Диагностика и тактика ведения пациенток с истмико-цервикальной недостаточностью

Доброхотова Ю.Э., Боровкова Е.И., Залесская С.А. и др. Диагностика и тактика ведения пациенток с истмико-цервикальной недостаточностью. Гинекология. 2018; 20 (2): 41–45. DOI: 10.26442/2079-5696_2018.2.41-45

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Dobrokhotova Yu.E., Borovkova E.I., Zalesskaya S.A. et al. Diagnosis and management patients with cervical insufficiency. Gynecology. 2018; 20 (2): 41–45. DOI: 10.26442/2079-5696_2018.2.41-45

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Аннотация

Статья посвящена методам диагностики, возможностям терапии и алгоритмам ведения пациенток с истмико-цервикальной недостаточностью (ИЦН). Факторами риска развития ИЦН являются приобретенные и врожденные аномалии шейки матки. Диагноз правомочен только во время беременности. Укорочение длины шейки матки менее 25 мм свидетельствует о наличии ИЦН и риске преждевременных родов. Оптимальными сроками для первичной оценки длины шейки матки являются 16–20 нед. При длине шейки матки более 25 мм, но менее 30 мм с профилактической целью с 19 до 34 нед назначается микронизированный прогестерон по 200 мг во влагалище. При выявлении ИЦН в сроки после 24 нед методом выбора являются назначение микронизированного прогестерона и установка разгрузочного акушерского пессария. Укорочение длины шейки матки в сроки до 24 нед беременности является показанием для хирургической коррекции и серкляжа с последующей терапией микронизированным прогестероном. Применение дифференцированного алгоритма ведения пациенток с ИЦН снижает вероятность неожиданных преждевременных родов и неонатальной заболеваемости и смертности.

Ключевые слова: истмико-цервикальная недостаточность, преждевременные роды, невынашивание беременности, серкляж, акушерский пессарий, микронизированный прогестерон, цервикометрия, эластометрия.

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The article is devoted to diagnostic methods, therapy possibilities and algorithms of management of patients with cervical insufficiency. Risk factors for the development of isthmic-cervical insufficiency are the acquired and congenital anomalies of the cervix. The diagnosis is only valid during pregnancy. Shortening the length of the cervix <25 mm indicates the presence of cervical insufficiency and the risk of premature birth. The optimal timing for the initial evaluation of cervical length are from 16 to 20 weeks. At length of a neck of a uterus more than 25 mm, but less than 30 mm with the preventive purpose from 19 to 34 weeks assigned micronized progesterone 200 mg in the vagina. Identification of cervical insufficiency after 24 weeks the method of choice is the appointment of micronized progesterone and the installation of unloading obstetric pessarium. Shortening of cervical length before 24 weeks of gestation is an indication for cerclage, with subsequent treatment of the micronized progesterone. The use of a differentiated algorithm for management of patients with cervical insufficiency reduces the likelihood of unexpected premature birth and neonatal morbidity and mortality.

Key words: isthmic-cervical insufficiency, preterm labor, miscarriage, cerclage, obstetric pessaries, micronized progesterone, cervicometria, elastography.

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27. Goya M, Pratcorona L, Merced C et al. Cervical pessary in pregnant women with a short cervix (PECEP): an open-label randomised controlled trial. Lancet 2012; 379: 1800.
28. Roberge S, Nicolaides KH, Demers S et al. Prevention of perinatal death and adverse perinatal outcome using low-dose aspirin: a meta-analysis. Ultrasound Obstet Gynecol 2013; 41: 491–9.

________________________________________________

1. McQueen DB, Bernardi LA, Stephenson MD. Chronic endometritis in women with recurrent early pregnancy loss and/or fetal demise. Fertil Steril 2014; 101 (4): 1026–30.
2. Bulanov M.N. Ultrazvukovaia diagnostika zabolevanii sheiki matki. M.: Vidar-M, 2017. [in Russian]
3. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No.142: Cerclage for the management of cervical insufficiency. Obstet Gynecol 2014; 123: 372.
4. Rackow BW, Arici A. Reproductive performance of women with müllerian anomalies. Curr Opin Obstet Gynecol 2007; 19: 229.
5. Shah PS, Zao J; Knowledge Synthesis Group of Determinants of preterm/LBW births. Induced termination of pregnancy and low birth weight and preterm birth: a systematic review and meta-analyses. BJOG 2009; 116: 1425.
6. Vyas NA, Vink JS, Ghidini A et al. Risk factors for cervical insufficiency after term delivery. Am J Obstet Gynecol 2006; 195: 787.
7. Warren JE, Silver RM, Dalton J et al. Collagen 1Alpha1 and transforming growth factor-beta polymorphisms in women with cervical insufficiency. Obstet Gynecol 2007; 110: 619.
8. Sidelnikova V.M. Privychnaia poteria beremennosti. M.: Triada-Kh, 2000. [in Russian]
9. Chan YY, Jayaprakasan K, Tan A et al. Reproductive outcomes in women with congenital uterine anomalies: a systematic review. Ultrasound Obstet Gynecol 2011; 38: 371.
10. Romero R, Lockwood CJ. Pathogenesis of spontaneous preterm labor. In: Creasy RK, Resnik R, Iams JD et al. (Eds). Creasy&Resnik's Maternal Fetal Medicine. Saunders, 2009.
11. Society for Maternal-Fetal Medicine Publications Committee, with assistance of Vincenzo Berghella. Progesterone and preterm birth prevention: translating clinical trials data into clinical practice. Am J Obstet Gynecol 2012; 206: 376.
12. Berghella V, Rafael TJ, Szychowski JM et al. Cerclage for short cervix on ultrasonography in women with singleton gestations and previous preterm birth: a meta-analysis. Obstet Gynecol 2011; 117: 663.
13. Berghella V, Mackeen AD. Cervical length screening with ultrasound-indicated cerclage compared with history-indicated cerclage for prevention of preterm birth: a meta-analysis. Obstet Gynecol 2011; 118: 148.
14. Iams JD, Cebrik D, Lynch C et al. The rate of cervical change and the phenotype of spontaneous preterm birth. Am J Obstet Gynecol 2011; 205: 130.
15. Berghella V, Figueroa D, Szychowski JM et al. 17-alpha-hydroxyprogesterone caproate for the prevention of preterm birth in women with prior preterm birth and a short cervical length. Am J Obstet Gynecol 2010; 202: 351.e1.
16. Rafael TJ, Mackeen AD, Berghella V. The effect of 17a-hydroxyprogesterone caproate on preterm birth in women with an ultrasound-indicated cerclage. Am J Perinatol 2011; 28: 389.
17. Myers KM, Feltovich H, Mazza E et al. The mechanical role of the cervix in pregnancy. J Biomech 2015; 48 (9): 1511–23.
18. Shiina T, Nightingale KR, Palmeri ML et al. WFUMB guidelines and recommendations for clinical use of ultrasound elastography: Part 1: basic principles and terminology. Ultrasound Med Biol 2015; 41 (5): 1126–47.
19. Thomas A, Degenhardt F, Farrokh A et al. Significant differentiation of focal breast lesions: calculation of strain ratio in breast sonoelastography. Acad Radiol 2010; 17 (5): 558–63.
20. Molina FS, Gómez LF, Florido J et al. Quantification of cervical elastography: a reproducibility study. Ultrasound Obstet Gynecol 2012; 39 (6): 685–9.
21. Fruscalzo A, Londero AP, Schmitz R. Quantitative cervical elastography during pregnancy: influence of setting features on strain calculation. J Med Ultrason 2015; 42 (3): 387–94.
22. Conde-Agudelo A, Romero R, Nicolaides K et al. Vaginal progesterone vs. cervical cerclage for the prevention of preterm birth in women with a sonographic short cervix, previous preterm birth, and singleton gestation: a systematic review and indirect comparison metaanalysis. Am J Obstet Gynecol 2013; 208: 42.e1.
23. Ehsanipoor RM, Seligman NS, Saccone G et al. Physical Examination-Indicated Cerclage: A Systematic Review and Meta-analysis. Obstet Gynecol 2015; 126: 125.
24. Alfirevic Z, Owen J, Carreras Moratonas E et al. Vaginal progesterone, cerclage or cervical pessary for preventing preterm birth in asymptomatic singleton pregnant women with a history of preterm birth and a sonographic short cervix. Ultrasound Obstet Gynecol 2013; 41: 146.
25. Gorski LA, Huang WH, Iriye BK, Hancock J. Clinical implication of intra-amniotic sludge on ultrasound in patients with cervical cerclage. Ultrasound Obstet Gynecol 2010; 36: 482.
26. Vousden N, Hezelgrave N, Carter J et al. Prior ultrasound-indicated cerclage: how should we manage the next pregnancy? Eur J Obstet Gynecol Reprod Biol 2015; 188: 129.
27. Goya M, Pratcorona L, Merced C et al. Cervical pessary in pregnant women with a short cervix (PECEP): an open-label randomised controlled trial. Lancet 2012; 379: 1800.
28. Roberge S, Nicolaides KH, Demers S et al. Prevention of perinatal death and adverse perinatal outcome using low-dose aspirin: a meta-analysis. Ultrasound Obstet Gynecol 2013; 41: 491–9.

Авторы

Ю.Э.Доброхотова*1, Е.И.Боровкова1, С.А.Залесская1, Е.А.Нагайцева2, Д.П.Раба3

1. ФГБОУ ВО «Российский национальный исследовательский медицинский университет им. Н.И.Пирогова» Минздрава России. 117997, Россия, Москва, ул. Островитянова, д. 1;
2. ГБУЗ «Городская клиническая больница №40» Департамента здравоохранения г. Москвы. 129301, Россия, Москва, ул. Касаткина, д. 7;
3. ФГБОУ ВО «Московский государственный медико-стоматологический университет им. А.И.Евдокимова» Минздрава России. 127473, Россия, Москва, ул. Делегатская, д. 20, стр. 1
*pr.dobrohotova@mail.ru

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Yu.E.Dobrokhotova*1, E.I.Borovkova1, S.A.Zalesskaya1, E.A.Nagaitseva2, D.P.Raba3

1. N.I.Pirogov Russian National Research Medical University of the Ministry of Health of the Russian Federation. 117997, Russian Federation, Moscow, ul. Ostrovitianova, d. 1;
2. Сity Сlinical Hospital №40 of the Department of Health of the Russian Federation. 129301, Russian Federation, Moscow, ul. Kasatkina, d. 7;
3. A.I.Evdokimov Moscow State University of Medicine and Dentistry of the Ministry of Health of the Russian Federation. 127473, Russian Federation, Moscow, ul. Delegatskaia, d. 20, str. 1
*pr.dobrohotova@mail.ru

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