Isthmic-cervical insufficiency: prevention and treatment. Treatment of isthmic-cervical insufficiency during pregnancy, symptoms, causes and prevention of ICI
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.
ICN - very serious pathology, which 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. During the 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 is trauma to the cervix during childbirth, abortion, and cervical surgery. Moreover, abortions are 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 cervical ruptures and subsequently cause isthmic-cervical insufficiency. However, external ruptures of the cervix do not affect pregnancy; only damage to the internal os poses a danger.
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 an 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 may also influence cervical health.
The infection itself cannot be the cause of isthmic-cervical insufficiency, but it significantly increases the risk of miscarriage. Also, an additional risk factor is smoking and 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.
You can determine the ICN using ultrasound examination, take into account, first of all, the length of the cervix, 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 the rupture of 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. In later stages, when suturing is impossible, 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 a short cervix, 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 isthmic-cervical insufficiency allows you to take appropriate measures and prevent pregnancy loss.
Any mother wants the pregnancy to proceed without complications, and the child to be born on time and to be completely healthy. Unfortunately, this does not always happen: pregnancy can often be accompanied by a number of complications. But to panic when you hear from a doctor about possible problems, not worth it. You need to know your enemy by sight, so I’ll try to find out more about one of the complications of pregnancy from a gynecologist at the antenatal clinic.
Isthmic-cervical insufficiency (ICI) is the 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 leaving the uterine cavity prematurely. 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).
Types of ICN
- Traumatic ICN
It is believed that during various (pre-pregnancy) intrauterine interventions associated with cervical dilatation, the integrity of the cervical muscle ring may be damaged. At the site of damage to any organ, a scar is formed, consisting of connective tissue and incapable of contraction and stretching. The same thing happens with the cervix. In this case, interventions mean such manipulations as, for example, abortions, diagnostic curettages, etc. In addition, the formation of connective tissue in place of muscle can occur after sufficiently deep ruptures of the cervix during previous births. - Functional ICN
Functional ICI occurs when there are hormonal disorders in the body - usually due to a deficiency of progesterone or an excess of androgens (male sex hormones).
ICI appears at 11–27 weeks of pregnancy, usually at 16–27 weeks.
It is during this period of intrauterine development that the adrenal glands begin to function in the fetus - an endocrine organ that secretes androgens, among other hormones. If this additional amount of male sex hormones “falls on the basis” of the pregnant woman’s already existing even slightly increased own level of androgens (or the woman has increased sensitivity to them), then under their action the cervix softens, shortens and opens. In this case, the tone of the uterus may be normal, and a woman, if she does not regularly visit a doctor, may not be aware of the formation of ICI.
How to understand that something is wrong
The basis for diagnosing this type of pathology is a visual and manual assessment of the extent of the problem. It is carried out only during pregnancy; there simply cannot be a question about isthmic-cervical insufficiency outside of pregnancy. The most reliable way to make a diagnosis is to conduct a vaginal examination in a gynecological chair, and then examine the cervical area using vaginal speculum.
When conducting these studies, the following types of signs may be detected: 
- shortening the length of the neck;
- its softening, sometimes very pronounced;
- thinning of the cervical area;
- the external pharynx in primigravidas will be closed or gaping;
- the cervical canal (inside the cervix) can be either closed or allowing the tip of a finger to pass through, and in severe cases it allows one finger or two fingers of the doctor to pass through, sometimes even with separation;
- in severe cases, examination in the speculum may reveal the opening of the external pharynx in the cervical area with the fetal bladder protruding into this area. Sometimes, if a vaginal examination in early stages the development of insufficiency in the cervical area does not show any special data; an ultrasound examination helps to determine the beginning of problems, which will show the expansion of the internal pharynx.
Saving the fetus
To treat isthmic-cervical insufficiency in pregnant women, surgical and non-operative methods can be used.
Surgery
Indications for surgical treatment of isthmic-cervical insufficiency during pregnancy are:
- history of spontaneous miscarriages (in the II-III trimester of pregnancy);
- progressive dysfunction of the cervix: a change in its consistency (softening) and shortening, a gradual increase in the gaping of the external pharynx and expansion of the entire canal of the cervix with opening of the internal pharynx.
Contraindications to surgical treatment of isthmic-cervical insufficiency are:
- diseases and pathological conditions in which continuation of pregnancy is contraindicated (severe forms of diseases of cardio-vascular system, liver, kidney, infectious, mental and genetic diseases);
- increased excitability of the uterus, which does not disappear under the influence of medications;
- pregnancy complicated by uterine bleeding;
- fetal deformity or non-developing pregnancy, confirmed by data objective research(ultrasound, cytogenetic);
III-IV degree of vaginal cleanliness and the presence of pathogenic flora in the discharge of the cervical canal.
The operation is usually performed between the 11th and 27th weeks of pregnancy. The timing of the operation is determined individually depending on the time of occurrence of clinical manifestations of isthmic-cervical insufficiency. In order to prevent intrauterine infection, it is advisable to perform surgery at 13-17 weeks. pregnancy, when there is no significant shortening and dilatation of the cervix. With increasing pregnancy, insufficiency of the obturator function of the uterine isthmus leads to mechanical descent and prolapse of the fetal bladder, which creates conditions for its infection. In addition, the amniotic sac, penetrating into the cervical canal, promotes its further expansion, therefore surgery in later stages of pregnancy with severe clinical manifestations isthmic-cervical insufficiency is less effective.
Main methods surgical treatment are mechanical narrowing of the functionally and (or) anatomically defective internal os of the cervix and suturing of the external os of the cervix. Operations that eliminate the inferiority of the internal os of the cervix are more physiological, because after operations, a drainage hole remains for the outflow of secretions from the uterus. These include various modifications of the Shirodkar method: U-shaped sutures according to the method of Lyubimova and Mamedalieva, a circular suture according to the Lyubimova method, a purse-string suture according to the McDoneld method. In the USSR, the most common operation is to apply U-shaped sutures to the cervix using the method of Lyubimova and Mamedalieva; it is the method of choice for prolapsed amniotic sac (the amniotic sac is first directed into the uterine cavity with a tampon).
The operation of applying a circular suture using the Lyubimova method
Consists of narrowing the internal pharynx of the cervical canal using a copper thread wires in a polyethylene sheath without cutting and repeated piercing of the vaginal mucosa. A purse-string suture according to MacDonald is placed at the border of the transition of the mucous membrane of the anterior part of the vaginal vault to the cervix, the ends of the threads are tied in the anterior part of the vaginal vault; Dacron, silk, and chrome-plated catgut are used as suture material.
After applying U-shaped sutures according to the method of Lyubimova and Mamedalieva, pregnant women with prolapsed membranes are prescribed bed rest for at least 10 days. To reduce the pressure of the presenting part and the amniotic sac on the lower segment of the uterus, the foot end of the bed is raised by 25-30 cm. Due to the fact that when the amniotic sac prolapses, favorable conditions are created for infection of its lower pole, antibacterial therapy is mandatory. The antibiotic is selected taking into account the sensitivity of the isolated microflora to it. More often, ampicillin is used (2 g per day) for 5-7 days.
In addition to antibacterial therapy, the vagina and cervix are treated daily with a 3% hydrogen peroxide solution and furatsilin solution (1:5000). The cervix can be treated with 5% or 10% liniment of synthomycin, cigerol, 5-6 days after surgery - rosehip oil, sea buckthorn. To prevent contractile activity of the uterus for 10-12 days, b-adrenergic agonists are used - partusisten or bricanil. Initially, they are administered intravenously, 0.5 mg per 400 ml. isotonic solution sodium chloride, then prescribed orally 5 mg 4 times a day, gradually reducing the dose to 5 mg per day. At the same time, use isoptin 0.04 g 3-4 times a day.
At the end of tocolytic therapy or if it is necessary to reduce the dose and duration of use of b-adrenergic agonists, magnesium electrophoresis and treatment with antispasmodics are performed. Patients must remain in the hospital for 1-11/3 months. Subsequently, outpatient monitoring is carried out: every 2 weeks. The cervix is examined using vaginal speculum. Sutures are removed at 37-38 weeks. pregnancy in hospital.
Scendi method
Among the methods of treating isthmic-cervical insufficiency by suturing the external os of the cervix, the Scendi method is the most widely used: after excision of the mucous membrane around the external os of the cervix, the anterior and posterior lips of the cervix are sutured together with separate catgut or silk sutures. When the external pharynx is sutured, a closed space is formed in the uterine cavity, which is very unfavorable if there is a hidden infection in the uterus. The Scendi operation is not effective for deformation of the cervix and prolapse of the amniotic sac; it is not advisable to carry out it in cases of cervical erosion, suspected hidden infection and copious amounts of mucus in the cervical canal.
After surgery using the Scendi method, the pregnant woman is allowed to get up on the 2-3rd day. Treatment of the vagina and cervix with a 3% solution of hydrogen peroxide, furatsilin solution (1:5000) or tsigerol is carried out daily in the first 4-5 days, then depending on the condition of the cervix. Catgut sutures are rejected after 9 days, silk and lavsan sutures are removed on the 9th day. In the area of the external pharynx, with effective surgery, a scar is identified, which is easily destroyed with the onset of labor. Antibacterial drugs and beta-agonists are prescribed in the same cases as after surgery with suturing of the internal os of the cervix.
After operations that eliminate the functional and (or) anatomical inferiority of the internal os, patients with isthmic-cervical insufficiency without prolapse of the membranes are allowed to stand up and walk immediately. During the first 2-3 days, suppositories with papaverine (0.02 g), no-shpa 0.04 g 3 times a day, and magnesium electrophoresis on the suprapubic area are prescribed for prophylactic purposes. In case of uterine excitability, b-adrenergic agonists are indicated - partusisten or bricanil 2.5 mg or 1.25 mg orally 4 times for 10-12 days. In the first 2-3 days after surgery, the cervix is examined using vaginal speculum and the vagina is treated and cervix with 3% hydrogen peroxide solution, furatsilin solution (1:5000) or tsigerol.
Possible complications after surgery
Most a common complication after surgical treatment of isthmic-cervical insufficiency using lavsan, silk, nylon sutures, the tissue of the cervix is cut through with a thread. This may occur in the following cases:
- if it occurs contractile activity uterus, but the stitches are not removed;
- if the operation was performed incorrectly and the cervix is tightened with sutures;
- if there are inflammatory changes in the cervix.
When applying circular sutures using the McDoneld or Lyubimova methods, 
the formation of bedsores, and subsequently fistulas, transverse or circular separations of the cervix. When tissue is cut through with U-shaped sutures, the rupture occurs mainly on the posterior lip of the cervix, where the sutures intersect.
If these complications occur, the sutures should be removed. To treat a wound on the cervix, tampons with cigerol, 5% or 10% synthomycin liniment, rosehip oil, and sea buckthorn are used. If the contents of the cervical canal are detected in cultures pathogenic microflora antibiotics are prescribed taking into account the sensitivity of the isolated microorganisms to them. In the future, when the wound on the cervix heals, the operation can be performed again. If repeated surgical correction is not possible, long-term bed rest in a bed with the foot end elevated and the prescription of drugs that reduce uterine excitability are indicated.
Is it possible to do without surgery?
Non-operative methods of treating isthmic-cervical insufficiency include the use of various vaginal pessaries (Goggia, Meyer rings). Non-operative methods have a number of advantages: they are bloodless, extremely simple and can be used in outpatient setting. Every 2-3 weeks. the vagina and pessary are treated with furatsilin solution (1:5000) to prevent infection.
Non-operative methods can be used for functional isthmic-cervical insufficiency, if only softening and shortening of the cervix is observed, but the cervical canal is closed, as well as if cervical insufficiency is suspected to prevent cervical dilatation. For severe manifestations of isthmic-cervical insufficiency, non-operative methods are not very effective. However, pessaries can be used after suturing the cervix to reduce pressure on the cervix and prevent complications (fistulas, cervical ruptures).
The prognosis with timely and rational treatment is favorable: the incidence of miscarriage is reduced by 2-3 times.
Prevention includes:
- careful delivery and expansion of the cervical canal during abortion to avoid damage to the internal os of the cervix;
- timely treatment of hormonal disorders of ovarian function.
Pessary insertion procedure
Maria Sokolova
Reading time: 9 minutes
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Main components female uterus are the body and neck. If the pregnancy proceeds normally, the fetus is located in the body of the uterus, and the muscles of the cervix are closed in a tight ring.
But sometimes muscle tissue can weaken prematurely, causing dire consequences. The danger of isthmic-cervical insufficiency lies in its asymptomatic nature: the true cause is often found out after a miscarriage or premature birth.
However, even with such a diagnosis, you can carry and give birth to a baby: the main thing is proper preparation and timely treatment.
Why is isthmic-cervical insufficiency dangerous?
Due to the inability of the muscle ring to cope with the load that the weight of the fetus puts on it, it begins to gradually open up.
All this can lead to the following consequences:
- Dropping of the fetus. The fetal membrane enters the uterine cavity, which can be damaged by sudden movement.
- Infection in the amniotic sac. This pathology occurs due to contact of the membrane with the vagina, which contains many different harmful microorganisms.
- Miscarriage at the beginning of the third trimester of pregnancy.
- Premature birth (after 22 weeks).
PPI often develops after the 16th week of pregnancy. Although in some cases such a defect can be diagnosed as early as 11 weeks.
Causes of ICI during pregnancy – who is at risk?
The pathology in question can arise against the background of several situations:
- Injury due to surgical procedures above the uterus/cervix: curettage for diagnostics; abortions; in vitro fertilization. These procedures lead to the appearance of a connective tissue scar that does not resolve over time.
- Miscarriages.
- Childbirth. In some cases, a gynecologist-obstetrician may use special tweezers to rupture the amniotic sac. This can negatively affect the integrity of the uterus. Risk factors also include abnormal positioning of the fetus.
- Disruptions in hormonal levels. The second most popular reason for the appearance of the disease in question is an excess of androgens (male hormones) in the blood. With hormonal disorders, PPI may appear as early as 11 weeks of pregnancy. It is during this period that the formation of the pancreas in the fetus occurs, which contributes to the entry of an additional portion of androgens into the blood of the expectant mother.
- Increased pressure on the walls of the uterus. Occurs with polyhydramnios, if the fetus is heavy, or with multiple births.
- Congenital anomalies of the uterus.
Signs and symptoms of isthmic-cervical insufficiency during pregnancy
Often, pregnant women who have this pathology do not have any complaints. Therefore, it will be possible to identify ICN only through transvaginal ultrasound . Here the doctor will take into account the length of the cervix (in the third trimester of pregnancy it should average 35 mm) and the shape of the opening of the internal pharynx. To accurately visualize the shape of the pharynx, a small test should be carried out: the pregnant woman is asked to cough or press on the fundus of the uterus.
Regular examinations with a local gynecologist also help to identify ICI in pregnant women, but they are not as effective as hardware examination. Many doctors limit themselves to examining the abdomen, measuring blood pressure in pregnant women - and that’s all. But to notice the softening of the cervix and a decrease in its parameters is possible only with the help of a gynecological speculum.
In some patients, the disease in question may manifest itself in the form of the following symptoms:
- Nagging pain in the lower abdomen and lumbar region.
- Vaginal discharge. They can be red or transparent with streaks of blood.
- Discomfort in the vagina: regular/periodic tingling, feeling of pressure.
Conservative and surgical methods of treatment of ICI during pregnancy
This pathology can be eliminated only after identifying the reasons that provoked its appearance.
Taking into account the duration of pregnancy, the condition of the fetus and membranes, the doctor may prescribe the following type of treatment:
- Hormone therapy. It is indicative if ICI developed against the background hormonal imbalances in organism. The patient must take hormonal medications for 10-14 days. At the expiration of of this period re-inspection is carried out. If the situation has stabilized, continue taking hormones: the dosage is determined by the doctor. If the situation worsens, the treatment method changes.
- Ustanovka . Relevant at the initial stage of development of the pathology in question. At later stages, the Meyer ring is used as aid treatment.
During the procedure, a small plastic structure is placed in the vagina to secure the cervix. This helps relieve pressure and maintain pregnancy. The ring can be used at almost any stage of pregnancy, but it is removed at 37 weeks.
Since by its nature this structure is a foreign body, smears are regularly taken from the patient to examine the vaginal microflora. Additionally, preventive sanitation with antiseptics is prescribed.
- Stitching.
This method of surgical treatment of IPC can be used in the following cases:
- Early pregnancy (up to 17 weeks). In exceptional situations, the operation is performed at a later date, but no later than 28 weeks.
- The fetus develops without abnormalities.
- The uterus is not in good shape.
- The amniotic sac is not damaged.
- The vagina is not infected.
- There is no discharge mixed with blood.
The suturing operation takes place in several stages:
- Diagnostics. A few days before the procedure, vaginal smears are taken; blood and urine tests are carried out.
- Preparatory stage. Provides for vaginal sanitation.
- The actual operation. Performed under local anesthesia. The operator stitches the internal os of the uterus with silk threads. After this, the manipulation area is treated with antiseptic drugs.
- Postoperative period.
To minimize complications, the following medications may be prescribed:
- Antispasmodics: drotaverine hydrochloride.
- Antibiotics: if necessary.
- Tocolytic therapy: ginipral, magnesia. Required if the uterus is in good shape.
Every 2 weeks you need to take smears from the vagina and check the condition of the sutures.
In a normal pregnancy, the sutures are removed in the gynecological chair at the 38th week. If there are exacerbations in the form of bleeding, leakage of amniotic fluid, the sutures are removed. After eliminating negative phenomena, it can be carried out reoperation for suturing.
Rules for planning and pregnant women with ICN - how to get pregnant and carry a child to term?
Women who are planning a pregnancy and have previously experienced miscarriages/premature births due to PPI, The following recommendations must be followed:
- After miscarriage/premature birth There is no need to rush into your next pregnancy. Several months must pass before the body and psyche recover. In addition, a complete examination is necessary to determine the cause of CPI.
- When planning a pregnancy, you need to get tested for infections, hormones, check the functioning of the thyroid gland. To exclude pathology in the structure of the genital organs, ultrasonography is performed.
- To exclude concomitant gynecological pathologies may be assigned endometrial biopsy. This procedure will give a complete picture of the condition of the uterus.
- Male partners need to go through the planning stage examination by a urologist-andrologist.
Pregnant women diagnosed with PPI should remember the following important points:
- Physical activity should be minimized , or generally limit yourself to bed rest. Here everything will depend on the specific case and past experience. But even if the CPI responds positively to treatment measures, it is still better to shift household chores to loved ones.
- Sexual contacts should be excluded.
- Scheduled visits to your local gynecologist are mandatory. Often, patients diagnosed with IPC undergo sutures at 12 weeks of pregnancy. Those with a Meyer ring should have pap smears every 14 days to prevent infection.
- The right psychological attitude is also important. Pregnant women should protect themselves as much as possible from stressful situations and think about good things. In such cases, motivating videos and meditations help a lot.
All information in this article is provided for educational purposes only; it may not be relevant to your specific health circumstances and does not constitute medical advice. The website сolady.ru reminds you that you should never delay or ignore visiting a doctor!
Expecting a child is a period that brings moments that are not always pleasant. Weight increases, constipation occurs, and a rash appears on the body. Sometimes another significant problem is isthmic-cervical insufficiency.
ICI is a pathology characterized by the opening lower section the uterus, which holds the fetus in the womb. During a normal pregnancy, organs grow along with the baby. If there is insufficiency, the uterus cannot function normally.
Features and symptoms of isthmic-cervical insufficiency during pregnancy
For women who were unable to get pregnant, the pathology does not pose a danger. However, if a representative of the fairer sex is carrying a child under her heart, ICI threatens to lead to the opening of the internal pharynx in the third trimester.
Statistics say that the likelihood of losing a fetus carried by a woman with isthmic-cervical insufficiency increases 16 times. Patients affected by this pathology at 7–9 months account for 50% of total number who have had the disease.
There are women in the world with isthmic-cervical insufficiency who were able to give birth to a child. However, such births proceed quickly. This fact can negatively affect the further development of the baby. It cannot be said that for such women childbirth takes place calmly. Injuries may occur, accompanied by heavy bleeding.
A woman will not be able to identify the disease, since for many pregnant women ICI occurs without symptoms. In rare cases, if abortions or functional curettages were performed, signs of insufficiency in the first 13 weeks resemble manifestations of other diseases:
- spotting with blood streaks;
- discomfort in the lower abdomen and lumbar region of the back.
In the later stages of pregnancy, as experts note, the following symptoms may appear:
- discharge that has increased in volume and changed consistency;
- frequent emptying of the bladder;
- pressure in the middle part of the pelvic cavity;
- distension in the perineum;
- pain under the abdomen and in the lumbar region;
- cough.
Reasons for the development of pathology during pregnancy
To make it easier to familiarize yourself with the factors for the development of pathology, a list is presented below. The disease can manifest itself due to the following reasons:
| Organic | Functional | Congenital |
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In all cases, the thinned lower segment of the uterus cannot resist the pressure of the growing baby, resulting in dilatation. The fruit continues to sink lower, reproductive organ opens wider, miscarriage or unplanned early birth occurs.
Doctors note that deficiency does not always occur for only one reason. Pathology can develop as a result of the presence of several diseases.
Diagnostic methods
It is very difficult to identify a deficiency in the subject. The exceptions are indicators such as anatomical changes that occur after injuries and some developmental deviations.
Doctors note that the main indicator of ICI is a shortened lower segment of the uterus. When examining a pregnant woman, a physician may reveal flaccid edges and dilatation of the transition of the cervix into the body of the uterus. The latter easily passes the gynecologist’s finger. However, not all doctors perform genital examinations. Many people are only interested in changes in weight, abdominal volume, blood pressure and pulse. Such an incomplete examination will not help the gynecologist detect ICI and its causes, therefore it is in the interests of the pregnant woman herself to insist on a thorough examination.
According to clinical protocol, when examining a woman, doctors should pay special attention to the location of the amniotic sac. Modern medicine distinguishes the following degrees of protrusion of membranes:
- above the upper opening of the cervix;
- at the level of the internal pharynx;
- below the top hole;
- in the organ of the internal reproductive system.
However, determining the degree of protrusion of the amniotic sac does not always help to detect an illness in the expectant mother. In primiparous women, the external os is closed, there are no signs of pathology, and risk factors cannot be identified using a gynecological instrument until childbirth.
In this situation, ultrasound will help. The results of the examination allow the doctor to refute the supposed ICI if the length of the cervix at the 6th month of pregnancy is 3.5–4.5 cm, at 7 months – 3–3.5 cm. After the 8th month of pregnancy, the length of the lower segment of the uterus should be 3 cm.
At what period can ICN cause spontaneous abortion? The threat of miscarriage or premature birth of the baby is indicated by a decrease in the length of the canal to 2.5 cm at a period of less than 28 weeks, V- or Y-shaped openings of the lower segment of the uterus and softening of its tissues. During the examination, the patient may be asked to cough so that the load on the uterus increases slightly.
The study is carried out with a transvaginal sensor. If echo signs confirm the pathology, the pregnant woman is prescribed medications. In addition, it will be necessary to monitor changes in the cervix twice a month.
It should be noted that even before pregnancy it is possible to find out whether a woman is developing the suspected pathology. To diagnose insufficiency, hysterosalpingography is done. Contrast agents are injected into the uterus and tubes and x-rays are taken. This method is effective, but doctors do not always have time to identify signs of pathology. Not all women are attentive to their body.
Conservative treatment
After a clinical examination, confirmation of the diagnosis and identification of the cause of the disease, the doctor prescribes the following medications to his patient for correction:
- vitamins, microelements;
- mild sedatives;
- drugs that relieve uterine tone (antispasmodics, tocolytics, etc.);
- fluoroquinolones or cephalosporins.
If the cause of the development of isthmic-cervical insufficiency is a hormone imbalance, the patient is prescribed replacement therapy. hormone therapy. The effect of treatment for ICI during pregnancy is aimed at restoring normal levels of biologically active substances.
The medication prescribed by the doctor should be continued for 7–14 days, after which the doctor should re-examine the patient. If the pregnant woman’s condition has not stabilized during treatment with ICN, the medication will continue. If the disease begins to progress again, the woman is offered other methods of combating the pathology.
The second way to correct the disease is to install an obstetric device (pessary). A plastic or silicone ring will support the lower segment of the uterus, redistribute the baby's weight and amniotic fluid. Meyer's ring, as a foreign object, can cause bacterial vaginosis, so it is important to remove it every 2 days and treat it with a disinfectant. A doctor should regularly take swabs for infection in a woman. If necessary, the doctor prescribes antibiotics to the expectant mother.
Obstetric pessary during pregnancy A woman who has an obstetric pessary fitted may experience constipation. The ring, as many patients note, seems to be pinching the passage. Pregnant women should not push, so the doctor must prescribe a mild remedy so that constipation stops bothering the woman.
Doctors note that a ring pessary can be installed at any stage of pregnancy. It is this device that doctors often advise pregnant women to treat the early stages of the disease. However, if the pathology is already pronounced, this device will become an auxiliary tool. The ring is removed after the first 2 weeks of the 9th month of pregnancy or when labor begins.
It is important to note that during treatment, a woman needs to give up physical activity and sexual intercourse. The expectant mother should avoid stressful situations, visit the doctor regularly and rest often. Another important point is the woman’s attitude. It is important to believe that doctors will help you get rid of ICN.
Surgical correction
In case of severe ICI, the doctor may insist on surgical correction - applying a horizontal, circular or seromuscular suture to the lower segment of the uterus. The operation is performed under general anesthesia at 13–27 weeks of pregnancy. The probability of having a healthy child will increase to 90%.
Before overlay surgical sutures The doctor must examine the expectant mother and take a smear from her. If necessary, the patient is prescribed treatment of the vaginal mucosa with antiseptics.
The doctor, based on the results of the tests, may refuse surgery for ICI. In particular, contraindications include:
- genetic abnormalities in the fetus;
- severe vaginitis;
- chronic diseases;
- intrauterine infection;
- bloody issues;
- complications of late toxicosis;
- violation of the muscle tone of the uterus;
- rapid development of ICN.
After the operation, which will take 15–20 minutes, the pregnant woman is prescribed the following medications according to indications:
- medications that relieve muscle spasms (Drotaverine, magnesia, etc. (we recommend reading: ).);
- medications whose action is aimed at relaxing the muscles of the uterus (Indomethacin, Ginipral, etc.);
- drugs containing hormones or hormonoids (Iprozhin, Endometrin, etc.).
During the recovery period, a woman should take care of herself and rest more often. Physical activity should be avoided.
Pregnancy is the most beautiful thing, but at the same time the most anxious time in the life of every woman. On the path to successful childbirth and happy motherhood, there are many obstacles that can provoke in the early stages.
One of these factors is ICI (isthmic-cervical insufficiency) - pathological condition, in which the muscles of the cervix are weakened so much that they are unable to cope with the increasing load.
To avoid complications or fatal outcome during pregnancy, every woman needs to know what ICI is and whether it is possible to prevent this pathology.
Definition
To understand why isthmic-cervical insufficiency (ICI) is dangerous, you need to know how the uterus works. The uterus is an organ that has a body and a cervix.
The fetus develops in the body, and the cervix helps keep it inside the cavity and protects it from infection.
The muscles of the cervix close during pregnancy and gradually relax towards childbirth. However, sometimes they relax earlier, then the cervix becomes unable to hold the fetus inside the uterus and opens under the pressure of the baby’s weight.
This is ICI - a condition when the muscles of the cervix weaken prematurely.
At the same time, the amniotic sac descends into the uterine cavity, the membranes are at risk of infection, open, and contractions begin. This can lead to miscarriage or premature birth - if labor begins in the third trimester.
Important! As a rule, a miscarriage with isthmic-cervical insufficiency begins with leakage of amniotic fluid or its discharge. However, it is painless.
ICI is a rare phenomenon, occurring in 1-9% of pregnant women, but women with so-called recurrent miscarriage - when a woman has three or more miscarriages in a row - are at greater risk. Mothers with this diagnosis face isthmic-cervical insufficiency in 15-42% of cases.
Causes
Depending on the causes of its occurrence, ICI occurs in two types: functional and traumatic (anatomical).
Traumatic ICI occurs in cases where, even before pregnancy, the cervix was “compromised” by some damaging factors.
Functional causes arise against the background of an increase in the level of the male hormone - androgen.
It is known that the female vagina is populated by a mass of bacteria, and with colpitis (an inflammatory process in the vagina), the number of these microorganisms increases significantly. This circumstance plays important role with existing isthmic-cervical insufficiency.
When the cervix shortens and opens slightly, the fertilized egg (lower pole) becomes infected, the membranes become soft, losing their strength and the amniotic fluid contained in them is poured out.
Most often, cervical insufficiency develops due to anatomical and functional factors.
Anatomical
Pathological changes in internal os occur due to traumatic injuries to the cervix. Typically this happens due to:
- artificial medical abortions;
- intrauterine diagnostic studies;
- birth injuries (cervical ruptures).
After any traumatic injury cervical canal Scar tissue forms, which subsequently leads to cervical incompetence during pregnancy.
Doctors believe that with various intrauterine interventions prior to pregnancy associated with the expansion of the uterine cervix, the integrity of the muscle ring (sphincter) can be damaged. At the site of such damage, a scar is formed from connective tissue, which is not capable of either contraction or stretching.
Intervention in this situation means such manipulations as, for example, diagnostic curettage, medical abortions, etc. In addition, the growth of connective tissue instead of muscle can occur after fairly deep ruptures of the uterine cervix, during previous delivery.
One of the possible damaging factors is also considered to be previous inflammatory processes affecting the cervix: cervicitis, endocervicitis, endocervicosis, colpitis, and so on.
The development of isthmic-cervical insufficiency can also be provoked by previous or existing cervical dysplasia (erosions) (including after treatment).
Functional
Nervous regulation ensures the consistency of contraction and relaxation of the uterine muscles: long-term increase the tone of the uterus leads to relaxation of the cervix, and when it is in a calm state, the internal and external pharynx are always closed. Inconsistency of innervation can cause ICI, and these situations arise with the following problems:
- hyperandrogenism;
- malformations or underdevelopment of the uterus;
- a pronounced decrease in hormonal activity of the ovaries.
In addition, the viability of the cervix is affected by Negative influence infection in the vagina (specific or banal colpitis, bacterial vaginosis, candidiasis) and pressure of the presenting part of the fetus.
The most common causes of functional ICI are hormonal disorders the body, usually occurring with an excess of androgens or a lack of progesterone.
Functional ICI usually manifests itself between eleven and twenty-seven weeks of pregnancy. At this stage of intrauterine development, the adrenal glands begin to work in the growing fetus - an endocrine organ that, among other hormones, secretes androgens.
If this additional volume of male sex hormones falls on the “fertile ground” of a woman’s already existing even slightly increased own level of androgens (or the pregnant woman has hypersensitivity to them), then under their influence the cervix softens and, as in childbirth, shortens and opens.
What’s interesting is that uterine hypertonicity is most often not observed, so a woman who does not visit a gynecologist may not be aware of the presence of ICI.
Symptoms and diagnosis
Unfortunately, this disease occurs without any obvious symptoms. Sometimes a woman is bothered by a pulling sensation in the lower abdomen, abundant mucous membranes streaked with blood, or spotting bloody discharge from the vagina.
Some pregnant women experience slight tingling in the vaginal area, bloating or pressure. And many people don’t notice anything at all.
It is impossible to detect the disease on your own, at home. Moreover, even timely visits to the doctor will do nothing if the woman is not regularly examined in the chair. Doctors pay special attention to those patients who have previously been diagnosed with ICI - during previous pregnancies.
Important! If a previous miscarriage had symptoms similar to ICI, you should tell your doctor about it at the first appointment.
In the future, when isthmic-cervical insufficiency has already developed, symptoms such as spotting, pain in the lower back or lower abdomen, and a feeling of pressure in the vagina can be detected. These are signs of a threatened miscarriage. It is important to remember: ICI can be completely asymptomatic.
Often, a doctor may not diagnose isthmic-cervical insufficiency immediately, since usually a woman does not present any complaints. Typically, the disorder is detected only when examining the expectant mother in a chair and using an ultrasound:
- Inspection on the chair. The gynecologist examines the cervix and evaluates its length and consistency, whether it is slightly open, whether the fingertip is missing, or whether there are scars on it. If a woman may experience traumatic ICI due to previous problems, then the doctor should monitor the condition of the cervix every week or once every two weeks starting from the 12th week of pregnancy.
- On ultrasound. When examined in a chair, the doctor cannot always estimate the length of the cervix in centimeters, so if he has an assumption that the pregnancy will be complicated by ICI, the specialist sends the expectant mother for an ultrasound. This study is carried out starting from the first trimester of pregnancy. Shortening of the neck to 2-2.5 cm indicates a violation and requires surgical treatment.
The doctor determines ICI by examination with mirrors, digital examination of the vagina, or ultrasound. It can detect shortening of the cervix, its softening, and dilatation.
The obstetrician-gynecologist can also perform a test - for example, ask the pregnant woman to cough or press on the fundus of the uterus. With isthmic-cervical insufficiency, the cervix may open slightly under such influences. An ultrasound is performed using a vaginal probe - the length of the cervix is less than two centimeters and the diameter is more than one centimeter - alarming symptoms.
If all studies confirm the development of ICI, the doctor makes a decision on treatment methods and the possibility of continuing the pregnancy.
During the first examination in the first trimester of pregnancy, the doctor must assess the condition of the cervix - length, density, location, condition of the external os. Normally, the cervix should be dense and long (up to 4 cm), with a closed external os.
During the first ultrasound examination at 11-14 weeks, the doctor must perform cervicometry, i.e. assess the length and consistency of the cervix.
If the doctor notices a discrepancy, for example, it seems too short, or if the woman has already had premature birth in the past, as well as miscarriages or abortions, the doctor will order regular examinations every two weeks to carefully monitor the condition of the cervix.
The danger of ICN also lies in the fact that a pregnant woman may not notice the bad changes that are occurring in her body. The uterine os can open painlessly.
Sometimes there are minor nagging pain and very scanty bleeding. The first suspicion of cervical incompetence will arise during a doctor's examination or ultrasound.
For those women who are pregnant for the first time, the length of the cervix, detected using ultrasound cervicometry, should not fall below 30 mm. The optimal length of the cervical canal will be from 36 to 40 mm.
Important! If, during cervicometry, the doctor finds a cervical size of 29 mm or lower, then treatment is necessary to maintain the pregnancy.
Treatment
Once a deficiency is detected, usually in the case of large quantity hormones, doctors are trying to correct the situation through various medications. If the excess is of a traumatic nature, then it is possible surgical intervention.
Then follows a long process of healing and caring for the sutures, since during this period bacteria can accumulate on the sutures on the uterus, and an infectious process can form.
Conservative
The first and main conditions successful treatment Istmic-cervical insufficiency is bed rest and emotional rest. In the first case, the pressure of the amniotic sac on the cervix is reduced due to horizontal position expectant mother, and the opening is suspended.
Well, in the second case, it is important not only the absence of stress, but also the positive attitude of the pregnant woman. Then the treatment will give positive results.
If the cause of isthmic-cervical insufficiency is functional and the disease develops due to an excess of hormones, especially androgens, drugs are prescribed that reduce this indicator and correct the level of hormones in the pregnant woman’s body.
After one or two weeks, the doctor examines the patient again - if the condition of the cervix is stable, then treatment is stopped, and the woman is simply observed throughout the pregnancy, paying special attention to the cervix. The doctor should regularly examine the cervix in order to detect the slightest changes in time.
Sometimes patients may have a Meyer ring - a pessary - placed in the vagina. The ring helps to redistribute the weight of the fetus, and the neck helps to hold it.
A plastic pessary is installed in the early stages of the disease or if cervical insufficiency is suspected. It is removed at 37 weeks or before birth.
Installation of a pessary is a painless procedure, so no anesthesia is required. If the ring is chosen correctly, the expectant mother will not feel it at all.
In order to improve the results, drugs that relax the uterus are prescribed along with the placement of the ring, hormonal agents to correct general hormonal levels with hyperandrogenism, and also prevent placental insufficiency (since it often occurs with ICI).
A pregnant woman is recommended to sanitize the vagina with antiseptics or, if necessary, prescribe antibiotics. This is done so that dysbiosis does not develop, which can be caused by the presence of a foreign body in the vagina.
There are a few important points things you need to know:
- Firstly, since the pessary is a foreign body in the vagina, the risk of infection increases, and to monitor the situation, the expectant mother will need to undergo a smear every 2-3 weeks.
- Secondly, after placing the ring, vaginal sex is prohibited.
The pessary, like sutures, is removed during full-term pregnancy or at the onset of labor. This procedure is completely painless.
Surgical
If drug treatment does not help or isthmic-cervical insufficiency has traumatic cause, the doctor decides on the surgical method of treatment. The operation involves suturing the cervix and is performed under anesthesia. In this case, the dosage and drugs are chosen to minimize the negative impact of anesthesia on the child.
The optimal time for surgery is 13-17 weeks, but if necessary, the doctor can suggest surgical correction up to 28 weeks.
The method of applying a U-shaped or circular suture to the cervix, closing the exit from the uterus, is used. Indications for surgery ICN correction are:
- the presence of two or more premature terminations of pregnancy in the 2nd trimester in the past;
- cervical length detected by ultrasound cervicometry is 20 mm or less;
- muscle incompetence in the cervical area discovered before pregnancy.
With such indications, the woman will be “sutured in” and she will most likely carry the pregnancy safely to 37 weeks (at this time the suture is removed).
The operation is most effective when the impact of the disease on the cervix is not yet so great. Non-absorbable sutures are placed on the cervix, which are removed by the 38th week of pregnancy, that is, at the moment when labor suddenly begins is not scary - the baby is full-term.
Before the sutures are removed, they are examined every two weeks. After removing the sutures, if there are complications, additional treatment.
Sutures can be removed earlier for several reasons: cutting through the sutures, rupture or leakage of amniotic fluid, the onset of labor, bleeding.
There are times when correction is necessary. This happens if the doctor, during an examination, finds a fertilized sac in the cervix. If the uterus often tenses, cutting of sutures may develop. To prevent this from happening, the pregnant woman is prescribed drugs that reduce the tone of the uterus - Magnesia, Ginipral, Papaverine.
If correction is not possible, the doctor prescribes bed rest and long-term use of tocolytics.
Surgery also has its contraindications. These are serious illnesses, non-developing pregnancy, congenital pathologies fetus, placenta previa.
In addition, the operation is performed under certain conditions: if the gestational age is at least 25 weeks, the amniotic sac is intact, the fetus is alive and has no malformations, and the tone of the uterus is normal.
The situation becomes much more complicated if the expectant mother has contraindications to this procedure.
- in the presence of acute vaginal infection;
- if the fetus has congenital malformations that are a contraindication to continuing the pregnancy;
- serious and dangerous diseases in a pregnant woman, in which it is impossible to bear or give birth;
- the presence of uterine bleeding of any intensity.
Childbirth with ICN
Due to the fact that this deficiency is characterized by the inability of the muscle ring to be in a closed state, childbirth with such complications occurs very quickly. Modern features allow the patient to bring the baby to the required period.
This is precisely why a hospital is needed, which allows for constant monitoring and does not provide opportunities for premature birth, which increases the possibility of miscarriage.
Unfortunately, this does not always work out. In case of early birth, the mother must be at the maternity hospital on time and have a folder with documents, a policy passport and an exchange card. It is very important not to forget the last element, because it contains the necessary information that obstetricians require in order to understand the situation in order to correctly deliver the child without complications.
Street notes that ICI is an infrequent occurrence, and if it is detected, there is no need to panic. After all, modern medicine makes it possible to cope with this pathology without any problems, especially with a timely diagnosis.
It is important not to be nervous and to comply with all the doctor’s requirements. Accept that you will have some physical changes that will be uncomfortable.
It is very important to control your diet when dealing with stress.
If you feel signs of neurosis, then try to dilute your diet with vegetables and fruits, without using special heat treatment. Timely rest is very useful in the fight against the mental influence of ICN.
Don't forget to sleep well, and we also recommend reading good books. Sometimes you can go for a walk fresh air, which will reduce the percentage of stress, but you don’t need to burden yourself for too long.
Remember that your psychological mood will play a very important role. Charge yourself with optimism, faith in the right outcome.
Fortunately, ICN does not appear so often, and if you are not at risk, then most likely this pathology It won't affect you. However, you should not be discouraged when you discover it.
Modern medicine has learned to deal with such a serious disease. The most important condition here is unquestioning execution medical recommendations. In addition, give up additional physical activity and lie down more.
Leave household chores in the care of your family and friends. Reception should not be ignored the necessary drugs, which will help solve this problem as quickly as possible.
Rehabilitation
After surgery, many questions arise. For example, is it possible for a woman to give birth on her own after such an operation or is this a direct indication for a cesarean section? How will your future health be? female organ?
After surgery, as a rule, women give birth on their own, after the stitches are removed. ICN is not an indicator of the need for caesarean section. Postpartum period proceeds in the same way as in other women in labor.
During and after treatment for isthmic-cervical insufficiency, the expectant mother must follow a regimen: reduce physical activity, avoid stress, visit a doctor, take prescribed medications in a timely manner, and get more rest.
When treating ICI, it is important not only to carry out therapy, but also to prolong pregnancy as much as possible.
A baby who is born to a mother diagnosed with “isthmic-cervical insufficiency” needs examination immediately after birth. And for some time afterward, the child should be observed and promptly examined in order to identify possible intrauterine infection, which could have occurred due to the fact that the cervix was slightly open.
A woman in labor with isthmic-cervical insufficiency is recommended to wait a couple of years for her next pregnancy, and before planning it, she needs to undergo necessary research and examination to eliminate the risk of relapse. Women with functional ICI are usually given appropriate therapy before their next pregnancy.
Important! Don't shy away from regular doctor's checkups. If your OB/GYN doesn't offer you such an exam, insist on having one anyway.
No matter how doctors correct the ICI, the expectant mother with this problem must adhere to the following rules:
- Minimize physical activity: stop playing sports, yoga, etc. You should rest more and, if possible, delegate household chores to loved ones.
- Avoid sexual contact. Like physical activity, this can provoke unwanted changes during pregnancy, so it is better to abstain until the baby is born.
- Do not lift weights - even if it is an older child. Any exercise stress can cause harm to the fetus or cause a miscarriage, so before childbirth and for the first time after it, you must avoid any exercise.
- Avoid stress. Equally important is a positive psychological attitude and belief in success.
- Visit your gynecologist regularly. Remember to take all your prescribed medications on time. At the slightest deterioration in your health, you should immediately go to your doctor. Your health and the birth of your child depend on this.
Pregnancy is a period when it is better to play it safe. Well, if you are nevertheless given an unpleasant - nothing more - diagnosis, follow all the doctor’s prescriptions and look forward with optimism.
Prevention
The best prevention ICN – refusal of medical abortion. In some cases, even a single artificial termination of pregnancy can cause cervical canal incompetence.
In order for the pregnancy to go well, it is necessary to carry out pre-conception preparation and prepare for it.
To prevent isthmic-cervical insufficiency it is important:
- pregnancy planning (careful adherence to contraception, since every surgical abortion injures the cervix);
- register with the antenatal clinic (up to 12 weeks) - it is on the chair that the doctor diagnoses ICN, the woman herself may not even be aware of it;
- regularly visit an obstetrician-gynecologist according to the schedule - this way the specialist will be able to monitor the condition of the cervix - the occurrence of ICI or the rate of opening of the cervix, if this disorder already exists.
If a miscarriage occurred during a previous pregnancy due to ICN, then you must prepare in advance for the next conception and gestation. When menstruation is delayed and positive test You must immediately begin the treatment prescribed by your doctor to help preserve the integrity of the cervix.
ICI occurs quite often - in almost every tenth woman (according to statistics in 9-10% of cases) in the first pregnancy and much more often with repeated ones. Moreover, the more births a woman has had, the greater the likelihood of isthmic-cervical insufficiency during subsequent pregnancy.
Regular assessment of cervical length using ultrasound cervicometry will be mandatory. When shortening begins, surgical intervention will be required to maintain and carry the pregnancy to term.