology (adhesions, endometrioid foci, myoma, etc.). The effectiveness of reconstructive plastic surgeries is increased by the use of modern methods, in particular, the use of a harmonic scalpel, which causes less tissue trauma, complete organ reparation and a decrease in adhesion formation.

Reconstructive plastic surgery for intrauterine septum is performed using hysteroscopy.

Surgical intervention for bicornuate uterus using the Strassman method, but laparoscopic access using hysteroscopy and an ultrasonic scalpel at the same time, ensures minimal tissue trauma. In this regard, the pregnancy outcome was favorable in 84% of women.

In case of uterine malformations, pregnancy termination in the first trimester is also observed quite often due to unfavorable implantation, decreased vascularization, and an incomplete second phase of the cycle. During these periods, pregnancy is rarely terminated due to uterine malformations, more often due to concomitant disorders - NLF, chronic endometritis.

When preparing for pregnancy, patients with intrauterine adhesions are recommended to destroy adhesions during hysteroscopy. A modern method of destroying adhesions is surgery using a laser. After surgery, as with removal of the uterine septum, it is advisable to insert an IUD, conduct cyclic hormonal therapy, and physiotherapy.

When pregnancy occurs, such patients are managed in the same way as patients with NLF and isthmic-cervical insufficiency.

Thus, after examination and preparation for pregnancy, pregnancy can be allowed if:

1. normal hemostasis parameters;
2. normal general blood test results;
3. 2-phase cycle;
4. no IgM antibodies to herpes simplex virus, cytomegalovirus;
5. no viruses in "C" by PCR method;
6. normal levels of proinflammatory cytokines;
7. normal interferon status indicators;
8. normocenosis of the vagina;
9. The husband's sperm count is within normal limits.