Modern methods of correction of isthmic-cervical insufficiency. Protocol for managing recurrent miscarriage. Surgical methods for correcting isthmic-cervical insufficiency

Miscarriage remains an important problem in modern obstetrics and perinatology. Relevance is determined by its social and medical significance. The incidence of miscarriage is 10-25% of all pregnancies. The 2015 FIGO guidelines for overcoming very early and early births state that over the past 40 years, the frequency of preterm births has not decreased, but there has been a trend towards an increase in miscarriage due to an increase in the number of undeveloped pregnancies. Prematurity is the leading cause of death among newborns. Premature babies account for over 50% of stillbirths, perinatal morbidity and mortality reaches 75-80%.

Isthmic-cervical insufficiency - ICI (lat. insufficientia isthmicocervicalis; anat. isthmus "isthmus of the uterus" + cervix "cervix") - a pathological condition of the isthmus and cervix during pregnancy, in which they are not able to withstand intrauterine pressure and hold the enlarging fetus in uterine cavity until timely birth. The incidence of ICI ranges from 7.2 to 13.5%, and the relative risk of this pathology increases with the number of induced labors. In the structure of habitual pregnancy loss, ICI accounts for 40% in the second trimester of pregnancy, and in the third trimester, ICI occurs in every third case. There are organic and functional ICN. Organic, or secondary, or post-traumatic ICI occurs as a result of previous curettage of the uterus, accompanied by mechanical expansion of the cervical canal, as well as pathological childbirth, including the use of minor obstetric operations (vacuum extraction of the fetus, application of obstetric forceps), leading to cervical ruptures uterus. Functional ICI is the result of a change in the proportional relationship between muscle and connective tissue and, as a consequence, pathological reactions of the cervix to neurocirculatory stimuli.

The mechanism of abortion with ICI does not depend on its type and lies in the fact that due to the shortening of the cervix, its softening, gaping of the internal pharynx and cervical canal, the fertilized egg does not have physiological support in the lower segment. With an increase in intrauterine pressure on the area of ​​the functionally insufficient lower segment of the uterus and internal os, the membranes protrude into the cervical canal, they become infected and open.

Making an accurate diagnosis of ICI is possible only during pregnancy, since in this case there are conditions for a functional assessment of the condition of the cervix and isthmus.

Pregnancy in cases of ICI usually proceeds without symptoms of threatened miscarriage. The pregnant woman has no complaints; normal uterine tone is noted upon palpation. When examining the cervix in the speculum, a gaping external os of the cervix with flaccid edges is visible; prolapse of the amniotic sac is possible. During bimanual vaginal examination, shortening and softening of the cervix is ​​determined, the cervical canal passes the finger beyond the area of ​​the internal pharynx. To diagnose ICN, obstetricians-gynecologists use scoring systems for the condition of the cervix.

In recent years, transvaginal echographic examination has been used to monitor the condition of the cervix. Despite the widespread use of echography in the diagnosis of fetal anomalies and other pregnancy pathologies, there are still no clearly regulated criteria for diagnosing ICI.

According to A.D. Lipman, the following criteria should be taken into account: a cervical length of 30 mm is critical in first- and multi-pregnant women with a gestation period of less than 20 weeks and requires intensive monitoring of the woman, classifying her as a risk group. A neck length of 20 mm or less is an absolute criterion for ICI and requires intensive treatment. In multiparous women, ICI is indicated by shortening of the cervix at 17-20 weeks to 29 mm. In women with multiple pregnancies before 28 weeks of pregnancy, the lower limit of normal is cervical length 37 mm in primigravidas and 45 mm in multigravidas.

According to L.B. Markina, A.A. Korytko, the ratio of the length of the cervix to the diameter of the cervix at the level of the internal os is less than 1.16 is a criterion for ICI with a norm of 1.53.

A.I. Strizhakov et al. It is believed that the characteristic of ICN is a V-shaped deformation of the internal os with prolapse of the amniotic sac.

According to S.L. Voskresensky, changes in the echostructure of the cervix (small fluid inclusions and hyperechoic linear echoes) indicate hemodynamic changes in the vessels of the cervix and may be the initial signs of cervical insufficiency.

According to the Fetal Medicine Foundation, the length of the cervical canal during transvaginal examination at 22-24 weeks of pregnancy normally has an average value of 36 mm (Fig. 1). The risk of spontaneous miscarriage is inversely proportional to cervical length and increases exponentially when the cervical canal length is less than 15 mm. In multiple pregnancies, the threshold for an exponential increase in risk is a cervical length of 25 mm. Dilatation of the internal pharynx, manifested on ultrasound by the appearance of a funnel in this area, is nothing more than an echographic criterion reflecting the process of shortening of the cervix, which subsequently leads to premature birth (Fig. 2).

Rice. 1.

Rice. 2.

According to the recommendations of the FIGO Congress in 2012, and then the resolution of the Expert Council at the 16th World Congress on Human Reproduction in 2015, the use of vaginal progesterone is indicated for the prevention of preterm birth in singleton pregnancies with a cervical length of 25 mm or less on transvaginal echography at a gestational age of 19-24 weeks.

According to FIGO 2015 recommendations, the length of the cervical canal with transvaginal ultrasound cervicometry of 35 mm or less indicates a threat of preterm birth, 25 mm or less indicates a high risk of immediate preterm birth. Expansion of the internal os to 5 mm or more, especially up to 10 mm, also indicates a high risk of premature birth.

We conducted our own study with the aim of conducting a comparative analysis of data obtained from bimanual vaginal examination and transvaginal echography of the cervix in pregnant women with suspected ICI.

Material and methods

A prospective analysis included 103 pregnant women admitted to the hospital. The criteria for selecting pregnant women for the study were: singleton pregnancy, absence of regular labor and rupture of amniotic fluid, absence of prolapse of the membranes. Transvaginal echography was performed within 30 minutes after a vaginal examination of the pregnant woman in the chair by an obstetrician-gynecologist.

Ultrasound examinations were carried out using a SonoAce-9900 device (Samsung Medison) with a transabdominal sensor of 3.5-6 MHz and a transvaginal sensor of 4.5-7.5 MHz. Initially, with transabdominal echography, fetometric parameters, the absence of congenital malformations and markers of chromosomal abnormalities, the absence of placenta previa, signs of placental abruption and prolapse of the amniotic sac were assessed. Then the length of the cervix was measured using a transvaginal sensor using the following method:

• the woman empties her bladder and lies on her back, with her legs bent at the knees;
• an ultrasound sensor is inserted into the vagina and located in the anterior fornix (you should try to avoid excessive pressure on the cervix, which can lead to an artificial increase in its length);
• a sagittal section of the cervix should be displayed on the screen, and the echogenic mucosa of the endocervix is ​​used as a guide to the real location of the internal os, thus avoiding erroneous measurement of the lower uterine segment;
• use calipers to measure the linear distance between the triangular area of ​​increased echogenicity of the external pharynx and the V-shaped notch in the area of ​​the internal pharynx;
• each measurement should be carried out with a break of 2-3 minutes. In 1% of cases, the length of the cervix may change due to uterine contractions, and in these cases the smallest value of the length of the cervical canal is documented.

Measuring cervical length using the transvaginal method is highly reproducible, and in 95% of cases the difference between two measurements performed by the same specialist or two different ones is 4 mm or less.

Statistical processing of the obtained material was carried out using the STATISTICA 6.0 package. In cases of distribution other than normal, the study results were presented as Me (25.75%), where Me is the median, and 25.75% are the upper and lower quartiles. In all cases, the critical significance level p was taken equal to 0.05.

Results and discussion

The average gestational age was 26 weeks 2 days (23 weeks 1 day; 30 weeks 2 days). The average length of the cervix during bimanual examination was significantly lower (p

The diagnosis of ICI after bimanual examination was made in 13 cases. Only in 3 cases was it confirmed by transvaginal echography of the cervix. Overdiagnosis of ICI was observed in 10 cases after vaginal examination. However, in 14 cases, transvaginal echography diagnosed ICI, despite the normal length and consistency of the cervix during vaginal examination.

In 28 pregnant women, in addition to transvaginal echographic measurement of cervical length, transabdominal cervicometry was performed. In 6 cases, it was not possible to measure the length of the cervix and assess the condition of the internal os during transabdominal examination due to the low position of the fetal head, lack of filling of the bladder, and characteristics of the subcutaneous fat.

Conclusion

Transvaginal echography in the diagnosis of ICI has 100% sensitivity and 80% specificity. With transabdominal echography, the measured length of the cervix may not correspond to the true length in most cases, especially with a shortened cervix. Moreover, successful imaging requires a woman's full bladder, which, by compressing her, increases the length of the cervix by an average of 5 mm.

When conducting routine ultrasound examinations of the fetus, according to the protocol, at 18-22 weeks of pregnancy, a transvaginal echographic assessment of the condition of the cervix is ​​necessary to form a risk group for the development of ICI and the prevention of premature birth.

In women at risk for the formation of ICI, dynamic monitoring of the condition of the cervix using transvaginal cervicometry is necessary, since bimanual vaginal examination is highly subjective, and repeated examinations can lead to increased excitability and contractile activity of the uterus.

Despite the fact that the effectiveness and reliability of cervical assessment using transvaginal echography has long been undeniable, the criteria for diagnosing ICI are constantly being adjusted.

Literature

1. Recommendations of the International Federation of Obstetricians and Gynecologists (FIGO) 2015. Improving practical approaches in obstetrics and fetal medicine. Newsletter / Ed. Radzinsky V.E. M.: editorial office of the magazine Status Praesens. 2015. 8 p.
2. Prevention of miscarriage and premature birth in the modern world. Resolution of the Expert Council at the 16th World Congress on Human Reproduction (Berlin, March 18-21, 2015) Newsletter. M.: editorial office of the magazine Status Praesens. 2015. 4 p.
3. Zhuravlev A.Yu., Dorodeiko V.G. The use of an unloading obstetric pessary in the treatment and prevention of miscarriage in isthmic-cervical insufficiency // Protection of motherhood and childhood. 2000. No. 1. P. 24-35.
4. Sidorova I.S., Kulakov V.I., Makarov I.O. Guide to obstetrics. M.: Medicine, 2006. pp. 331-335.
5. Sidelnikova V.M. Habitual pregnancy loss. M.: Triada-X, 2002. P. 304.
6. Lipman A.D. Ultrasound criteria for isthmicocervical insufficiency // Obstetrics and gynecology. 1996. No. 4. P. 5-7.
7. Markin L.B., Korytko A.A. 1st Congress of the Association of Ultrasound Diagnostics in Medicine: Abstracts, Moscow, 1991. P. 37.
8. Strizhakov A.I., Bunin A.T., Medvedev M.V. Ultrasound diagnostics in an obstetric clinic. M., Medicine, 1991. P. 23-31.
9. Voskresensky S.L. Possibilities of ultrasound in the diagnosis of miscarriage // Ultrasound diagnostics in obstetrics, gynecology and pediatrics. 1993. No. 3. P. 118-119.
10. Guide to outpatient care in obstetrics and gynecology / Edited by Kulakov V.I., Prilepskaya V.N., Radzinsky V.E. M.: GOETAR-Media, 2007. pp. 133-137.

Isthmicocervical insufficiency (ICI) is a pathological condition characterized by insufficiency of the isthmus and cervix, leading to spontaneous abortion in the second and third trimesters of pregnancy. In other words, this is a condition of the cervix during pregnancy in which it begins to thin out, becoming soft, shortening and opening, losing the ability to hold the fetus in the uterus for up to 36 weeks. ICI is a common cause of miscarriage between 16 and 36 weeks.

Reasons for ICN

In accordance with the reasons, ICNs are divided into:

- organic ICN– as a result of previous injuries to the cervix during childbirth (ruptures), curettage (during abortion/miscarriage or for diagnosing certain diseases), during the treatment of diseases, for example, erosion or polyp of the cervix using the method of conization (excision of part of the cervix) or diathermocoagulation (cauterization). As a result of injury, normal muscle tissue in the cervix is ​​replaced by scar tissue, which is less elastic and more rigid (harder, stiffer, inelastic). As a result of this, the cervix loses the ability to both contract and stretch and, accordingly, cannot fully contract and retain the contents of the uterus inside.

- functional ICN, which develops for two reasons: due to a violation of the normal ratio of connective and muscle tissues in the cervix or a violation of its sensitivity to hormonal regulation. As a result of these changes, the cervix becomes too soft and pliable during pregnancy and dilates as pressure from the growing fetus increases. Functional ICI may occur in women with ovarian dysfunction or may be congenital. Unfortunately, the mechanism of development of this type of ICI has not yet been sufficiently studied. It is believed that in each individual case it is individual and there is a combination of several factors.

In both cases, the cervix is ​​not able to resist the pressure of the growing fetus from inside the uterus, which leads to its dilatation. The fetus descends into the lower part of the uterus, the fetal bladder protrudes into the cervical canal (prolapses), which is often accompanied by infection of the membranes and the fetus itself. Sometimes, as a result of infection, amniotic fluid leaks.

The fetus descends lower and puts even more pressure on the cervix, which opens more and more, which ultimately leads to late miscarriage (from 13 to 20 weeks of pregnancy) or premature birth (from 20 to 36 weeks of pregnancy).

Symptoms of ICN

There are no clinical manifestations of ICI during or outside of pregnancy. The consequence of ICI in the second and third trimesters is spontaneous termination of pregnancy, which is often accompanied by premature rupture of amniotic fluid.

Outside of pregnancy, isthmicocervical insufficiency does not threaten anything.

Diagnosis of ICI during pregnancy

The only reliable method of diagnosis is vaginal examination and examination of the cervix in speculums. A vaginal examination reveals the following signs (individually or in combination with each other): shortening of the cervix, in severe cases - sharp, softening and thinning; the external pharynx can be either closed (more often in primigravidas) or gaping; the cervical (cervical) canal may be closed or allow the tip of a finger, one finger or two to pass through, sometimes with separation. When examined in the speculum, a gaping of the external os of the cervix with a prolapsed (protruding) amniotic sac may be detected.

Sometimes, if there is questionable data from a vaginal examination in the early stages of development, ultrasound helps diagnose ICI, which can detect an expansion of the internal os.

Complications of ICI during pregnancy

The most severe complication is termination of pregnancy at various stages, which can begin with or without rupture of amniotic fluid. ICI is often accompanied by infection of the fetus due to the lack of a barrier to pathogenic microorganisms in the form of a closed cervix and cervical mucus, which normally protects the uterine cavity and its contents from bacteria.

Treatment of ICI during pregnancy

Treatment methods are divided into operative and non-operative/conservative.

Surgical treatment of ICI

The surgical method involves placing sutures on the cervix to narrow it, and is carried out only in a hospital. There are various methods of suturing, their effectiveness is almost the same. Before treatment, an ultrasound of the fetus is performed, its intrauterine condition, the location of the placenta, and the condition of the internal os are assessed. From laboratory tests, a smear analysis of the flora is required, and if inflammatory changes are detected in it, treatment is carried out. The operation is performed under local anesthesia; after the operation, the patient is prescribed antispasmodic and painkillers for prophylactic purposes for several days.

After 2-3 days, the consistency of the sutures is assessed and if their condition is favorable, the patient is discharged under the supervision of a doctor at the antenatal clinic. Complications of the procedure may include: increased uterine tone, prenatal rupture of amniotic fluid, infection of sutures and intrauterine infection of the fetus.

If there is no effect and ICI progresses, it is not recommended to prolong pregnancy, since the sutures can cut through, causing bleeding.

Contraindications for suturing the uterus are:

Untreated genitourinary tract infections;
- history of pregnancy terminations in the second and third trimesters (recurrent miscarriage);
- the presence of intrauterine fetal malformations incompatible with life;
- uterine bleeding ;
- severe concomitant diseases that are a contraindication for prolonging pregnancy (severe cardiovascular diseases, impaired renal and/or liver function, some mental illnesses, severe gestosis in the second half of pregnancy - nephropathy of degrees II and III, eclampsia and preeclampsia);
- increased uterine tone that cannot be treated with medication;
- progression of ICN - rapid shortening, softening of the cervix, opening of the internal pharynx.

Conservative treatment of ICI

The non-operative method consists of narrowing the cervix and preventing it from opening by installing a pessary. A pessary is a ring made of latex or rubber that is “put” on the cervix so that its edges rest against the walls of the vagina, holding the ring in place. This method of treatment can be used only in cases where the cervical canal is closed, i.e. in the early stages of ICI or if it is suspected, and can also be an addition to suturing.

Every 2-3 days, the pessary is removed, disinfected and reinstalled. The method is less effective than the first, but has several advantages: bloodlessness, ease of implementation and no need for hospital treatment.

Prediction of pregnancy outcome with ICI

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

Prevention of ICN

It consists of careful curettage, examination and suturing of cervical ruptures after childbirth, cervical plastic surgery when old ruptures are detected outside of pregnancy, and treatment of hormonal disorders.

Obstetrician-gynecologist Kondrashova D.V.

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1 ISTHMICO-CERVICAL INSUFFICIENCY. PREGNANCY MANAGEMENT TACTICS ICI is a painless dilatation of the cervix in the absence of uterine contractions, leading to spontaneous termination of pregnancy. Most often, the diagnosis is made retrospectively, since rapid and painless dilatation of the cervix in the 2nd or 3rd trimester ends in miscarriage or early premature birth. There are no objective criteria in the early stages. More often there is a combination of causative factors leading to ICI. Mechanism of abortion in ICI As a rule, due to an increase in mechanical load on the area of ​​the incompetent internal os, prolapse of the membranes into the cervical canal occurs, followed by infection of its membranes due to contact with the vaginal flora, rupture of the membranes and rupture of amniotic fluid. Classification of ICI According to etiology Functional (ovarian hypofunction, hyperandrogenism). Organic (traumatic) abortions, terminations of pregnancy, traumatic births, after cesarean section with full dilatation of the cervix, surgical interventions on the cervix. Congenital (abnormal uterine structure, hypoplasia). According to the shape of the cervix (sonographic classification) T-shaped internal os Y-shaped internal os V-shaped internal os U-shaped internal os the most unfavorable forms Risk groups for the development of ICI

2 History of cervical trauma. Hyperandrogenism. Malformations of the uterus. Connective tissue dysplasia (CTD). Genital infantilism. Pregnancy that occurs after induction of ovulation by gonadotropins. Multiple pregnancy. Increased load on the cervix during pregnancy (polyhydramnios, large fetus). Diagnosis of ICI Vaginal examination data Cervical length. Condition of the cervical canal. The location of the cervix in relation to the axis of the uterus. The consistency of the cervix, which can only be determined by vaginal examination. Location of the presenting part. Ultrasound data (transvaginal echography “gold standard”) Length of the cervix. The length of the closed part is assessed; shortening it to 25 mm requires more detailed observation and expansion of indications for correction. Cervical shortening of less than 20 mm is an absolute indication for cervical correction. Condition of the cervical canal. Condition of the internal os and cervical canal. In patients with an opening of the internal pharynx, its shape is assessed. Ultrasonographic criteria for changes in the cervix during pregnancy complicated by ICI (transvaginal technique) The length of the cervix, equal to 3 cm, is critical in first- and multi-pregnant women with a gestational age of less than 20 weeks and requires intensive monitoring of the woman, classifying her as a risk group. A cervical length of 2 cm or less is an absolute criterion for ICI and requires intensive treatment. In multiparous women

3 women on ICN indicates a shortening of the cervix in weeks up to 2.9 cm. The width of the cervical canal of 1 cm or more during pregnancy up to 21 weeks indicates cervical insufficiency. The ratio of length to diameter of the cervix at the level of the internal os is less than 1.6 is a criterion for ICI. Prolapse of the amniotic sac with deformation of the internal os is characteristic of ICN. The V and U-shape is considered the most unfavorable. Changes in the echostructure of the cervix (small liquid inclusions and bright line echoes) indicate hemodynamic changes in the vessels of the cervix and may be the initial signs of cervical insufficiency. When assessing the information content of the length of the cervix, it is necessary to take into account the method of its measurement. The results of a transabdominal ultrasound significantly differ from the results of a transvaginal ultrasound and exceed them by an average of 0.5 cm. Assessment of the ICN The assessment of the ICN is carried out using the Stember scale and with a score of 6-7 or more, correction of the cervix is ​​indicated. Methods for correcting ICI Conservative method (application of an obstetric pessary) Principles and mechanism of action of the pessary Closing the cervix with the walls of the central opening of the pessary. Formation of a shortened and partially open cervix. Reducing the load on the incompetent cervix due to the redistribution of pressure on the pelvic floor. Physiological sacralization of the cervix due to fixation in the central opening of the pessary displaced posteriorly. 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. Preserving the mucus plug and reducing sexual activity can reduce the likelihood of infection.

4 Protection of the lower pole of the ovum thanks to the combination of active components. Improving the psycho-emotional state of the patient. Indications for the use of obstetric pessary Isthmic-cervical insufficiency, including for the prevention of suture failure during surgical correction of ICI. Pregnant women potentially at risk of miscarriage. Women with a history of late miscarriages and premature births, suffering from recurrent miscarriage. Pregnancy after prolonged infertility. Old and young pregnant women. Women with ovarian dysfunction, suffering from genital infantilism. Women with a threat of miscarriage of the current pregnancy in combination with progressive changes in the cervix. Patients with cicatricial deformity of the cervix. Women with multiple pregnancies. Women with a threat of termination of a current pregnancy and altered psychoadaptive reactions regarding the completion of pregnancy. As the main method of treating cervical insufficiency, an obstetric unloading pessary should not be used in cases of severe degrees of ICI (prolapse of the membranes). Advantages of the method: Simplicity and safety, can be used on an outpatient basis, including for the prevention of suture failure. Possibility of use for periods longer than weeks. No anesthesia required. Economic efficiency. Disadvantages of the method Impossibility of using the method in case of severe ICI Types of obstetric pessaries

5 When choosing the size of a domestically produced unloading pessary, the size of the upper third of the vagina, the diameter of the cervix and the presence of a history of childbirth are taken into account. As a rule, a type 1 pessary is used for primiparous women, and a type 2 pessary for multiparous women. When choosing the size of a flexible silicone pessary with perforations type ASQ (Arabin), the width of the cervix (the inner diameter of the pessary corresponds to it), the diameter of the vaginal vault (the outer diameter of the pessary) and anatomical features (the height of the pessary) are taken into account. There are 17 types of Arabian Passaria. These are soft, flexible rings that are easy to insert, do not cause pain to the patient and very rarely become dislodged. In some cases, after its removal, slight swelling is observed, which goes away within a few days and does not affect the birth process in any way. Surgical method Transabdominal cerclage (correction of ICI using abdominal access) Transvaginal cerclage Transvaginal cerclage is performed in a hospital setting under aseptic conditions using spinal anesthesia. A circular suture is placed on the cervix in a modification of the McDonald method using mersilene tape. The advantage of this suture material is that it is a flat, wide tape that fits well into the tissue and does not cut through. Contraindications to surgical and conservative correction of ICI Malformations of the fetus, in which prolongation of pregnancy is inappropriate. Suspicion of leakage of amniotic fluid. It is mandatory to use modern test systems for water leakage if there is a suspicion, since patients with ICI often have mucous discharge and need to be differentiated. Choriamnionitis. Stitching may be unsafe for the patient's life. Regular labor/pronounced uterine tone. Suturing can lead to miscarriage, so tocolytic therapy is mandatory in preparation for surgical correction.

6 Bloody discharge from the genital tract due to placental abruption. Suspicion of failure of the uterine scar. Conditions in which prolongation of pregnancy is inappropriate (severe extragenital pathology). Factors negatively affecting the effectiveness of surgical correction History of late spontaneous miscarriages. History of ICI. History of premature birth. Long-term threat of miscarriage. Infection. If pathogenic flora is detected, sanitation is recommended before and after correction. The length of the cervix according to ultrasound before suturing is less than 20 mm. Funnel-shaped expansion of the internal pharynx according to ultrasound is more than 9 mm. Disadvantages of surgical correction Invasiveness of the method. The need for anesthesia and complications associated with it. Complications associated with the method (damage to the membranes, induction of labor). There is a danger of suturing for more than a week due to the high risk of complications. The risk of sutures cutting through at the onset of labor. Tactics of pregnancy management in ICI Clinic of ICI, ultrasound markers, anamnesis data, score of ICI. At 1 week, an obstetric pessary is installed. For up to 23 weeks, the type of ICN (organic or functional) is determined. With organic ICI, surgical correction is indicated, or surgical correction together with the application of a pessary (in cases of severe ICI or multiple pregnancies). For functional ICI, an obstetric pessary is applied. After correction of the ICI, the following is carried out:

7 Bacterioscopic examination of smears (every 2-3 weeks); Ultrasound monitoring of the condition of the cervix (every 2-3 weeks); Tocolytic therapy (if indicated). Early removal of sutures and removal of the pessary is carried out according to indications in the presence of labor. Planned removal of sutures and removal of the pessary is carried out at 37 weeks. Management of patients after pessary insertion. Insertion of the pessary. Ultrasound monitoring of the condition of the cervix and bacterioscopic examination of smears. In the absence of pathology, the pessary is removed at 37 weeks, followed by sanitization of the genital tract. If there are changes according to ultrasound data Up to 20 weeks of hospitalization for suturing and pessary weeks of hospitalization with suturing and tocolytic therapy as indicated. More than 23 weeks of hospitalization with additional treatments. If there are changes in the microflora, sanitation is carried out against the background of a pessary during the day. If the treatment has a positive effect, the pessary is removed at 37 weeks. If the effect is negative, after 36 weeks the pessary is removed and the genital tract is sanitized. At up to 36 weeks, the pessary is removed, the genital tract is sanitized, followed by the introduction of a pessary. Correction of ICI using abdominal access was first performed in 1965 using laparotomy access. Today, cerclage is performed laparoscopically; sutures are placed at the level of the isthmus, which improves the obturator function. Stages: The vesicouterine fold is opened, the bladder is displaced downward, and bifurcations of the accessory branches of the uterine arteries are visualized.

8 A “window” is created medial to the uterine artery on each side by dissecting the broad ligament of the uterus. An injection is made through one “window”, the posterior portion of the cervix is ​​sutured at the level of the uterosacral ligaments. The injection is made through the second “window”. The ends of the thread are tied in front of the uterus with double knots. Peritonization is not performed. Indications Absence or sudden shortening of the cervix with a history of pregnancy loss. History of unsuccessful attempts at suturing via vaginal access. Advantages Correction can be carried out for those patients who cannot undergo correction through vaginal access. Sutures are placed in the isthmus area, which is more reliable. Disadvantages The patient undergoes two transabdominal correction surgeries and a cesarean section, since this is the only method of delivery for laparoscopic correction of ICI. Contraindications Prolapse or rupture of membranes Intrauterine infection Vaginal bleeding Antenatal fetal death Labor General contraindications to laparoscopic intervention % of laparoscopic correction procedures for ICI are performed during pregnancy, the rest preventively before pregnancy. This allows you to avoid surgery during pregnancy and reduce blood loss. Preventive sutures do not interfere with spontaneous pregnancy.

9 Sutures may be removed during caesarean section or left in place for subsequent pregnancies. During pregnancy, sutures can be removed laparoscopically if necessary. Questions about the lecture 1. A pessary is a foreign body, which is an excellent substrate for the development of pathogenic saprophytic flora. What to do in this situation? Following the recommendations given in today's webinar, indications for antibacterial therapy can be expanded if pathogenic flora is detected. 2. How to measure the vaginal vault to select an obstetric pessary? Manufacturers of imported pessaries offer special rings for measuring the vaginal vault. You can also use palpation data. 3. How can a pessary close the internal os? Sacralization is questionable; the central foramen is not displaced posteriorly. This directly concerns the domestic pessary. The opening is located ventro-sacral and actually fixes the neck posteriorly. It does not close the internal os, but it is important that it allows you to maintain the length and improve the psycho-emotional state of the patient. 4. It is recommended to carry out ultrasound control vaginally. What about the pessary? As for the soft pessary, no problems arise during the study. With a rigid pessary, you can start with a transabdominal examination. If necessary, we also perform vaginal. 5. During IVF, several embryos are often transferred; maybe preventive cerclage should be performed immediately? If we are talking about cervical correction during pregnancy, then when a multiple pregnancy occurs, the indications for one or another type of correction expand. If we are talking about patients with cervical defects, then transabdominal cerclage is recommended before transfer.

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

CLASSIFICATION OF ISTHMICO-CERVICAL INSUFFICIENCY

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

DIAGNOSIS OF ISTHMICO-CERVICAL INSUFFICIENCY

Criteria for diagnosing ICI 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 deformation of the cervix).

The severity of ICI is determined using 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 ICI: the length of the cervix, the condition of the internal pharynx and the cervical canal are assessed.

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

Ultrasound monitoring of the cervix should be performed starting in the first trimester of pregnancy to truly assess the reduction in cervical length. A cervical length of 30 mm is critical at less than 20 weeks and requires intensive ultrasound monitoring.

Ultrasound signs of ICN:

· 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 an opening of the internal pharynx, it is advisable to evaluate its shape (Y, V or U-shaped), as well as the severity of the depression.

INDICATIONS FOR SURGICAL CORRECTION OF ISTHMYCOCERVICAL INSUFFICIENCY

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

CONTRAINDICATIONS TO SURGICAL CORRECTION OF ISTHMYCOCERVICAL INSUFFICIENCY

· Diseases and pathological conditions that are a contraindication to prolongation of pregnancy.
· Bleeding during pregnancy.
· Increased uterine tone that cannot be treated.
· Congenital malformation of the fetus.
· Acute inflammatory diseases of the pelvic organs (PID) - III–IV degree of purity of vaginal contents.

CONDITIONS FOR THE OPERATION

· Gestation period is 14–25 weeks (the optimal gestational age for cervical cerclage is up to 20 weeks).
· Whole amniotic sac.
· Lack of significant cervical effacement.
· Absence of pronounced prolapse of the membranes.
· No signs of chorioamnionitis.
· Absence of vulvovaginitis.

PREPARATION FOR OPERATION

· Microbiological examination of vaginal discharge and cervical canal.
· Tocolytic therapy as indicated.

METHODS OF PAIN RELIEF

· 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 s intravenously until clinical symptoms of anesthesia appear. The average dose is 1.5–2.5 mg/kg body weight.

SURGICAL METHODS FOR CORRECTION OF ISTHMICO-CERVICAL INSUFFICIENCY

The most acceptable method currently is:

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

It is also possible to use other methods for correcting ICN:

· Shaped sutures on the cervix according to the method of A.I. Lyubimova and N.M. Mamedalieva.
Operation technique:
At the border of the transition of the mucous membrane of the anterior vaginal vault, 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 posterior part of the vaginal vault.
The end of the thread is transferred to the left lateral part of the vaginal vault, 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 Mylar thread is transferred to the right lateral part of the vaginal vault, then the mucous membrane and part of the thickness of the uterus are pierced with a puncture in the anterior part of the vaginal vault. Leave the tampon in for 2–3 hours.

· Suturing the cervix using the method of V.M. Sidelnikova (for severe ruptures of the cervix on one or both sides).
Operation technique:
The first purse string suture is placed using the MacDonald method, just above the cervical rupture. The second purse-string suture is carried out as follows: below the first, 1.5 cm, a thread is passed through the thickness of the wall of the cervix from one edge of the rupture to the other in a circular manner along a spherical circle. One end of the thread is stuck inside the cervix into the back lip and, picking up the side wall of the cervix, the puncture is made in the front part of the vaginal vault, twisting the torn lateral anterior lip of the cervix like a snail, and brought out into the front part of the vaginal vault. Threads bind.
For suturing, modern suture material “Cerviset” is used.

COMPLICATIONS

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

FEATURES OF MANAGEMENT IN THE POSTOPERATIVE PERIOD

· You are allowed to stand up and walk immediately after the operation.
· Treatment of the vagina and cervix with a 3% solution of hydrogen peroxide, benzyldimechloride monohydrate, chlorhexidine (in the first 3–5 days).
· The following medications are prescribed for therapeutic and prophylactic purposes.
- 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 at a high risk of infectious complications, taking into account microbiological examination of vaginal discharge with sensitivity to antibiotics.
· Discharge from the hospital is carried out on days 5–7 (if the postoperative period is uncomplicated).
· On an outpatient basis, cervical examination is performed every 2 weeks.
· Sutures from the cervix are removed at 37–38 weeks of pregnancy.

INFORMATION FOR THE PATIENT

· If there is a threat of miscarriage, especially with recurrent miscarriage, it is necessary to monitor the condition of the cervix using ultrasound.
· The effectiveness of surgical treatment of ICI and pregnancy rate is 85–95%.
· It is necessary to observe a medical regime.

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

Correlation of ICD-10 and ICD-9 codes:

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

Protocol users: GPs, midwives, obstetricians-gynecologists, therapists, anesthesiologists-resuscitators

Level of evidence scale:

Classification

Spontaneous abortion

By stage of pregnancy:
· early – spontaneous termination of pregnancy before the full 13 weeks of gestation.
· late – spontaneous termination of pregnancy from 13 to 22 weeks.

By stages of development there are:
· threatened abortion;
· abortion in progress;
· incomplete abortion;
· complete abortion;
· failed abortion (cessation of development of the embryo/fetus) – non-developing pregnancy.

Diagnostics (outpatient clinic)

OUTPATIENT DIAGNOSTICS

Diagnostic criteria

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

In case of threatened abortion:
· pain of varying intensity in the lower abdomen;
· moderate bleeding from the genital tract.

During an abortion:
· prolonged pain in the lower abdomen with increasing dynamics to intense pain, having a cramping character;

In case of incomplete/complete abortion:
· nagging pain in the lower abdomen, with increasing dynamics to intense pain, which may have a cramping character and periodically decrease;
· profuse bleeding from the genital tract.

In case of undeveloped pregnancy:
· disappearance of subjective signs of pregnancy, sometimes bloody discharge from the genital tract.

For recurrent miscarriage: termination of three or more pregnancies up to 22 weeks.

Anamnesis:
· there may be spontaneous miscarriages;
· menstrual dysfunction;
· absence of pregnancy for more than 1 year (infertility);

In case of incomplete/complete abortion:
Expulsion of the fertilized egg.

For recurrent miscarriage:
three or more episodes of miscarriage.

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

Physical examination:
· Blood pressure, pulse (with a threatened abortion, hemodynamics are stable; with an abortion in progress/complete/incomplete, a decrease in blood pressure and an increase in heart rate may be observed).

Inspection on mirrors:
· with a threatened abortion and a non-developing pregnancy, there may be scanty or moderate bleeding.
· during an ongoing/complete/incomplete abortion, the external os is open, there is a large amount of bleeding, parts of the fertilized egg in the cervical canal, leakage of amniotic fluid (may be absent in the early stages of pregnancy).
· with recurrent miscarriage, congenital/acquired anatomical defects of the ectocervix, prolapse of the membranes from the external os of the cervix.

Bimanual vaginal examination:
· in case of threatened abortion: there are no structural changes in the cervix, the uterus is easily excitable, its tone is increased, the size of the uterus corresponds to the gestational age;
· during an abortion: the degree of opening of the cervical canal is determined;
· with complete/incomplete abortion: the uterus has a soft consistency, size is less than the gestational age, varying degrees of cervical dilatation;
· with a non-developing pregnancy: the size of the uterus is less than the gestational age, the cervical canal is closed;
· with recurrent miscarriage: possible shortening of the cervix by less than 25 mm/dilatation of the cervical canal by more than 1 cm in the absence of uterine contractions.

Laboratory research[UD-B,C]:

Instrumental studies:

Ultrasonography:
In case of threatened abortion:
· fetal heartbeat is determined;
· the presence of local thickening of the myometrium in the form of a roller protruding into the uterine cavity (in the absence of clinical manifestations, it has no independent significance);
· deformation of the contours of the fetal egg, its indentation due to hypertonicity of the uterus (in the absence of clinical manifestations, it has no independent significance);
· presence of areas of detachment of the chorion or placenta (hematoma);
· self-reduction of one of several embryos.

During abortion in progress:
· complete/almost complete detachment of the ovum.

In case of incomplete abortion:
· the uterine cavity is dilated > 15 mm, the cervix is ​​dilated, the fertilized egg/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.

In case of undeveloped pregnancy:
Diagnostic criteria:
· Fetal CTE is 7 mm or more, no heartbeat;
· the average diameter of the ovum is 25 mm or more, there is no embryo;
· absence of an embryo with a heartbeat 2 weeks after an ultrasound showed a fertilized egg without a yolk sac;
· absence of an embryo with a heartbeat 11 days after an ultrasound showed a fertilized egg 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 higher, then the patient definitely, with 100% probability, has a non-developing 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, - absence of an embryo with a heartbeat 7-10 days after an ultrasound showed a gestational sac with a yolk sac, - absence of an embryo 6 weeks after the start of the last menstruation, - yolk sac larger than 7 mm, - small gestational sac relative to the size of the embryo (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 frozen pregnancy is diagnosed if:
· there is no embryo and no heartbeat both during the first ultrasound and during the second ultrasound 7 days later;
· empty fertilized egg measuring 12 mm or more/fertilized egg with a yolk sac, the same results after 14 days.
N.B.! The absence of a fetal heartbeat is not the only and not obligatory sign of a non-developing pregnancy: at a short stage of pregnancy, the fetal heartbeat is not yet observed.

In case of recurrent miscarriage, threatening 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. Cervical length clearly correlates with the risk of preterm birth and is a predictor of preterm birth. Transvaginal ultrasound measurement of cervical length is a necessary standard in groups at risk of prematurity.

Risk groups for preterm birth include:
· women with a history of premature birth in the absence of symptoms;
women with shortened cervix<25 мм по данным трансвагинального УЗИ в средних сроках при одноплодной беременностипри отсутствии бессимптомов;
· women with a risk of premature birth during this pregnancy;
· women who have lost 2 or more pregnancies at any stage;
· 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 intrauterine pregnancy is confirmed.
NB! Exclusion of pathological conditions characterized by bloody discharge from the genital tract and pain in the lower abdomen, according to current protocols:
· endometrial hyperplasia;
· benign and precancerous processes of the cervix;
· uterine leiomyoma;
· dysfunctional uterine bleeding in women of reproductive and perimenopausal age.

Diagnostics (ambulance)

DIAGNOSIS AND TREATMENT AT THE EMERGENCY CARE STAGE

Diagnostic measures:
Complaints:
· bloody discharge from the genital tract, pain in the lower abdomen.
Anamnesis:
delay of menstruation
A physical examination is aimed at assessing the severity of the patient’s general condition:
· pallor of the skin and visible mucous membranes;
· decreased blood pressure, tachycardia;
· assessment of the degree of external bleeding.

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

Diagnostics (hospital)

DIAGNOSTICS AT THE INPATIENT LEVEL

Diagnostic criteria at the hospital level: see outpatient level.

Diagnostic algorithm: see outpatient level.

List of main diagnostic measures:
· UAC;
Ultrasound OMT (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

Treatment (outpatient clinic)

OUTPATIENT TREATMENT

Treatment tactics:
· antispasmodic therapy - there is no evidence of effective and safe use to prevent miscarriage (LE - B).
· sedative therapy - there is no evidence of effective and safe use to prevent miscarriage (LE - B).
· hemostatic therapy – hemostatics. There is no evidence base for their effectiveness in threatening abortion; the FDA category of safety during pregnancy has not been determined.
· progesterone preparations (for threatened abortion) – with a delay of menstruation of up to 20 days (pregnancy up to 5 weeks) and stable hemodynamics. Progestogen therapy provides better outcome than placebo or no therapy for the treatment of threatened miscarriage and there is no evidence of an increased incidence of gestational hypertension or postpartum hemorrhage as adverse maternal effects, as well as an increased incidence of congenital anomalies in newborns (CA-C).
· removal of the fetal egg during an abortion in progress, incomplete abortion, or non-developing pregnancy by manual vacuum aspiration using an MVA syringe (see the clinical protocol “Medical Abortion”). If pregnancy does not develop, 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 medications.
NB! It is mandatory to obtain written consent for medical and surgical interventions.
NB! If there are clinical signs of threatened abortion in less than 8 weeks of pregnancy and unfavorable signs of pregnancy progression (see Table 2), therapy aimed at maintaining pregnancy is not recommended.
NB! If the patient insists on therapy aimed at maintaining 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.

Drug treatment
· progesterone preparations (UD - B):

Progesterone preparations:
· progesterone solution (intramuscular or vaginal);
micronized progesterone (vaginal capsules);
· synthetic derivatives of progesterone (oral).

When antiphospholipid syndrome (AD-B) is established:
· acetylsalicylic acid 75 mg/day – Acetylsalicylic acid is started as soon as the pregnancy test is positive and continued until delivery (EL-B, 2);
· heparin 5,000 units– subcutaneously every 12 hours/low molecular weight heparin in an average prophylactic dose.
NB! The use of heparin begins as soon as cardiac activity of the embryo is recorded using ultrasound. Heparin use is stopped at 34 weeks of pregnancy (UD-B, 2). When using heparin, platelet levels are monitored weekly for the first three weeks, then every 4 to 6 weeks.
If thrombosis occurred during previous pregnancies, therapy can be continued before childbirth and in the postpartum period (see CP: “Thromboembolic complications in obstetrics” pr. 7 dated August 27, 2015, therapeutic tactics at the stage of delivery).

· progesterone, solution for 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 5000 units
· nadroparin calcium 2850 – 9500 IU anti-Xa

Table - 1. Comparisons of drugs:

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

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

N.B.! Detection and treatment of bacterial vaginosis in early pregnancy reduces the risk of spontaneous abortion and premature birth (UD-A).

· consultation with a hematologist – if antiphospholipid syndrome and abnormalities in the hemostasiogram are detected;
· consultation with a therapist – in the presence of somatic pathology;
· consultation with an infectious disease specialist – if there are signs of TORCH infection.

Preventive actions:
· women with a history of premature birth and/or shortening of the cervix should be identified as a high-risk group for miscarriage for timely administration of vaginal progesterone: in the presence of a history of premature birth from early pregnancy, in case of shortening of the cervix - from the moment of diagnosis.
· use of progesterone to support the luteal phase after ART. The method of administration of progesterone does not matter (you must follow the instructions for the drugs).

Monitoring the patient's condition: after diagnosis and before 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 a given pregnancy (Table No. 2).

Table 2. Prognostic criteria for pregnancy progression

NB! In case of initial detection of unfavorable signs of pregnancy progression, a repeat ultrasound should be performed after 7 days, if the pregnancy has not been terminated. If there is any doubt about the final conclusion, the ultrasound should be performed by another specialist at a higher level of care.

Indicators of treatment effectiveness:
· further prolongation of pregnancy;
· no complications after evacuation of the fertilized egg.

Treatment (inpatient)

INPATIENT TREATMENT

Treatment tactics

Non-drug treatment: No

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

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

List of essential medicines:
Mifepristone 600mg tablets
Misoprostol 200 mg tablets No. 4

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

Table – 2. Comparisons of drugs. Modern reliably effective regimens for medical abortion up to 22 weeks of pregnancy, WHO, 2012.

Surgical intervention:

Other types of treatment: No.

Indications for consultation with specialists:
· consultation with an anesthesiologist-resuscitator – in the presence of hemorrhagic shock/complications of abortion.

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

Indicators of treatment effectiveness.
· prolongation of pregnancy in case of threatened abortion and recurrent miscarriage;
· absence of early complications after evacuation of the fertilized egg.

Further management (1.9):
· prevention of infectious and inflammatory diseases, rehabilitation of foci of chronic inflammation, normalization of vaginal biocenosis, diagnosis and treatment of TORCH infections if they are present/indicated in the anamnesis;
· nonspecific preconception preparation of the patient: psychological assistance to the patient after an abortion, anti-stress therapy, normalization of diet, it is recommended 3 months before conception to prescribe folic acid 400 mcg per day, work and rest schedule, giving up bad habits;
· medical and genetic counseling of women with recurrent miscarriage/confirmed presence of fetal malformation before termination of pregnancy;
· in the presence of anatomical causes of recurrent miscarriage, surgical elimination is indicated. Surgical removal of the intrauterine septum, synechiae, and submucous 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 (POI) and does not lead to an improvement in the prognosis of subsequent pregnancy. After surgery to remove the intrauterine septum and synechiae, contraceptive estrogen-gestagen drugs are prescribed; in case of extensive lesions, an intrauterine contraceptive (intrauterine device) or a Foley catheter is introduced into the uterine cavity along with hormonal therapy for 3 menstrual cycles, followed by their removal and continuation of hormonal therapy for another over 3 cycles.
· women after the third spontaneous termination of pregnancy (recurrent miscarriage), when excluding genetic and anatomical causes of miscarriage, should be examined for possible coagulopathy (family history study, 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;
· failed abortion;
· non-developing pregnancy.