Management tactics with Isthmiko-cervical insufficiency at pregnancy

In recent years, a transvaginal echographic study has been used to monitor the condition of the cervix. In order to assess the state of the isthmic department of the cervix and for prognostic purposes, according to the consolidated literature data, AD Lipman et al. (1996), the following points should be considered:

• The length of the cervix, equal to 3 cm, is critical for the threat of termination of pregnancy in the first-pregnancy and re-pregnant with a period of less than 20 weeks and requires intensive monitoring of the woman with its classification as a risk group.
• In women with multiple pregnancy up to 28 weeks, the lower limit of the norm is the length of the cervix, equal to 3.7 cm - for the first-pregnant, 4.5 cm - for re-pregnancy (pritravsginal scanning).
• In the case of multiple-birth women, the normal cervical length of 13-14 weeks is 3.6-3.7 cm without a statistically significant difference in healthy women and patients with ischemic-cervical insufficiency. On ismiko-cervical failure indicates the shortening of the cervix in 17-20 weeks to 2.9 cm.
• The length of the cervix, equal to 2 cm, is an absolute sign of miscarriage and requires appropriate surgical correction.
• When evaluating the information length of the cervix, it is necessary to take into account the method of its measurement, since the results of the transabdominal ultrasound study significantly differ from the transvaginal results and exceed them by an average of 0.5 cm.
• The width of the cervix at the level of the internal pharynx normally increases gradually from the 10th to the 36th week from 2.58 to 4.02 cm.
• A prognostic sign of the threat of termination of pregnancy is a decrease in the ratio of the length of the cervix to its diameter at the level of the internal throat to 1.16 + 0.04 at a rate equal to 1.53 + 0.03.

The change in the above parameters of the cervix is significantly affected by the low location of the placenta and the tone of the uterus.

To diagnose "isthmico-cervical failure" only according to ultrasound is not enough. More accurate information can be obtained only when examining the cervix in the mirrors, with vaginal examination - the identification of the soft and short cervix.

Treatment of pregnant women with ischemic-cervical insufficiency

Methods and modifications of surgical treatment of isthmic-cervical insufficiency during pregnancy can be divided into group sodium:

1. mechanical narrowing of the functionally defective inner throat of the cervix;
2. stitching of the external throat of the cervix;
3. narrowing the cervix by creating a muscular duplication along the lateral walls of the cervix.

The method of narrowing the cervical canal by creating a muscular duplication along its lateral walls is the most pathogenetically grounded. However, it has not been widely used due to complexity, and also because it is unacceptable with the expressed shortening of the cervix, cicatricial changes, old ruptures.

The method of narrowing the internal pharynx of the cervix is used more widely for all variants of ischemic-cervical insufficiency. In addition, the methods of constriction of the internal pharynx are more favorable, since during these operations a drainage hole remains. When the outer throat is sewn in the uterine cavity, a closed space is formed, which is unfavorable if there is a latent infection in the uterus. Among the operations that eliminate the inferiority of the internal pharynx of the cervix, the most widely used modifications are the Shirodkar method: the MacDonalda method, the Lyubimova circular seam, the U-shaped seams according to the Lyubimova and Mammadaliyeva method. When sewing the outer throat of the cervix, Czendi method is most often used, with narrowing of the cervical canal - a modification of the Teryan method.

Indications for surgical treatment of ischemic-cervical insufficiency are as follows:

• the presence in the anamnesis of spontaneous miscarriages and premature birth (in the II-III trimester of pregnancy);
• progressive, according to clinical examination, insufficiency of the cervix: a change in consistency, the appearance of flabbiness, a shortening, a gradual increase in the "gaping" of the external throat and the entire cervical canal and the opening of the internal pharynx.

Contraindications to surgical treatment of ismiko-cervical insufficiency are:

• diseases and pathological conditions, which are contraindication to the preservation of pregnancy (severe forms of diseases of the cardiovascular system, liver, kidneys, infectious, mental and genetic diseases);
• increased excitability of the uterus, which does not disappear under the influence of medicamentous agents;
• pregnancy, complicated by bleeding;
• malformations of the fetus, the presence of a non-developing pregnancy according to objective research (ultrasound scan, the results of a genetic examination);
• III-IV degree of purity of the vaginal flora and the presence of pathogenic flora in the canal of the cervix. It should be noted that erosion of the cervix is not a contraindication to surgical correction of ischemic-cervical insufficiency, unless pathogenic microflora is released. In this case, it is advisable to apply methods of narrowing the internal pharynx of the cervix. The Czendi method is contraindicated.

Surgical correction of ischemic-cervical insufficiency is usually carried out in the period from 13-27 weeks of pregnancy. The duration of the operation should be determined individually, depending on the time of the onset of clinical manifestations of ischemic-cervical insufficiency. The results of microbiological studies show that with surgical correction of ischemic-cervical insufficiency later than 20 weeks, as well as in the prolapse of the bladder at any time of pregnancy, opportunistic pathogens are sown in large quantities from the cervical canal significantly more often compared with those operated at 13-17 weeks pregnancy.

For the prevention of intrauterine infection, it is advisable to perform surgery at 13-17 weeks, when there is no significant shortening and opening of the cervix. With the increase in the duration of pregnancy, the inadequacy of the "blocking" function of the isthmus leads to a mechanical lowering and prolapse of the fetal bladder. This creates the conditions for infection of the lower pole by its ascending path - from the lower genital tracts to the background of the violation of the barrier antimicrobial function of the contents of the cervical canal. In addition, the fetal bladder, penetrating into the cervical canal, contributes to its further expansion. In this regard, surgical intervention in later terms of pregnancy with severe clinical manifestations of ischemic-cervical insufficiency is less effective.

The following methods of surgical correction of ischemic-cervical insufficiency are suggested:

The method of sewing the cervix in a circular suture by MacDonald

In aseptic conditions, the cervix is exposed using vaginal mirrors. The Muco tongs grasp the anterior and posterior lips of the cervix and pull them up and down. On the border of the transition of the mucous membrane of the anterior vaginal fornix to the cervix, a suturing suture is laid, the ends of the strings are knotted in the anterior vault of the vagina. As a suture material, you can use lavsan, silk, chrome-plated catgut. In order to prevent the eruption of tissues during tightening of the pouch, it is advisable to insert the dilator Geghar No. 5 into the cervical canal.

Instead of the sutured suture, the method of MacDonald uses a modification of VK Lysenko. Et al. (1973). Capron or lavsan thread is carried in the submucosal layer of the vaginal part of the cervix at the level of the vault with a puncture in the anterior and posterior arches. The ends of the ligatures are connected in the front arch. The submucosal circular arrangement of the filament ensures uniform cervical integrity throughout the circumference and excludes slipping of the filaments.

Circular seam by the method of Lyubimova AI

The essence of this method consists in narrowing the isthmic part of the cervix in the region of the internal pharynx with a thread of copper wire in a polyethylene sheath, without dissection and multiple piercing of the cervix. In aseptic conditions, the cervix is exposed in mirrors, and gripped with Myso forceps. Copper wire in a polyethylene cover is fixed with four lavsan or silk sutures on the anterior, posterior and lateral walls of the cervix closer to the internal throat. The wire is gradually tightened with a clamp. In order not to overtighten the wire and cause a disruption in the supply of cervical tissue to the canal, expander Geghar No. 5 is placed. The circular suture is placed on the surface of the mucous membrane. Its relaxation is eliminated by simply twisting the wire with a soft clamp. A circular suture is applied with a sufficient length of the cervix and no gross deformity.

U-shaped seams on the cervix by the method of Lyubimova AI and N.Mamedaliyeva.

In aseptic conditions, the cervix is exposed using vaginal mirrors. The Muco tongs grasp the anterior and posterior lips of the cervix and pull them up and down. At the border of the transition of the mucous membrane of the anterior layer of the vagina to the cervix, leaving 0.5 cm from the middle line on the right, the cervix is pierced with a needle with a filament of lavsan through the entire thickness, having made a pin in the posterior fornix. Then the end of the thread is transferred to the lateral arch on the left, the needle is pierced by the mucosa and part of the cervical column with a puncture in the anterior arch at the level of the first incision. Thread ends are taken on the clamp. The second lavsan thread is also carried through the entire thickness of the cervix, making an injection 0.5 cm to the left of the midline. The end of the second lavsan thread is transferred to the lateral arch on the right, then pierce the mucous membrane and part of the cervical mass with a puncture in the anterior arch. The ends of the thread are tightened and tied with three knots in the front arch. In the vagina for 2-3 hours a tampon is inserted.

Modification of Orekhov LG and Karakhanova G.V. Teryan's method

Narrowing of the cervical canal by creating a muscular duplication along the lateral walls of the cervix. After proper treatment, the cervix is exposed in the mirrors, the front and back lips are grasped with Myso forceps and pull the cervix anteriorly and downward. At 3 and 9 o'clock, the mucous membrane of the vaginal portion of the cervix is cut longitudinally into the vaults (by 2 cm) and separated by 0.5 cm in the sides. From the muscular tissue on both sides, by applying 3-4 catgut sutures, a duplicate (without excision of tissues). For this purpose, the needle is drawn closer to the edge of the cut off mucosa with the capture of a sufficient portion of the muscular layer sideways and into the interior. The needle is removed from the needle, slightly short of the middle line. The same needle with a thread is performed by a similar grip of the muscle tissue on the other half from the midline. When tying the thread, the muscle tissues trapped in the depth are protruded, creating a duplication that helps narrow the lumen of the cervical canal. The mucous membrane is sutured with separate catgut sutures. To assess the effectiveness of the duplication at the time of application and tying of sutures into the channel of the cervix uterus, expander Gegar № 5 is introduced. If the operation is successful, the walls of the cervical canal closely surround the expander.

Treatment of ischemic-cervical insufficiency with coarse ruptures of the cervix from one or both sides (the method of treatment proposed by Sidelnikova, VM et al., 1988).

In the lateral (or lateral) rupture of the cervix, it is advisable to create a duplicate of the torn portion of the cervix.

The first sash is applied using the MacDonald method, starting the pouch just above the cervical rupture. Then the second seam is carried out as follows: below the first circular weld by 1.5 cm, through the thickness of the wall of the cervix from one edge of the rupture to the other circularly along the spherical circle thread is carried. One end of the thread splits inside the cervix into the posterior lip and, after picking up the side wall of the cervix, a pin is made in the anterior arch by twisting the torn front lip of the cervix as a cochlea. The second part of the thread is pierced by the lateral wall of the cervix, and is removed into the anterior arch. The filaments are connected.

Along with the operations aimed at eliminating the gaping of the internal pharynx by superimposing a circular seam, methods of treatment of ischemic-cervical insufficiency by sewing the outer throat of the cervix can be used.

The most widely used method was Czendi B. (1961). The cervix is exposed in the mirrors. With the help of soft intestinal clamps, fix the foreleg of the cheek of the uterus and excise the mucous membrane with a width of 0.5 cm around the external pharynx. Then fix the posterior lip and cut out the mucous membrane with a width of 0.5 cm in the outer throat area. After this, the anterior and posterior lip of the cervix is sewn between themselves separate catgut or silk sutures. In the vagina for 2-3 hours, insert a tampon.

Czendi surgery is ineffective in the deformation of the cervix and prolapse of the bladder. This type of surgical intervention is inexpedient to carry out with cervical erosions, suspicion of latent infection and abundant mucus in the cervical canal.

The method of WedenW. Et al. (1960): after exposing the cervix in the mirrors in the front and back of the lips, a flap 1-1.5 cm wide is cut. The anterior and posterior lips of the cervix are sewn in the anterior-posterior direction by separate sutures. The resulting "bridge" prevents the prolapse of the fetal bladder. On the sides there are holes for the outflow of the contents of the cervical canal.

Management of the postoperative period with istrmico-cervical insufficiency without prolapse of the fetal bladder

In case of surgery on the cervix by the methods of McDonald, Lyubimova, the imposition of U-shaped sutures on the cervix, the narrowing of the canal by the method of Orekhov and Karakhanova is allowed to get up and walk right after the operation. During the first 2-3 days with a prophylactic purpose prescribe antispasmodics: a suppository with papaverine, but-spawn to 0.04 g 3 times a day, magne-Vb. In case of increased excitability of the uterus, it is advisable to use beta-mimetics (ginipral, salgim, partusist or briikanil) 2.5 mg (1/2 tablet) or 1.25 mg (1/4 part of the tablet) 4 times a day for 10- 12 days. In this period of pregnancy, the uterus does not always respond to beta mimetics. With an increase in the tone of the uterus in the II trimester, it is more appropriate to use indomethacin in tablets of 25 mg 4 times a day, or in suppositories of 100 mg once a day for 5-6 days. With the preventive purpose it is possible to recommend carrying out acupuncture, magnesium electrophoresis with a sinusoidal modulated current.

In the first 2-3 days after the operation, the neck is examined with the help of mirrors, treatment of the vagina and cervix with a 3% solution of hydrogen peroxide, a solution of furicillin 1: 5000, boroglycerol or cicerol (5-6 ml), miromistin, pliquosept.

Antibacterial therapy is prescribed for extensive erosion and the appearance of a stab-shear in the blood formula, taking into account the sensitivity of the microflora to antibiotics. It is necessary to consider the possibility of adverse effects of drugs on the fetus. In this situation, the drugs of choice are semi-synthetic penicillins, which are most widely used in obstetric practice. However, you can also use cephalosporins and gentamicin, vilprafen. Most often the patient is administered ampicillin at a dose of 2.0 g per day for 5-7 days. At the same time, nystatin is prescribed for 500,000 units 4 times a day. In the uncomplicated course of the postoperative period, the pregnant woman can be discharged for outpatient monitoring 5-7 days after the operation. On an outpatient basis, the cervix is examined every 2 weeks. Lavasanovye seams are removed in 37-38 weeks of pregnancy. After removing the joints on the neck, a dense fibrous ring is defined.

In an operation using the Czendi method or its modification, the pregnant woman is allowed to get up on the 2-3 day after the operation. Treatment of the vagina and cervix with a 3% solution of hydrogen peroxide, a solution of furacillin (1: 5000), boroglycerin or cicerol, dioxydin, miramistin, pliquosept in the first 4-5 days produced daily, then every other day or depending on the condition of the cervix. Catgut sutures are rejected after 9 days. Silk and lavsan seams are removed on the 9th day. In the area of the external throat, an effective operation determines the scar.

Antibacterial drugs and beta-mimetics are prescribed depending on the clinical situation, as in the operation with suturing the inner throat of the cervix.

Management of postoperative period with ischemic-cervical insufficiency with prolapse of fetal bladder

When the prolapse of the bladder is a method of choice for surgical correction of ischemic-cervical insufficiency, the method of imposing U-shaped sutures is used. The procedure of the operation is the same as described above, but the fetal bladder is filled with a moist tampon. Carefully apply lavsan seams and, pulling them, gently remove the tampon. After the operation, bed rest is prescribed for at least 10 days. To reduce the pressure of the presenting part and the bladder to the lower segment of the uterus, the foot end of the bed is raised by 25-30 cm.

In connection with the fact that with the prolapse of the fetal bladder, favorable conditions are created for infection of its lower pole, all pregnant women are treated with antibacterial therapy. The antibiotic is selected taking into account the sensitivity of the isolated bacteria to it. At microbiological research at the moment of prolapse of a fetal bladder, 2-3 types of microorganisms are most often found: escherichia and enterococcus, mycoplasma and streptococcus of group A or B, mycoplasmas, klebsiella and enterococci.

As antibacterial agents most often prescribed ampicillin at a dose of 2.0 g per day for 5-7 days. It is possible to use cephalosporins of the third generation, vilprafen. At the same time, the activation of viral infection is prevented: immunoglobulin, viferon, imunofan. Arsenal of antibacterial drugs in pregnancy is limited due to the adverse effects of some of them on the fetus. It should be noted that antibiotic therapy often gives a short-term effect. In repeated studies, there is often a change in some conditionally pathogenic bacterial species by others. Apparently, in conditions of prolonged hospitalization against a background of a reduced immunological status, conditions favorable for the selection of hospital strains of microorganisms are created. Elimination of certain types of microorganisms with the help of medicines creates conditions for the population of the biotope not with the conventional conditionally pathogenic flora, but resistant to the used drugs by hospital strains of conditionally pathogenic microorganisms. Simultaneously with antimicrobial agents should use immunoglobulin in a dose of 25.0 ml of intravenous drip № 3 every other day. With a decrease in IgA levels, allergic reactions to immunoglobulin may occur. To reduce allergic reactions, you can use immunoglobulins, such as Octagam in a dose of 2.5 g 2 times with an interval of 2 days. For preventive maintenance of complications prescribe plentiful drink (tea, juice, mineral drink). Before the introduction of immunoglobulin, it is advisable to administer antihistamines. To normalize immunity, it is advisable to use imunofan 1.0 ml intramuscularly once a day for 10 days.

In addition to antibiotic therapy, daily sanitation of the vagina is prescribed, treatment of the cervix with a 3% solution of hydrogen peroxide, a solution of furacillin 1: 5000, dioxin. To treat the cervix, you can use sintomitsinovuyu emulsion, tsigerol, boroglycerin, after 5-6 days - rosehip oil, sea buckthorn, miromistin, plivosept. For the prevention of contractile activity, the uterus is prescribed beta mimetics - ginipral, salgim, partusisten or briikanil in a dose of 0.5 ml in 400 ml of isotonic sodium chloride solution by intravenous drip, and then switch to the tablet preparation 5 mg 4 times a day, gradually reducing dose to 5 mg per day. The treatment is carried out for 10-12 days, at the same time isopin is prescribed to 0.04 g 3-4 times a day. At the end of tocolytic therapy or, if necessary, to reduce the dose and duration of beta mimetics, magnesium electrophoresis and spasmolytic treatment are performed. With an increase in the tone of the uterus, it is advisable to treat indomethacin in tablets or candles. Patients with this pathology should be in the hospital for 1-1.5 months, depending on the course of pregnancy and possible complications. In the future, outpatient monitoring of the course of pregnancy is carried out: every 2 weeks, the cervix is examined in mirrors. Sutures are removed in 37-38 weeks of pregnancy.

The most common complication after surgical correction of ischemic-cervical insufficiency with the use of lavsan, silk, nylon sutures is the eruption of the cervical tissue with a thread. This can occur, firstly, in the event that there is contractile activity of the uterus, and the seams are not removed; secondly, if the operation is technically wrong and the cervix is overstretched; in the third, if the tissue of the cervix is affected by the inflammatory process.

In these cases, when applying circular seams on MacDonald or Lyubimova, bedsores are possible, and later fistulas, transverse or circular detachments of the cervix. When the Π-shaped sutures are erupted, the cervical rupture occurs mainly on the posterior lip, where the sutures intersect. In case of eruption seams should be removed. Treatment of wounds on the cervix is carried out by washing the wound with dioxin, using tampons with cicerol, sintomycin emulsion, rosehip oil, sea-buckthorn.

In the presence of pathogenic microflora in the cultures of the cervical canal, antibiotics are prescribed taking into account the sensitivity of the isolated microorganisms to them. In the future, when the wound is wound on the cervix, the operation can be repeated. With the impossibility of repeated surgical correction, conservative therapy is shown, consisting in prolonged observance of bed rest in a bed with an elevated leg end and the appointment of medications aimed at removing the excitability of the uterus. Raise the foot end of the bed is not possible with infection, colpitis phenomena.

Non-surgical correction methods

In recent years, non-surgical correction methods have been described. For this purpose, various pessaries are used. You can use the Golgi ring.

Non-surgical methods have a number of advantages: they are bloodless, extremely simple and are applicable in outpatient settings. Treatment of the vagina and the pessary ring should be carried out with furicillin and boroglycerin every 2-3 weeks to prevent infection. These methods can be used for functional ischemic-cervical failure if only softening and shortening of the cervix is observed, but the cervical canal is closed, if there is a suspicion of isthmico-cervical insufficiency for prevention of cervical dilatation.

With severe manifestations of ischemic-cervical insufficiency, these methods are of little effect. However, the ring-shaped pessary and the Golgi ring can be used after sewing the cervix to reduce pressure on the cervix and prevent more severe consequences of ischemic-cervical insufficiency (fistulas, cervical ruptures).

Due to the fact that it is often difficult to draw a line between functional and organic ischemic-cervical insufficiency, and also because this pathology occurs in patients with hyperandrogenism, at which the level of progesterone is high, we do not apply for the treatment of ischemic-cervical insufficiency large doses of progesterone, in addition, it is necessary to consider the possibility of adverse virilizing effects on the fetus of large doses of progesterone.

Thus, the timely diagnosis of ischemic-cervical insufficiency and rational etiotropic therapy with the help of medicamentous and non-medicament means aimed at removing the symptoms of the threat of interruption contribute to the prolongation of pregnancy and favorable perinatal outcomes.