Miscarriage- spontaneous abortion, which ends with the birth of an immature and non-viable fetus up to the 22nd week of pregnancy, or the birth of a fetus weighing less than 500 grams, as well as spontaneous abortion of 3 and / or more pregnancies up to 22 weeks (recurrent miscarriage).

Correlation between ICD-10 and ICD-9 codes:

ICD-10		ICD-9
The code	Name	The code	Name
O02.1	Missed miscarriage	69.51	Aspiration curettage of the uterus to terminate pregnancy
O03	Spontaneous abortion	69.52	Curettage of the uterus
O03.4	Incomplete abortion without complications	69.59	Aspiration curettage
O03.5	Complete or unspecified abortion complicated by infection of the genital tract and pelvic organs
O03.9	Complete or unspecified abortion without complications
O20	Bleeding in early dates pregnancy
O20.0	Threatened abortion
O20.8	Other bleeding in early pregnancy
O20.9	Bleeding in early pregnancy, unspecified
N96	Habitual miscarriage

Date of development/revision of the protocol: 2013 (revised 2016).

Protocol Users: GPs, midwives, obstetrician-gynecologists, internists, anesthesiologists-resuscitators

Level of evidence scale:

Gradation of recommendations
Level and type of evidence
1	Evidence obtained from meta-analysis a large number well-balanced randomized trials. Randomized trials with low level false positive and false negative errors
2	The evidence is based on the results of at least one well-balanced randomized trial. Randomized trials with high level false positive and false negative errors. The evidence is based on well-designed, non-randomized studies. Controlled studies with one group of patients, studies with a group of historical control, etc.
3	The evidence is based on well-designed, non-randomized studies. Controlled studies with one group of patients, studies with a group of historical control, etc.
4	Evidence from non-randomized trials. Indirect comparative, descriptive correlation and case studies
5	Evidence based on clinical cases and examples
AND		Level I evidence or sustained multiple Level II, III, or IV evidence
AT		Level II, III, or IV evidence considered generally strong evidence
FROM		Level II, III, or IV evidence, but the evidence is generally unstable
D		Weak or non-systematic experimental evidence

Classification

Spontaneous abortion

By gestational age:
early - spontaneous termination of pregnancy before the full 13 weeks of gestation.
late - spontaneous abortion from 13 to 22 weeks.

According to the stages of development, there are:
threatening abortion;
Abortion in progress
Incomplete abortion
complete abortion;
Abortion failed (cessation of development of the embryo / fetus) - non-developing pregnancy.

Diagnostics (outpatient clinic)

DIAGNOSTICS AT OUTPATIENT LEVEL

Diagnostic criteria

Complaints and anamnesis:
Complaints:
delayed menstruation;
appearance pain syndrome lower abdomen of varying intensity;
· bloody issues from the genital tract of varying intensity.

For threatened abortion:
Pain of varying intensity in the lower abdomen;
Moderate bloody discharge from the genital tract.

During an abortion in progress:
prolonged pain in lower sections abdomen with an increase in dynamics to intense, having a cramping character;

For incomplete/complete abortion:
· nagging pain in the lower abdomen, with an increase in dynamics to intense, may have a cramping character, periodically decrease;
Abundant bloody discharge from the genital tract.

For non-developing pregnancy:
The disappearance of subjective signs of pregnancy, sometimes bloody discharge from the genital tract.

With habitual miscarriage: interruption of three or more pregnancies up to 22 weeks.

Anamnesis:
There may be spontaneous miscarriages;
violation of menstrual function;
no pregnancy for more than 1 year (infertility);

For incomplete/complete abortion:
expulsion of the ovum.

With habitual miscarriage:
three or more episodes of abortion.

Priisthmic-cervical insufficiency:
a sudden break membranes followed by relatively painless contractions;
Cases of spontaneous painless cervical dilatation up to 4-6 cm in previous pregnancies;
· Availability surgical interventions on the cervix, ruptures of the cervix of the second / third degree in past births;
instrumental dilatation of the cervix during artificial termination of pregnancies.

Physical examination:
BP, pulse (with a threatened abortion, hemodynamics is stable, with an ongoing / complete / incomplete abortion, there may be a decrease in blood pressure and an increase in heart rate).

Looking at mirrors:
• With threatened abortion and non-developing pregnancy, there may be scant or moderate spotting.
during abortion in progress / complete / incomplete abortion, the external os is open, spotting in in large numbers, parts of the fetal egg in the cervical canal, leakage of amniotic fluid (may be absent in early pregnancy).
· with habitual miscarriage, congenital / acquired anatomical defects of the ectocervix, prolapse of the fetal bladder from the external cervical os.

Bimanual vaginal examination:
in threatened abortion: none structural changes cervix, the uterus is easily excitable, its tone is increased, the size of the uterus corresponds to the gestational age;
during abortion in progress: the degree of disclosure is determined cervical canal;
In case of complete/incomplete abortion: the uterus is of a soft consistency, dimensions less time gestation, varying degrees dilatation of the cervix;
In non-developing pregnancy: the size of the uterus is less than the gestational age, the cervical canal is closed;
in case of habitual miscarriage: shortening of the cervix less than 25 mm / dilatation of the cervical canal more than 1 cm is possible in the absence of uterine contractions.

Laboratory studies [EL-B,S]:

Development stage	Determination of the concentration of hCG in the blood	Examination for APS (presence of lupus anticoagulant, antiphospholipid and anticardiolipid antibodies)	Hemostasiogram	Karyotype research and	Examination for diabetes and thyroid disease	Determining the level of progesterone	Testing for TORCH infection
Threatened abortion	+ level corresponds to gestational age	–	–	–	–	–	–
Abortion in progress	–	–	–	–	–	–	–
Complete/incomplete abortion	–	–	–	–	–	–	–
Non-developing pregnancy	+ level below gestational age or diagnostically insignificant increase in level	–	+ Determination of INR, AchTV, fibrinogen in case of embryo death for more than 4 weeks	–	–	–	–
Recurrent miscarriage, threatened miscarriage	_	+ The presence of two positive titers of lupus anticoagulant or anticardiolipin antibodies of immunoglobulin G and / or M at the level of medium or high titer (more than 40 g / l or ml / l or above 99 percentile) for 12 weeks (with an interval of 4-6 weeks).	+ Determination of AhTV, antithrombin 3, D-dimer, platelet aggregation, INR, prothrombin time - signs of hypercoagulability	+ detection of carriage of chromosomal abnormalities, including inherited thrombophilia (factor V Leiden, factor II - prothrombin and protein S).	+	+ progesterone level below 25 nmol / l - is a predictor of unviable pregnancy. A level above 25 nmol / l - indicates the viability of the pregnancy. A level above 60 nmol / l - indicates the normal course of pregnancy.	+ in cases where there is a suspicion of infection or information about the presence of an infection in the past or its treatment

Instrumental research:

Ultrasound procedure:
With threatened abortion:
The fetal heartbeat is determined;
· Availability local thickening myometrium in the form of a roller protruding into the uterine cavity (in the absence of clinical manifestations does not have independent value);
deformation of the contours of the fetal egg, its indentation due to uterine hypertonicity (in the absence of clinical manifestations, it has no independent significance);
The presence of areas of detachment of the chorion or placenta (hematoma);
self-reduction of one of several embryos.

With an abortion in progress:
Complete / almost complete detachment of the fetal egg.

With incomplete abortion:
The uterine cavity is dilated > 15 mm, the cervix is ​​open, the ovum/fetus is not visualized, tissues of heterogeneous echostructure can be visualized.

With a complete abortion:
uterine cavity<15 мм, цервикальный канал закрыт, иногда не полностью, плодное яйцо/плод не визуализируется, остатки продукта оплодотворения в полости матки не визуализируются.

With an undeveloped pregnancy:
Diagnostic criteria :
fetal KTR 7 mm or more, no heartbeat;
The average diameter of the fetal egg is 25 mm or more, there is no embryo;
absence of an embryo with a heartbeat 2 weeks after the ultrasound showed a fetal egg without a yolk sac;
Absence of an embryo with a heartbeat 11 days after the ultrasound showed a gestational sac with a yolk sac.
If the fetal sac is 25 mm or more, the embryo is absent and / or its heartbeat is not recorded and the CTE is 7 mm or more, then the patient definitely, with 100% probability, does not develop a pregnancy.
Prognostic criteria for a non-developing pregnancy with transvaginal ultrasound: - CTE of the fetus is less than 7 mm, there is no heartbeat, - the average diameter of the fetal sac is 16-24 mm, there is no embryo, - the absence of an embryo with a heartbeat 7-13 days after the ultrasound showed a fetal sac without yolk sac - no embryo with heartbeat 7-10 days after ultrasound showed gestational sac with yolk sac - no embryo 6 weeks after last menstrual period - yolk sac over 7mm - small gestational sac relative to embryo size (the difference between the average diameter of the fetal sac and the CTE of the fetus is less than 5 mm).

With repeated ultrasounds, a missed pregnancy is diagnosed if:
There is no embryo and heartbeat both at the first ultrasound and at the second one after 7 days;
Empty gestational sac 12 mm or more / gestational sac with yolk sac, same results after 14 days.
NB! The absence of a fetal heartbeat is not the only and not an obligatory sign of a non-developing pregnancy: with a short gestation period, the fetal heartbeat is not yet observed.

With habitual miscarriage, threatened miscarriage:
Identification of congenital / acquired anatomical disorders of the structure of the reproductive organs;
shortening of the cervix to 25 mm or less according to the results of transvaginal cervicometry in the period of 17-24 weeks. The length of the cervix clearly correlates with the risk of preterm birth and is a predictor of preterm birth. Transvaginal ultrasound measurement of the length of the cervix is ​​a necessary standard in risk groups for prematurity.

Risk groups for preterm birth include:
women with a history of preterm labor in the absence of symptoms;
Women with a short cervix<25 мм по данным трансвагинального УЗИ в средних сроках при одноплодной беременностипри отсутствии бессимптомов;
· women with the threat of premature birth during this pregnancy;
women who have lost 2 or more pregnancies at any time;
women with bleeding in early pregnancy with the formation of retrochorial and retroplacental hematomas.

Diagnostic algorithm :
Scheme - 1. Algorithm for diagnosing miscarriage

NB! Hemodynamic parameters should be carefully monitored until uterine pregnancy is confirmed.
NB! Exclusion of pathological conditions, which are characterized by bloody discharge from the genital tract and pain in the lower abdomen, according to the current protocols:
endometrial hyperplasia;
benign and precancerous processes of the cervix;
Leiomyoma of the uterus
Dysfunctional uterine bleeding in women of reproductive and perimenopausal age.

Diagnostics (ambulance)

DIAGNOSTICS AND TREATMENT AT THE EMERGENCY STAGE

Diagnostic measures:
Complaints:
bleeding from the genital tract, pain in the lower abdomen.
Anamnesis:
Delayed menstruation
Physical examination is aimed at assessing the severity of the general condition of the patient:
pallor of the skin and visible mucous membranes;
decrease in blood pressure, tachycardia;
assessment of the degree of external bleeding.

Drug treatment provided at the stage of emergency emergency care: in the absence of bleeding and severe pain syndrome, therapy at this stage is not required.

Diagnostics (hospital)

DIAGNOSTICS AT THE STATIONARY LEVEL

Diagnostic criteria at the hospital level: see ambulatory level.

Diagnostic algorithm: see ambulatory level.

List of main diagnostic measures:
UAC;
OMT ultrasound (transvaginal and/or transabdominal)

List of additional diagnostic measures:
determination of blood type, Rh factors;
blood coagulogram;

Differential Diagnosis

Differential diagnosis and rationale for additional studies

Diagnosis	Rationale for differential diagnosis	Surveys	Diagnosis Exclusion Criteria
Ectopic pregnancy	Symptoms: delayed menstruation, pain in the lower abdomen and spotting from the genital tract	Bimanual vaginal examination: the uterus is smaller than the norm adopted for this period of pregnancy, determination of the test consistency of the formation in the area of ​​​​the appendages	Ultrasound: there is no fetal egg in the uterine cavity, visualization of the fetal egg, an embryo outside the uterine cavity is possible, free fluid in the abdominal cavity can be determined.
Menstrual irregularity	Symptoms: delayed menstruation, spotting from the genital tract	On mirrors: bimanual examination: the uterus is of normal size, the cervix is ​​closed.	Blood for hCG is negative. Ultrasound: The fetal egg is not determined.

Treatment (ambulatory)

TREATMENT AT OUTPATIENT LEVEL

Treatment tactics:
antispasmodic therapy - there is no evidence of effective and safe use in order to prevent abortion (LE-B).
· sedative therapy - there is no evidence of effective and safe use in order to prevent abortion (LE-B).
hemostatic therapy - hemostatics. There is no evidence base for their effectiveness in threatened abortion, and the FDA safety category for pregnancy has not been determined.
Progesterone preparations (with threatening abortion) - with a delay in menstruation up to 20 days (pregnancy up to 5 weeks) and stable hemodynamics. Progestogen therapy provides a better outcome than placebo or no therapy for the treatment of threatened miscarriage and there is no evidence of an increase in the incidence of gestational hypertension or postpartum haemorrhage as adverse effects for the mother, as well as an increased incidence of congenital anomalies in newborns (LE-C).
Removal of the fetal egg during abortion in progress, incomplete abortion, non-developing pregnancy by manual vacuum aspiration using an MVA syringe (see clinical protocol "Medical abortion"). In non-developing pregnancy, the use of medical abortion is recommended.

NB! The patient must be informed about the results of the examination, the prognosis of this pregnancy and possible complications associated with the use of drugs.
NB! It is mandatory to obtain written consent for medical and surgical interventions.
NB! If there are clinical signs of threatened abortion at less than 8 weeks of gestation and adverse signs of pregnancy progression (see Table 2), pregnancy-preserving therapy is not recommended.
NB! If the patient insists on carrying out therapy aimed at maintaining the pregnancy, she should be appropriately informed about the high proportion of chromosomal abnormalities at this stage of pregnancy, which are the most likely cause of the threat of termination and the low effectiveness of any therapy.

Non-drug treatment: no.

Medical treatment
progesterone preparations (UD - V):

Progesterone preparations:
progesterone solution (intramuscularly or vaginally);
micronized progesterone (vaginal capsules);
Synthetic derivatives of progesterone (orally).

NB! There was no statistically significant difference in the effectiveness of various methods of prescribing progesterone (i / m, orally, intravaginally). They cannot be given at the same time. At the same time, it is important to make a personalized choice of drug, taking into account bioavailability, ease of use of the drug, available safety data and personal preferences of the patient. Do not exceed the dosage recommended by the manufacturer. Routine prescription of progestin drugs in case of threatened miscarriage does not increase the percentage of gestation, and therefore is not justified (LE - A) (9,10,11)

Indications for the use of progesterone: 1. Treatment of threatened abortion 2. History of two or more spontaneous miscarriages in the first trimester (recurrent miscarriage) 3. Luteal phase deficiency brought to pregnancy 4. Primary and secondary infertility associated with insufficiency of the luteal phase 5. Pregnancy resulting from assisted reproductive technologies

When establishing antiphospholipid syndrome (UD-B):
· acetylsalicylic acid 75 mg/day - acetylsalicylic acid is started as soon as the pregnancy test becomes positive and continues until delivery (LE-B, 2);
· heparin 5,000 IU- subcutaneously every 12 hours / low molecular weight heparin at an average prophylactic dose.
NB! The use of heparin is started as soon as the cardiac activity of the embryo is registered with the help of ultrasound. Heparin is discontinued at 34 weeks of gestation (LE-B, 2). When using heparin, platelet levels are monitored weekly for the first three weeks, then every 4 to 6 weeks.
If thrombosis has occurred during previous pregnancies, therapy can be continued until delivery and in the postpartum period (see CP: "Thromboembolic complications in obstetrics" pr. 7 of August 27, 2015, treatment tactics at the stage of delivery).

progesterone, injection 1%, 2.5%, 1 ml; gel - 8%, 90 mg
micronized progesterone, capsules 100-200 mg,
Dydrogesterone tablets 10 mg

acetylsalicylic acid 50-75-100 mg, tablets;
heparin 5000ED
nadroparin calcium 2850 - 9500 IU anti-Xa

Table - 1. Comparisons of drugs:

A drug	UD	Termination symptoms	Maximum duration of therapy	Note
progesterone injection	AT	+	With a habitual miscarriage, the drug can be administered up to the 4th month of pregnancy.	Contraindicated in the 2nd and 3rd period of pregnancy, ectopic pregnancy and missed abortion in history. The risk of congenital anomalies, including sexual anomalies in both sexes, associated with exposure to exogenous progesterone during pregnancy has not been fully established.
Micronized progesterone 200mg capsules (vaginal capsules)	AT	+	Up to 36 weeks pregnant	Expert Council, Berlin 2015 - regulates the use of vaginal progesterone at a dose of 200 mg for the prevention of preterm labor in women with a singleton pregnancy and a cervical length of 25 mm or less according to cervicometry at 17-24 weeks (MISTERI study). Progesterone 400 mg 200 mg twice daily appears to be safe for both mother and fetus (PRO-MISE study). Therefore, it is justified to start therapy with preconception preparation and prolongation, according to indications, for a period of more than 12 weeks of pregnancy.
Dydrogesterone, tab 10 mg	AT	+	Up to 20 weeks pregnant	A 2012 systematic review showed that the use of dydrogesterone 10 mg 2 times a day reduced the risk of spontaneous abortion by 47% compared with placebo, and there is evidence of the effectiveness of dydrogesterone in recurrent miscarriage. The European progestin club recommends dydrogestrone for patients with a clinical diagnosis of threatened abortion due to its significant reduction in the incidence of spontaneous miscarriage.

Algorithm of actions in emergency situations:
study of complaints, anamnesis data;
Examination of the patient
assessment of hemodynamics and external bleeding.

Other types of treatment:
Overlay pessary(however, to date there is no reliable data on their effectiveness).
Indications:
Identification of a short cervix.

NB! Detection and treatment of bacterial vaginosis in early pregnancy reduces the risk of spontaneous abortion and preterm birth (LEA).

consultation of a hematologist - in case of detection of antiphospholipid syndrome and abnormalities in the hemostasiogram;
consultation of a therapist - in the presence of somatic pathology;
consultation of an infectious disease specialist - with signs of TORCH infection.

Preventive actions:
Women with a history of preterm labor and / or shortening of the cervix should be identified as a high risk group for miscarriage for the timely administration of vaginal progesterone: if there is a history of preterm birth from early pregnancy, with shortening of the cervix - from the moment of establishment.
The use of progesterone to support the luteal phase after the use of ART. The method of administration of progesterone does not matter (you must follow the instructions for the drugs).

Patient monitoring: after establishing the diagnosis and before starting treatment, it is necessary to determine the viability of the embryo / fetus and the subsequent prognosis of pregnancy.
To do this, use the criteria for a favorable or unfavorable prognosis of this pregnancy (table No. 2).

Table 2. Predictive Criteria for Pregnancy Progression

signs	Favorable prognosis	Unfavorable prognosis
Anamnesis	Progressive pregnancy	Presence of spontaneous abortions
		Woman's age > 34 years
Sonographic	The presence of heart contractions with a fetal KTR of 6 mm (transvaginally) Absence of bradycardia	The absence of heart contractions with a KTR of the fetus 6 mm (transvaginally) 10 mm (transabdominally) - bradycardia.
		Empty fetal egg with a diameter of 15 mm at a gestational age of 7 weeks, 21 mm at a period of 8 weeks (Reliability of sign 90.8%)
		The diameter of the fetal egg is 17-20 mm or more in the absence of an embryo or yolk sac in it. (Reliability of sign 100%).
	Conformity of the size of the embryo to the size of the fetal egg	Mismatch between the size of the embryo and the size of the fetal egg
	The growth of the fetal egg in dynamics	Lack of growth of the fetal egg after 7-10 days.
	–	subchorial hematoma. (The predictive value of subchorionic hematoma size has not been fully elucidated, but the larger the subchorionic hematoma, the worse the prognosis.)
Biochemical	Normal levels of biochemical markers	HCG levels below normal for gestational age
		HCG levels increase by less than 66% in 48 hours (up to 8 weeks of pregnancy) or decrease
		Progesterone levels are below normal for gestational age and are declining

NB! In the case of primary detection of adverse signs of pregnancy progression, a second ultrasound should be performed after 7 days if the pregnancy is not terminated. If there is any doubt about the final conclusion, the ultrasound should be performed by another specialist at a higher-level institution of care.

Treatment effectiveness indicators:
further prolongation of pregnancy;
No complications after evacuation of the fetal egg.

Treatment (hospital)

TREATMENT AT THE STATIONARY LEVEL

Treatment tactics

Non-drug treatment: No

Medical treatment(depending on the severity of the disease):

Nosology	Events	Notes
Abortion in progress	In case of bleeding after expulsion or during curettage, one of the uterotonics is administered to improve uterine contractility: Oxytocin 10 IU / m or / in drip in 500 ml of isotonic sodium chloride solution at a rate of up to 40 drops per minute; misoprostol 800 mcg rectally. Prophylactic antibiotic use is mandatory. All Rh-negative women who do not have anti-Rh antibodies are given anti-D immune globulin according to the current protocol.	Antibiotic prophylaxis is carried out 30 minutes before the manipulation by intravenous administration of 2.0 gcefazolin after the test. If it is intolerable/unavailable, clindamycin and gentamicin may be used.
Complete abortion	The need for prophylactic antibiotics.
incomplete abortion	Misoprostol – 800-1200 mcg once intravaginally in a hospital. The drug is injected into the posterior fornix of the vagina by a doctor when viewed in the mirrors. A few hours (usually within 3-6 hours) after the introduction of misoprostol, uterine contractions and expulsion of the remnants of the ovum begin. Observation: A woman remains for observation in a hospital for a day after expulsion and can be discharged from the hospital if: No significant bleeding No symptoms of infection · Possibility to immediately apply to the same medical facility at any time around the clock. NB! 7-10 days after discharge from the hospital on an outpatient basis, a control examination of the patient and ultrasound are performed. The transition to surgical evacuation after medical evacuation is carried out in the following cases: the occurrence of significant bleeding; the appearance of symptoms of infection; if the evacuation of residues has not begun within 8 hours after the administration of misoprostol; Identification of the remains of the fetal egg in the uterine cavity during ultrasound in 7-10 days.	The medical method can be used: · only in case of confirmed incomplete abortion in the first trimester; if there are no absolute indications for surgical evacuation; Only on condition of hospitalization in a medical institution that provides emergency assistance around the clock. Contraindications Absolute: adrenal insufficiency; long-term therapy with glucocorticoids; hemoglobinopathies / anticoagulant therapy; anemia (Hb<100 г / л); · porphyria; mitral stenosis; · glaucoma; Taking non-steroidal anti-inflammatory drugs within the previous 48 hours. Relative: Hypertension severe bronchial asthma. Medical method of evacuation of the contents of the uterine cavity · can be used at the request of women who are trying to avoid surgery and general anesthesia; The effectiveness of the method is up to 96%, depending on several factors, namely: the total dose, the duration of administration and the method of administration of prostaglandins. The highest success rate (70-96%) is observed when using large doses of prostaglandin E1 (800-1200 mcg), which are administered vaginally. The use of the drug method contributes to a significant reduction in the incidence of pelvic infections (7.1% compared to 13.2%, P<0.001)(23)
Missed abortion	Mifepristone 600 mg Misoprostol 800 mg	See Clinical Protocol "Medical Abortion".

NB! The patient must be informed about the results of the examination, the prognosis of this pregnancy, the planned therapeutic measures, and give written consent to the conduct of medical and surgical interventions.
NB! The use of misoprostol is an effective intervention for early miscarriage (LE-A) and is preferred in cases of non-continuing pregnancy (LE-B).

List of essential medicines:
Mifepristone 600mg tablets
Misoprostol 200mg tablets #4

List of additional medicines:
Oxytocin, 1.0 ml, ampoules
Cefazolin 1.0 ml, vials

Table - 2. Comparisons of drugs. Current evidence-based medical abortion regimens up to 22 weeks of gestation, WHO, 2012

Drug/Modes	UD	Timing	The urgency of the recommendations
mifepristone 200 mg orally Misoprostol 400 mcg orally (or 800 mcg vaginally, buccally, sublingually) 24-48 hours later	AND	Up to 49 days	high
mifepristone 200 mg orally Misoprostol 800 mcg vaginally (buccal, sublingual) 36-48 hours later	AND	50-63 days	high
mifepristone 200 mg orally Misoprostol 800 mcg vaginally every 36-48 hours followed by 400 mcg vaginal or sublingual every 3 hours for up to 4 doses	AT	64-84 days	low
mifepristone 200 mg orally Misoprostol 800 mcg vaginally or 400 mcg po 36 to 48 hours later, then 400 mcg vaginally or sublingually every 3 hours for up to 4 doses	AT	12-22 weeks	low

Surgical intervention:

Nosology	Events	Notes
Abortion in progress	Manual vacuum aspiration / curettage of the walls of the uterine cavity.	Curettage of the walls of the uterine cavity or vacuum aspiration is performed under adequate anesthesia; in parallel, they carry out activities aimed at stabilizing hemodynamics in accordance with the volume of blood loss.
incomplete abortion		Absolute indications for the surgical method(curettage or vacuum aspiration): Intense bleeding Expansion of the uterine cavity> 50 mm (ultrasound); An increase in body temperature above 37.5 ° C. Mandatory use of prophylactic antibiotic therapy. Aspiration curettage has advantages over curettage of the uterine cavity, since it is less traumatic and can be performed under local anesthesia (UR-B).
Missed abortion
habitual miscarriage	Preventive suture on the cervix. Indicated for high-risk women with a history of three or more miscarriages in the second trimester / preterm birth, in the absence of other reasons than CCI. Performed at 12 to 14 weeks of gestation [LE: 1A]. In the presence of 1 or 2 previous pregnancy losses in a woman, it is recommended to control the length of the cervix. Urgent cerclage is performed in women whose cervix is ​​open to<4 см без сокращений матки до 24 недель беременности . Cerclage should be considered in singleton pregnancies in women with a history of spontaneous preterm birth or possible cervical insufficiency if cervical length ≤ 25 mm before 24 weeks of gestation There is no benefit to cerclage in a woman with occasional finding of a short cervix by ultrasound but without any prior risk factors for preterm birth. (II-1D). Existing evidence does not support suturing in multiple pregnancies, even if there is a history of preterm birth—therefore, it should be avoided (EL-1D)	Correction of ICI, see the clinical protocol "Premature birth"

Other types of treatment: no.

Indications for expert advice:
consultation with an anesthesiologist-resuscitator - in the presence of hemorrhagic shock / complications of abortion.

Indications for transfer to the intensive care unit and resuscitation:
hemorrhagic shock.

Treatment effectiveness indicators.
prolongation of pregnancy in case of threatened abortion and habitual miscarriage;
The absence of early complications after the evacuation of the fetal egg.

Further maintenance (1.9):
Prevention of infectious and inflammatory diseases, rehabilitation of foci of chronic inflammation, normalization of the vaginal biocenosis, diagnosis and treatment of TORCH infections if they are present/indicated in history;
non-specific preconception preparation of the patient: psychological assistance to the patient after an abortion, anti-stress therapy, normalization of the diet, it is recommended 3 months before conception to prescribe folic acid 400 mcg per day, work and rest regimen, abandon bad habits;
· genetic counseling for women with recurrent miscarriage/confirmed fetal malformation prior to termination of pregnancy;
In the presence of anatomical causes of recurrent miscarriage, surgical removal is indicated. Surgical removal of the intrauterine septum, synechia, and submucosal fibroid nodes is accompanied by the elimination of miscarriage in 70-80% of cases (UD-C).

NB! Abdominal metroplasty is associated with a risk of postoperative infertility (LE-I) and does not lead to an improvement in the prognosis of subsequent pregnancies. After surgery to remove the intrauterine septum, synechia, contraceptive estrogen-progestin preparations are prescribed, with extensive lesions, an intrauterine contraceptive (intrauterine device) or a Foley catheter is inserted into the uterine cavity against the background of hormone therapy for 3 menstrual cycles, followed by their removal and continued hormone therapy for another over 3 cycles.
women after the third miscarriage (recurrent miscarriage), with the exclusion of genetic and anatomical causes of miscarriage, should be examined for possible coagulopathy (family history, determination of lupus anticoagulant / anticardiolipin antibodies, D-dimer, antithrombin 3, homocysteine, folic acid, antisperm antibodies ).

Hospitalization

Indications for planned hospitalization:
Isthmic-cervical insufficiency - for surgical correction.

Indications for emergency hospitalization:
Abortion in progress
Incomplete spontaneous abortion
A failed abortion
non-developing pregnancy.

and Perinatology FPO

Head department: d.m.s., prof.

Lecturer: ass.

Report

On the topic: "Surgical correction of isthmic-cervical insufficiency"

Prepared by: 5th year student, group No. 21

IIFaculty of Medicine

specialty: "Pediatrics"

Lugansk 2011

Despite the significant progress made over the past decades in the field of obstetrics and gynecology, the problem of miscarriage is still relevant. Preterm birth is one of the main causes of neonatal morbidity and mortality. The causes of miscarriage are complex and varied. At the same time, the main one is isthmic-cervical insufficiency (ICI), which accounts for 30-40% of all late abortions and preterm births.

If conservative therapy is not effective, surgical correction of the ICI is necessary, which is most effective in the early stages of pregnancy, when there is no significant shortening and opening of the cervix, as well as the risk of infection of the fetus.

According to the annex to the order of the Ministry of Health No. 000 of 01.01.2001, the treatment of isthmic-cervical insufficiency consists in the imposition of a prophylactic or therapeutic (urgent) suture (cerclage) on the cervix.

General conditions for the use of the seam:

Live fetus without visible malformations;

A whole fetal bladder;

No signs of chorionamnionitis;

Absence of labor activity and / or bleeding;

The first or second degree of purity of the vagina.

Preventive suture on the cervix.

It is indicated for high-risk women who have a history of two or more miscarriages or preterm births in the second trimester of pregnancy. It is carried out within a week of pregnancy in the presence of the above conditions.

Therapeutic suture on the cervix

Indicated for women at risk according to ultrasound data:

Short neck (less than 2.5 cm) without wedge-shaped transformation of the cervical canal;

Short neck in combination with progressive wedge-shaped transformation of the cervical canal;

A short neck in combination with a progressive wedge-shaped transformation of the cervical canal by 40% or more in a single study.

An urgent or therapeutic suture on the cervix is ​​offered to women from the moment of diagnosis. It is carried out up to 22 weeks.

Contraindications for surgical correction of CI:

1. Diseases and pathological conditions that are a contraindication to prolongation of pregnancy.

2. Bleeding during pregnancy.

3. Increased tone of the uterus, not amenable to treatment.

4. fetal CM.

5. Acute inflammatory diseases of the pelvic organs - 3-4 degree of purity of the vaginal contents.

Preparing for the operation:

1. Microbiological examination of the vaginal discharge and cervical canal.

2. Tocolytic therapy according to indications.

Anesthesia methods:

1. Premedication: atropine sulfate at a dose of 0.3-0.6 mg and midozolam at a dose of 2.5 mg intramuscularly.

2. Ketamine 1-3 mg/kg body weight intravenously or 4-8 mg/kg body weight intramuscularly.

3. Propofol 40 mg IV every 10 seconds until clinical signs of anesthesia appear. The average dose is 1.5-2.5 mg/kg of body weight.

The success of surgical treatment of CI depends on a number of conditions:

1. Strict justification of indications for surgical intervention.

2. Correct choice of operation method.

3. Prevention of increased excitability and contractile activity of the uterus.

4. Absence of pathogenic microflora in the vagina.

5. The quality of the material used (silk, lavsan, mersilene).

The effectiveness of surgical treatment of CI and pregnancy is 85-95%.

Currently, various methods of surgical treatment of CI have been developed. Studies confirm that this method is less traumatic, effective and does not adversely affect the health of the mother of the fetus.

The most common methods of surgical correction of CI are:

1. The imposition of a circular suture on the cervix.

2. Narrowing of the internal pharynx according to McDonald (MC Donald), Shirodkar (Shirodkar), Lyubimova, Mikhailenko, Sidelnikova.

3. Sewing of the uterine opening according to Scendi (Sreridi).

4. Creation of duplication of cervical tissues according to Orekhova and Karimova.

The main methods of surgical treatment are the mechanical narrowing of the functionally and (or) anatomically defective internal cervical os and the suturing of the external cervical os with non-absorbable suture material. Operations that eliminate the inferiority of the internal pharynx of the cervix are more physiological, because after the operation, a drainage hole remains for the outflow of secretions from the uterus.

The most accepted method currently is:

The method of suturing the cervix with a circular purse-string suture according to Mac Donald (1957). Operation technique: at the border of the transition of the mucous membrane of the anterior vaginal fornix, a purse-string suture made of durable material (lavsan, silk, marsilene) is applied to the cervix with the needle passed deep through the tissues, the ends of the threads are tied in a knot in the anterior vaginal fornix. Leave the long ends of the ligatures so that they are easy to detect before childbirth and can be easily removed.

It is also possible to use other methods of correction of ICI:

The imposition of U-shaped sutures on the cervix according to the method of Lyubimova and Mamedaliyeva (1981). This technique is the method of choice for prolapse of the fetal bladder (previously, the fetal bladder is sent to the uterine cavity with a swab). Operation technique: at the border of the transition of the mucous membrane of the anterior vaginal fornix, retreating 0.5 cm from the midline on the right, the cervix is ​​pierced with a needle with mylar thread through the entire thickness, making a puncture in the back of the vaginal fornix. The end of the thread is transferred to the left lateral part of the vaginal fornix, the mucous membrane and part of the thickness of the uterus are pierced with a needle, making an injection 0.5 cm to the left of the midline. The end of the second lavsan thread is transferred to the right lateral part of the vaginal fornix, then the mucous membrane and part of the thickness of the uterus are pierced with a prick in the anterior part of the vaginal fornix. The tampon is left for 2-3 hours.

Cerkelage by Shirodkar (1956)- a single-row suture applied around the circumference of the cervix at the level of the internal opening of the cervical canal after the displacement of the bladder forward and the rectum back. The suture is tightened in front and behind and the incisions of the mucous membrane are closed.

Sewing of the cervix according to the method of Sidelnikova(with gross ruptures of the cervix on one or both sides). Operation technique: the first purse-string suture is applied according to the McDonald method, just above the rupture of the cervix. The second purse-string suture is carried out as follows: below the first 1.5 cm through the thickness of the cervical wall from one edge of the gap to the other circularly, a thread is passed along a spherical circle. One end of the thread is injected inside the cervix into the posterior lip and, having picked up the lateral wall of the cervix, the puncture is made in the anterior part of the vaginal fornix, twisting the torn lateral anterior lip of the cervix like a cochlea, leading to the anterior part of the vaginal fornix. The threads are connected.

Scendi Method: after excision of the mucous membrane around the external cervical os, the anterior and posterior lip of the cervix are sutured together with separate catgut or silk sutures. When sewing up the external pharynx, a closed space is formed in the uterine cavity, which is very unfavorable if there is a latent infection in the uterus. The Scendi operation is not effective for cervical deformity and prolapse of the fetal bladder; it is not advisable to carry out with erosion of the cervix, suspected latent infection and copious amounts of mucus in the cervical canal. The Scendi method attracts with its simplicity, and there is reason to believe that it will be widely used.

Complications:

1. Spontaneous abortion.

2. Bleeding.

3. Rupture of the amniotic membranes.

4. Necrosis, eruption of cervical tissue with threads.

5. The formation of bedsores, fistulas.

6. Chorioamnionitis, sepsis.

7. Circular separation of the cervix (at the onset of labor and the presence of sutures).

Features of the postoperative period:

1. You are allowed to get up and walk immediately after the operation.

2. Treatment of the vagina and cervix with a 3% solution of hydrogen peroxide, chlorhexidine (in the first 3-5 days).

3. For therapeutic purposes, the following drugs are prescribed:

ü Antispasmodics

ü B-agonists

o Antibacterial therapy

An extract from the hospital is carried out for 5-7 days.

On an outpatient basis, examination of the cervix is ​​​​performed every 2 weeks.

Stitches from the uterus are removed at 37-38 weeks of pregnancy.

Conclusion

For effective prevention of premature termination of pregnancy, early diagnosis of this pathology in the antenatal clinic is necessary, which will make it possible to start surgical treatment in a timely manner. The imposition of a circular submucosal suture on the cervix is ​​an effective method for correcting CI.

List of used literature:

1. Obstetrics: A National Guide. Ed. , .

2. Aylamazyan: Textbook for medical schools 4th edition., add./. - St. Petersburg: SpecLit, 2003. - 582 p.: ill.

3. , and Rozovsky's miscarriage, p. 136, M., 2001.

5. Sidelnikov's loss of pregnancy. – M.: Triada-X, 200s.

6. Willis Operative Gynecology. - 2nd ed., revised. and additional - M.: Medical literature, 2004. - 540 p.

One of the most common causes of early termination of pregnancy in the second and third trimesters is CCI (insolvency, incompetence of the cervix). ICI - asymptomatic shortening of the cervix, expansion of the internal os, leading to rupture of the fetal bladder and loss of pregnancy.

CLASSIFICATION OF ISTHMIC-CERVICAL INSUFFICIENCY

Congenital ICI (with genital infantilism, malformations of the uterus).
· Acquired ICN.
- Organic (secondary, post-traumatic) ICI occurs as a result of medical and diagnostic manipulations on the cervix, as well as traumatic childbirth, accompanied by deep ruptures of the cervix.
- Functional CI is observed in endocrine disorders (hyperandrogenism, ovarian hypofunction).

DIAGNOSTICS OF ISTHMIC-CERVICAL INSUFFICIENCY

Criteria for diagnosing CCI during pregnancy:
Anamnestic data (history of spontaneous miscarriages and premature births).
Vaginal examination data (location, length, consistency of the cervix, condition of the cervical canal - patency of the cervical canal and internal os, cicatricial deformity of the cervix).

The severity of ICI is determined by the Stember point scale (Table 141).

A score of 5 or more requires correction.

Ultrasound (transvaginal echography) is of great importance in the diagnosis of CCI: the length of the cervix, the condition of the internal os and the cervical canal are assessed.

Table 14-1. Scoring of the degree of isthmic-cervical insufficiency according to the Stember scale

Ultrasound monitoring of the state of the cervix should be carried out starting from the first trimester of pregnancy for a true assessment of the reduction in the length of the cervix. A cervical length of 30 mm is critical at less than 20 weeks and requires intensive ultrasound monitoring.

Ultrasound signs of ICI:

· Shortening of the cervix to 25–20 mm or less, or opening of the internal os or cervical canal to 9 mm or more. In patients with the opening of the internal os, it is advisable to evaluate its shape (Y, V or U-shaped), as well as the severity of the deepening.

INDICATIONS FOR SURGICAL CORRECTION OF ISTHMICOCERVICAL INSUFFICIENCY

· History of spontaneous miscarriages and premature births.
Progressive CI according to clinical and functional research methods:
- signs of ICI according to vaginal examination;
- ECHO signs of CI according to transvaginal sonography.

CONTRAINDICATIONS TO SURGICAL CORRECTION OF ISTHMICOCERVICAL INSUFFICIENCY

Diseases and pathological conditions that are a contraindication to the prolongation of pregnancy.
· Bleeding during pregnancy.
Increased tone of the uterus, not amenable to treatment.
fetal CM.
· Acute inflammatory diseases of the pelvic organs (PID) - III-IV degree of purity of the vaginal contents.

CONDITIONS FOR THE OPERATION

· The gestation period is 14–25 weeks (the optimal gestation period for cervical cerclage is up to 20 weeks).
· A whole fetal bladder.
Lack of significant smoothing of the cervix.
No pronounced prolapse of the fetal bladder.
No signs of chorioamnionitis.
Absence of vulvovaginitis.

PREPARATION FOR OPERATION

Microbiological examination of the vaginal discharge and cervical canal.
Tocolytic therapy according to indications.

PAIN RELIEF METHODS

Premedication: atropine sulfate at a dose of 0.3–0.6 mg and midozolam (dormicum ©) at a dose of 2.5 mg intramuscularly.
· Ketamine 1–3 mg/kg body weight intravenously or 4–8 mg/kg body weight intramuscularly.
· Propofol at a dose of 40 mg every 10 seconds intravenously until the onset of clinical symptoms of anesthesia. The average dose is 1.5-2.5 mg / kg of body weight.

SURGICAL METHODS FOR CORRECTION OF ISTHMIC-CERVICAL INSUFFICIENCY

The most accepted method currently is:

The method of suturing the cervix with a circular purse-string suture according to MacDonald.
Operation technique: At the border of the transition of the mucous membrane of the anterior vaginal fornix, a purse-string suture is applied to the cervix from a durable material (lavsan, silk, chrome-plated catgut, mersilene tape) with the needle passed deep through the tissues, the ends of the threads are tied in a knot in the anterior vaginal fornix. The long ends of the ligature are left so that they are easy to detect before childbirth and can be easily removed.

It is also possible to use other methods of correction of ICI:

· Shaped sutures on the cervix according to the method of A.I. Lyubimova and N.M. Mammadaliyeva.
Operation technique:
At the border of the transition of the mucous membrane of the anterior vaginal fornix, 0.5 cm away from the midline on the right, the cervix is ​​pierced with a needle with mylar thread through the entire thickness, making a puncture in the back of the vaginal fornix.
The end of the thread is transferred to the left lateral part of the vaginal fornix, the mucous membrane and part of the thickness of the cervix are pierced with a needle, making an injection 0.5 cm to the left of the midline. The end of the second lavsan thread is transferred to the right lateral part of the vaginal fornix, then the mucous membrane and part of the thickness of the uterus are pierced with a prick in the anterior part of the vaginal fornix. The tampon is left for 2-3 hours.

· Sewing of the cervix according to the method of V.M. Sidelnikova (with gross ruptures of the cervix on one or both sides).
Operation technique:
The first purse-string suture is applied according to the MacDonald method, just above the rupture of the cervix. The second purse-string suture is carried out as follows: below the first 1.5 cm through the thickness of the wall of the cervix from one edge of the gap to the other, a thread is passed circularly along a spherical circle. One end of the thread is injected inside the cervix into the posterior lip and, having picked up the lateral wall of the cervix, the puncture is made in the anterior part of the vaginal fornix, twisting the torn lateral anterior lip of the cervix like a cochlea, and is brought out into the anterior part of the vaginal fornix. The threads are connected.
For suturing, modern suture material "Cerviset" is used.

COMPLICATIONS

· Spontaneous abortion.
· Bleeding.
Rupture of the amniotic membranes.
Necrosis, eruption of the cervical tissue with threads (lavsan, silk, nylon).
Formation of bedsores, fistulas.
Chorioamnionitis, sepsis.
Circular avulsion of the cervix (at the onset of labor and the presence of sutures).

FEATURES OF THE POSTOPERATIVE PERIOD

You are allowed to get up and walk immediately after the operation.
Treatment of the vagina and cervix with a 3% solution of hydrogen peroxide, benzyldimethyl-myristoylaminopropylammonium chloride monohydrate, chlorhexidine (in the first 3-5 days).
For therapeutic and prophylactic purposes, the following drugs are prescribed.
- Antispasmodics: drotaverine 0.04 mg 3 times a day or intramuscularly 1-2 times a day for 3 days.
- b Adrenomimetics: hexoprenaline at a dose of 2.5 mg or 1.25 mg 4 times a day for 10-12 days, at the same time verapamil is prescribed at a dose of 0.04 g 3-4 times a day.
- Antibacterial therapy according to indications with a high risk of infectious complications, taking into account the data of a microbiological study of a vaginal discharge with sensitivity to antibiotics.
Discharge from the hospital is carried out on the 5-7th day (with an uncomplicated course of the postoperative period).
On an outpatient basis, examination of the cervix is ​​carried out every 2 weeks.
The sutures from the cervix are removed at 37–38 weeks of gestation.

INFORMATION FOR THE PATIENT

· With the threat of termination of pregnancy, especially with recurrent miscarriage, it is necessary to monitor the condition of the cervix using ultrasound.
· The effectiveness of surgical treatment of CCI and pregnancy is 85-95%.
· It is necessary to observe the medical-protective regimen.

Isthmic-cervical insufficiency (incompetence) - asymptomatic shortening of the cervix and expansion of the internal pharynx, leading to a possible prolapse of the fetal bladder into the vagina.

Epidemiology
Isthmic-cervical insufficiency occupies a significant place in the structure of the causes of late miscarriages and premature births. The frequency of isthmic-cervical insufficiency in the population is 9.0%, with miscarriage from 15.0 to 42.0%.

Classification of isthmic-cervical insufficiency:
Congenital isthmic-cervical insufficiency (malformations of the uterus, genital infantilism)
Acquired isthmic-cervical insufficiency:
- functional isthmic-cervical insufficiency (endocrine dysfunctions: hyperandrogenism, ovarian hypofunction);
- organic isthmic-cervical insufficiency (post-traumatic) - occurs due to: traumatic childbirth, accompanied by deep ruptures of the cervix, medical and diagnostic manipulations on the cervix; operations.

Diagnosis of isthmic-cervical insufficiency
Diagnosis of isthmic-cervical insufficiency during pregnancy:
- anamnestic data (history of spontaneous miscarriages, especially in the II trimester and premature birth);
- during vaginal examination, shortening, softening of the cervix, low location of the presenting part of the fetus. Vaginal examination should be carried out carefully, without assessing the patency of the cervical feces and internal os;
- Ultrasound transvaginal echography.

Ultrasound monitoring of the state of the cervix is ​​carried out starting from the first trimester of pregnancy: the length of the cervix, the size of the internal os and the cervical canal are estimated.

Ultrasonographic criteria for isthmic-cervical insufficiency:
- the length of the cervix - 3 cm is critical in first- and second-time pregnant women with gestational ages up to 20 weeks, the length of the cervix - 2.0-2.5 cm - the absolute criterion of isthmic-cervical insufficiency;
- the width of the cervical canal is 0.9 mm or more with gestation periods up to 21 weeks. Risk factors for the development of isthmic-cervical insufficiency:
- reproductive losses and isthmic-cervical insufficiency in history;
- inflammatory diseases of the genitals (sexually transmitted infections, conditionally pathogenic flora);
- ovarian dysfunction;
- uterine fibroids;
- anomalies in the structure of the uterus;
- pathology of the cervix (cicatricial deformity, ectopia, condition after reconstructive treatment of diseases of the cervix.

Treatment
Correction of isthmic-cervical insufficiency is carried out by suturing the cervix (cervical or transabdominal cerclage); the introduction of an obstetric pessary: ​​or their joint use.

Indications, contraindications, conditions for correction of isthmic-cervical insufficiency with suturing and obstetric pessary do not differ significantly, except for the timing of their use.

Suturing is advisable from 14-16 to 22 weeks, obstetric pessary from 17 weeks to 32-33 weeks. Indications, contraindications, conditions for cerclage and the introduction of a pessary do not differ.

Indications for correction of isthmic-cervical insufficiency.
Signs of isthmic-cervical insufficiency according to vaginal examination.
ECHO-signs of isthmic-cervical insufficiency according to transvaginal sonography.
The number of points is 5-6 or more (on a scale for assessing isthmic-cervical insufficiency).
Altered psychoadaptive responses to termination of pregnancy.

The presence in the anamnesis of spontaneous miscarriages, multiple pregnancy, premature birth, cicatricial deformity of the cervix, exacerbates the need for correction of isthmic-cervical insufficiency. The combined use of a cervical cerclage and an obstetric pessary is advisable when the head is located low, to prevent suture failure during surgical correction.

Contraindications for correction of isthmic-cervical insufficiency:
- diseases that are a contraindication to prolongation of pregnancy;
- congenital malformations of the fetus, not amenable to correction;
- acute inflammatory diseases of the pelvic organs - III-IV degree of purity of the vaginal contents;
- bleeding at the time of detection of isthmic-cervical insufficiency, due to the presence of retrochorial hematoma, placenta previa;
- increased tone of the uterus, not amenable to treatment;
- the presence of signs of chorioamnionitis and / or vulvovaginitis.

Conditions for the correction of isthmic-cervical insufficiency:
- gestational age for cervical cerclage from 15-16 to 20-22 weeks; obstetric pessary from 17 weeks to 32-33 weeks;
- a whole fetal bladder;
- no pronounced prolapse of the fetal bladder into the vagina.

Preparing for the operation:
- microbiological examination of the vaginal discharge and cervical canal of the cervix;
- tocolytic therapy according to indications;
Antibacterial therapy according to indications, taking into account the sensitivity of the flora to antibiotics.

Suturing the cervix
Cervical cerclage.

Cervical cerclage is performed under intravenous or spinal anesthesia.

The most commonly used methods currently are.
Closure of the uterus with a circular purse-string suture (according to MacDonald). At the border of the transition of the mucous membrane of the anterior fornix of the vagina, a purse-string suture is applied to the cervix of a durable material (lavsan, silk, chrome-plated catgut, mersilene tape) with the needle passed deep through the tissues, the ends of the threads are tied in a knot in the anterior fornix of the vagina. The long ends of the ligature are left so that they are easy to detect before childbirth and can be easily removed.
U-shaped sutures on the cervix. At the border of the transition of the mucous membrane of the anterior vaginal fornix, 0.5 cm away from the midline on the right, the cervix is ​​pierced with a needle with mylar thread through the entire thickness, making a puncture in the back of the vaginal fornix. The end of the thread is transferred to the left lateral part of the vaginal fornix, the mucous membrane and part of the thickness of the cervix are pierced with a needle, making an injection 0.5 cm to the left of the midline. The end of the second lavsan thread is transferred to the right lateral part of the vaginal fornix, then the mucous membrane and part of the thickness of the uterus in the anterior part of the vaginal fornix are pierced. A tampon is left in the vagina for 2-3 hours.

Transabdominal cerclage. In exceptional cases, with pronounced anatomical defects of the cervix, it is possible to perform a transabdominal cerclage, using the laparoscopic method, or to perform a laparotomy. Transabdominal cerclage is performed when planning a pregnancy.

Indications: condition after high conization of the cervix, when suturing the vaginal part of the uterus is impossible.

Contraindications and conditions for transabdominal cerclage are the same as for vaginal cerclage.

Operation technique. Transsection is performed by laparoscopic or laparotomy method, under regional anesthesia. Laparoscopy or abdominal surgery is performed according to the usual technique. The vesicouterine fold is opened with laparoscopic scissors in the transverse direction, the bladder is separated down. The mersilene tape is applied above the cardinal and utero-sacral ligaments by piercing the sheets of the broad ligament paracervically, the ends of the tape are tied together in front by intracorporeal knot formation. After completion of laparoscopy, hysteroscopy is performed to control the correct suturing: the mersilene tape in the lumen of the cervical canal should not be detected. A month later, a control ultrasound is performed. The presence of sutures on the cervix after a transabdominal cerclage is an indication for caesarean section with the development of labor or other complications of pregnancy.

Complications of correction of isthmic-cervical insufficiency:
- spontaneous abortion;
- bleeding;
- rupture of the amniotic membranes;
- necrosis, eruption of cervical tissue with threads;
- the formation of bedsores, fistulas;
- circular separation of the cervix (at the onset of labor and the presence of sutures).

Disadvantages of surgical correction of isthmic-cervical insufficiency:
- invasiveness of the method;
- the need for anesthesia;
- complications associated with the method (damage to the fetal bladder, induction of labor);
- the risk of suturing in terms >24-25 weeks due to the risk of complications;
- the risk of damage to the cervix at the onset of labor.

Obstetric pessaries
Currently, various types of obstetric pessaries are used to prevent isthmic-cervical insufficiency. The most common obstetric unloading pessary "Juno" (Belarus) and "Doctor Arabin" (Germany).

Benefits of an obstetric pessary:
- simplicity and safety of the method, the possibility of application, both in a hospital and outpatient;
- use in terms of gestation more than 23-25 ​​weeks, when suturing the neck is associated with possible complications;
- economic efficiency of the mechanism of action of the obstetric pessary;
- does not require anesthesia.

The mechanism of action of the obstetric pessary:
- closure of the cervix with the walls of the central opening of the pessary.
- formation of a shortened and partially open neck.
- reducing the load on the incompetent neck due to the redistribution of the pressure of the presenting part on the pelvic floor.
- physiological sacralization of the cervix due to fixation in the central hole of the pessary displaced backwards.
- partial transfer of intrauterine pressure to the anterior wall of the uterus due to the ventral-oblique position of the pessary and sacralization of the cervix.
- preservation of the mucous plug, reduced sexual activity can reduce the likelihood of infection.
- protection of the lower pole of the fetal bladder due to the combination of active ingredients
- improvement of the psycho-emotional state of the patient.

The technique of introducing the unloading obstetric pessary "Juno" (Belarus). Sizes are selected depending on the size of the vagina, the diameter of the neck, the presence of childbirth in history.

After emptying the bladder, the pessary is treated with glycerin and placed vertically. The wide base is located at the entrance to the vagina. The lower pole of the wide base is inserted first, then, by pressing on the back wall of the vagina, the upper half-ring of the wide base is inserted. After complete insertion, the pessary is located in the vagina with a wide base in the posterior fornix; the small base is under the pubic joint.

The method of inserting the obstetric pessary "Doctor Arabin" (Germany). The pessary is inserted into the vagina in the sagittal plane. In the wide plane of the cavity of the small pelvis, it unfolds into the frontal plane with a convex side to the cervix. The neck should be in the inner ring of the pessary.

After the introduction of the pessary, you should make sure that there is no pain, and the pessary does not fall out when straining. After the introduction of the pessary, an examination is made every 10-14 days to determine the effectiveness and treatment of the vagina. The technique for removing the pessary is the reverse of insertion.

After removing the pessary, the vagina is sanitized. Features of the management of pregnant women after correction of isthmic-cervical insufficiency:
- you are allowed to get up and walk immediately after the operation;
- treatment of the vagina and cervix with one of the indicated solutions: 3% solution of hydrogen peroxide monohydrate, benzyldimethyl-myrostoylamino propylammonium chloride monohydrate, chlorhexidine (in the first 3-5 days);
- for therapeutic and prophylactic purposes, the following drugs are prescribed (according to indications):
- β-agonists: hexoprenaline 10 mcg in 10 ml of 0.9% sodium chloride solution or calcium antagonists (nifedipine);
- antibiotic therapy according to indications with a high risk of infectious complications, taking into account the data of microbiological examination of the vaginal discharge and sensitivity to antibiotics;
- on an outpatient basis, the sanitation of the vagina is carried out every 2 weeks.

Indications for suture removal and pessary removal:
- gestational age 37 weeks;
- the need for emergency delivery;
- outpouring of amniotic fluid;
- development of labor activity;
- chorioamnionitis.

Information for the patient:
With the threat of termination of pregnancy, especially with habitual miscarriage, it is necessary to monitor the condition of the cervix using ultrasound.
The effectiveness of surgical treatment of isthmic-cervical insufficiency and pregnancy is 85-95%.
It is necessary to observe the medical and protective regimen.

Among the reasons leading to premature termination of childbearing in the II and III trimester, one of the leading positions is occupied by ICI - isthmic-cervical insufficiency. By this term, experts mean the failure of the cervix, its asymptomatic shortening with a concomitant expansion of the internal os. As a result of such changes, the fetal membrane ruptures, followed by a miscarriage.

Classification, causes and signs of pathology

Isthmic-cervical insufficiency is classified as follows:

• a congenital condition that provokes malformations of the uterus and the presence of genital infantilism;
• an acquired condition, which is divided into functional and organic ICI. The first develops under the influence of endocrine dysfunctions, including ovarian hypofunction and hyperandrogenism, the second occurs against the background of complicated childbirth with concomitant ruptures of the uterine cervix, due to surgical interventions and various therapeutic and diagnostic actions affecting the cervix.

The main reason for the formation of isthmic-cervical insufficiency is previous damage, usually it is a difficult birth with ruptures, abortions or diagnostic curettage of the uterine cavity with instrumental cervical dilatation.

Functional ICI can form against the background of a hormonal failure - with a deficiency or excess of certain sex hormones, reduced ovarian functionality, and underdeveloped genital organs. The result can be a disturbed balance of connective and muscle tissue in the uterine neck and isthmus, the muscle cells of the organs react in an unnatural way to the nerve impulses passing through them. In this case, there are no specific symptoms, a woman carrying a child may feel:

• heaviness in the lower abdomen;
• discomfort in the lumbar region;
• frequent urination against the background of the pressure of the child on the bladder.

These signs are rare, usually the discomfort of expectant mothers does not bother. But whatever caused the disease, correction of ICI during pregnancy becomes a reasonable necessity.

Non-surgical treatments for CCI

In medicine, two methods have been developed for correcting isthmic-cervical insufficiency, the treatment of a pathological condition can be non-surgical or surgical. The first include the use of special devices inserted into the vagina - obstetric pessaries. In shape, they are similar to a ring that must be worn on the cervix.

Thus, an obstacle is created for its further disclosure and maintenance of the presenting part of the fetus. Non-surgical methods have many positive aspects:

• pessaries can be used both outpatient and inpatient;
• the use of devices is completely safe and does not cause difficulties;
• you can apply the method when the gestational age exceeds 23-25 ​​weeks and it is quite dangerous to apply stitches to the neck;
• the use of anesthesia is not required;
• economically, this method is not financially costly.

When the device is applied, the uterine cervix is ​​closed by the walls of the hole located in the center of the pessary. The formation of a partially open and shortened organ begins, due to the redistribution of pressure, the load on it decreases. To a certain extent, intrauterine pressure is transmitted to the anterior uterine wall. This method of correction of isthmic-cervical insufficiency ensures the safety of the mucous plug, reduces sexual activity and reduces the risk of infection. The cumulative effect of the components allows you to organize the protection of the lower pole of the bubble, while an additional bonus is the improved psycho-emotional state of the victims.

Today, in order to correct the ICI, various types of pessaries can be used, however, the Juno products and Simurg silicone pessaries in the shape of a butterfly and a ring are in the greatest demand. Dimensions are selected based on the parameters of the vagina, uterine cervix. When collecting an anamnesis, the number of births is taken into account.

Some features of the procedure

After the patient empties the bladder, the pessary is treated with glycerin and placed in a vertical position with a wide base towards the vaginal entrance. This side is introduced first, after pressing on the posterior vaginal wall, the upper half-ring of the base is inserted. The neck should fall into the central hole of the fixture.

After the pessary is inserted, you will need to make sure that there is no pain. Also, the device should not fall out if the woman is pushing. After placing the pessary in the vagina, examinations should be made every 10 days or two weeks, which are necessary to determine the effectiveness and control of the vaginal treatment.

Before placing the ring in the vagina, it is obligatory to take a smear on the flora - in this way it is possible to identify the presence of an inflammatory process that requires treatment. After placing the pessary in the vagina, regular treatment - at intervals of 2 or 3 weeks - will be required, the same rule applies to the ring. For this, antiseptic solutions are used.

Surgical intervention

It should be understood that the use of a pessary is not always effective. Surgical correction of the ICI will be required when the fetus bulges into the uterine cervical canal or with severe insufficiency. The surgical method is based on suturing the organ, which is indicated in the case of:

• history of spontaneous abortions;
• previously observed premature labor activity;
• progressive insufficiency of the uterine cervix, when its length is less than 25 mm in accordance with the results of trans-vaginal ultrasound.

Contraindications to surgical intervention are pathologies in the presence of which the preservation of pregnancy is impractical. These can be problems with the heart and blood vessels, liver diseases, genetic abnormalities. The surgical method is not used with increased uterine excitability and tone, in case of bleeding, with malformations of the fetus, inflammatory processes occurring in the vagina.

Usually, sutures are placed on the uterine cervix during the period of 13-27 weeks of gestation, while the exact period is determined individually. The most favorable time period for surgical intervention falls on the 15-19th week. At this time, there is no bulging of the fetal bladder into the canal, and the opening of the uterine cervix is ​​weakly expressed. Sutures are removed at 37-38 weeks of gestation, this procedure is completely safe and painless.

Our obstetric "butterfly" unloading pessaries are an effective measure for the prevention and treatment of CCI. The products have passed all the necessary clinical trials and have all the necessary certificates and permits.