Cervix during pregnancy: what changes may occur?

Despite its relatively small size, the cervix is ​​a rather complexly organized organ, and its pathology is very diverse. The inside of the cervical (cervical) canal is lined with cells of single-layer columnar epithelium. It has many depressions - glands that produce mucus, the properties of which vary depending on the age of the woman and the phase of the menstrual cycle. Outside (from the vagina), the cervix is ​​covered with a completely different layer of cells—stratified squamous non-keratinizing epithelium. It moves to the vaginal vault and lines the vaginal cavity from the inside. It has no glands and changes less during the menstrual cycle. The border between these two types of epithelium is most often located in the area of ​​the external uterine pharynx (entrance to the cervical canal of the uterus) and is called the transformation zone (Fig. 1).

Figure 1. Zonal anatomy of the cervix.

More than 90% of cervical neoplasia (precancerous condition) and cancerous lesions occur in the transformation zone.

What is “cervical erosion”?

The term "erosion" refers to a tissue defect. For example, we commonly call such a defect on the skin “abrasion.” True erosion of the cervix is ​​extremely rare and is of a traumatic or radiation nature. For some reason, in Russian-speaking usage, in the old fashioned way, this term refers to any change in the cervix that is visible to the eye and has a brighter color than the usual mucous membrane. This is an outdated, incorrect term. It was used by gynecologists in the pre-colposcopic and pre-histological era, when any change in the cervix was regarded on the basis of examination as erosion and it was IMPOSSIBLE to make a more accurate diagnosis.

What lies behind the brightly colored “spot” in the area of ​​the external uterine pharynx, which is found in every fourth woman of reproductive age, and which is called “congenital erosion”? As already mentioned, the border of two types of cellular lining of the cervix (single-layer cylindrical and stratified squamous epithelium) is most often located in the area of ​​the external uterine pharynx (entrance to the cervical canal) and is called the transformation zone (Fig. 1). But this border is not fixed throughout a woman’s life. In all girls, before the onset of puberty, the border runs outward from the external pharynx, and then gradually shifts inward. In postmenopausal (menopausal) women, the transformation zone is located approximately at the border of the middle and lower third of the cervical canal (Fig. 2).

Figure 2. Cervical transformation zone.

During reproductive age, due to individual variations, about a quarter of young women have an outward displacement of the transformation zone. Since single-layer cylindrical epithelium has a brighter color and a more “juicy” appearance, during a gynecological examination in the speculum it has a characteristic appearance, which doctors used to mistake for erosion. The correct name for this phenomenon is ectopia (or ectropion ), which literally translates as “located outside” (Fig. 3).

Figure 3. Localization of cervical ectopia.

The appearance of cervical ectopia is shown in Fig. 4.

Figure 4. Cervical ectopia.

How does the cervix change, including the so-called erosion?

Let's look at this in more detail. The uterus consists of 3 parts: the cervix, its isthmus and the uterus itself.

The body of the uterus can be imagined as a muscle lined from the inside with a special tissue - endometrium . The endometrium has the ability to change rapidly; it helps the fetus develop.

The inner part of the cervix consists of special cells laid out in one layer - columnar epithelium. Its cells form the cervical canal leading to the uterine cavity. The outer part of the cervix is ​​lined with multilayered epithelium, which covers this entire organ, reaching the edges of the external opening, and there gradually turns into columnar epithelium.

Most often, inflammatory changes in the cervix are initiated by various viruses and microbes. For example, during the acute inflammation phase after infection with trichomoniasis or gonorrhea, the surface cells of the squamous epithelium are damaged in the mucous membrane. This causes the lining of the cervix to be exposed. When open, it is more susceptible to infection, and blood vessels burst faster. For example, after sexual intercourse a woman may experience bleeding. This is how erosion of the cervix occurs, the size of which can range from several millimeters to several centimeters.

At first it is true erosion, which then turns into pseudo-erosion.

Is “congenital” ectopia a pathology?

No. This is an individual feature. With age, most likely, the transformation zone will shift to the cervical canal. But even if this does not happen, nothing needs to be done. Previously, “cauterization of erosion” was performed for most women whose ectopia persisted after childbirth. Now this tactic is considered incorrect, since women are exposed to an unreasonable risk of even a small surgical intervention, which has more complications and side effects than even a very long-term existence of ectopia can bring. Therefore, today, treatment of ectopia without concomitant pathology is carried out only in the case of an extremely large area, especially with the transition to the vaginal vaults (this condition is called adenosis), and sometimes with increased secretion of glands, the ducts of which open on the surface of the ectopia. In a word, ectopia is not a disease or even a risk factor for the disease, and therefore is only subject to observation once a year for cytological control.

What are Nabothian cysts (Ovula Nabothii)?

In the transformation zone, the flat epithelium gradually “creeps” onto the columnar epithelium, “closing” the ectopia. However, the excretory ducts of the glands may become closed, and the mucus they produce accumulates in the form of small cysts. These cysts can be multiple and range in size from 1 mm to 2 cm. Small cysts do not require any treatment. Only large (severely deforming the cervix) and continuing to grow cysts may require opening and evacuation of the contents. But this happens extremely rarely.

Diseases of the cervix include the following:

• Inflammation of the cervical canal (endocervicitis).
• Cicatricial post-traumatic (postpartum or postoperative) deformity.
• Human papillomavirus infection (HPV), including cervical condylomas.
• Cervical intraepithelial neoplasia (CIN) (Other names: dysplasia, dyskeratosis, squamous intraepithelial formation (SIL)) and cervical intraepithelial glandular neoplasia (CIGN).
• Cervical cancer: squamous cell carcinoma or adenocarcinoma.
• Endometriosis of the cervix.
• Polyps and fibroids of the cervical canal.

Read about diagnostic methods (colposcopy, targeted biopsy, cytological and histological studies) and treatment of precancerous diseases of the cervix (laser coagulation, cryodestruction, diathermoexcision, conization of the cervix) in the sections diagnostics, treatment and services.

1. Inflammation of the cervical canal - endocervicitis . Most often it is caused by sexually transmitted infections (chlamydia, mycoplasma, gonococci) or nonspecific infections (streptococcus, staphylococcus, E. coli, corynebacteria, enterococcus, etc.). In the first case, infection occurs through sexual contact. The second group of microorganisms enters the cervix most often by lymphogenous (through lymphatic vessels) or contact (from the rectum) route; however, sexual intercourse is not necessary for their development, but can contribute to inflammation. Other provoking factors may be some benign diseases of the cervix (see below), cicatricial deformation of the cervix, weakening of general and local immunity. Endocervicitis is manifested by profuse mucous leucorrhoea, sometimes with an unpleasant odor. Endocervicitis can be one of the causes of miscarriage and premature birth. The disease can be suspected already during a gynecological examination: a large amount of mucus is released from the cervical canal, the transformation zone has a bright pink color. To diagnose the infection that caused the process, the following tests are taken: a smear for the degree of purity, culture for flora and sensitivity to antibiotics, testing for the presence of chlamydia, mycoplasma and ureaplasma (by PCR or culture), sometimes culture on special media to isolate trichomonas, fungus genus candida, gonococcus. Treatment for endocervicitis depends on what infection is causing it.
2. Deformation of the cervix occurs due to traumatic childbirth or surgical interventions on the cervix. During labor, the cervix shortens, flattens, and then dilates to a diameter of 10 cm, allowing the fetal head to pass through the mother's birth canal. Sometimes, during the passage of the head, the cervix ruptures. This is facilitated by the following factors: rapid and rapid labor, weakness of labor with early ineffective pushing, inappropriate behavior of the woman in labor during pushing, which is often observed against the background of fatigue and painful contractions, the application of “high” obstetric forceps, a large fetus (weighing more than 4000 grams). ), previous operations on the cervix, including cervical excision, diathermocoagulation of ectopia, etc., ruptures in previous births. Most often, ruptures occur on the sides of the neck (at 3 and 9 o'clock). They can be of several degrees in depth. At the most severe degree, the ruptures reach the vaginal fornix and spread to the body of the uterus. After childbirth, the obstetrician examines the cervix “in the speculum” and, if ruptures are detected, closes them with absorbable sutures. Unfortunately, not all ruptures are diagnosed and carefully sutured. In such cases, the cervix after childbirth is formed defective - the cervical canal often remains gaping, and the cervix itself can take on the most bizarre shapes. If a woman is not planning a pregnancy, then nothing may bother her, and she will only find out about the presence of scars and deformities during the next gynecological examination. However, problems may arise during the next pregnancy - most often, spontaneous abortions (miscarriages) and premature births. There are extremely many reasons for spontaneous abortions, and cervical pathology is not the most common of them. However, cervical insufficiency can be suspected if the miscarriage occurs more than 16 weeks, begins with rupture of amniotic fluid, and there is a history of traumatic birth or cervical surgery. Diagnosis includes a visual examination in a gynecological chair, and, if necessary, cervicohysterography (X-ray examination with the introduction of a contrast agent into the lumen of the cervical canal and the uterine cavity). Treatment is required if a woman suffers from miscarriage due to severe deformation of the cervix. In such cases, surgical treatment is performed - cervical plastic surgery (tracheloplasty). If a cervical deformity is detected during pregnancy in the presence of signs of a threatening miscarriage, a special circular suture is placed on the cervix in order to preserve the pregnancy, designed to compensate for the lost mechanical function of the cervix. This suture usually remains until full term pregnancy. It is removed either on the eve of the expected birth, or in the event of the onset of labor.
3. Papillomavirus infection (HPV) , including exophytic condylomas of the cervix. In short, you should know that: 1) the development of exophytic condylomas on the surface of the cervix, most often caused by papillomavirus type 6, leads to changes in the mucosa, which can be characterized as a mild degree of dysplasia (see point 4). 2) They themselves do not lead to the development of cancer and precancerous conditions of the cervix. 3) Small condylomas often undergo spontaneous regression (disappear on their own). 4) Oncogenic serotypes of HPV viruses (16, 18, 35, 39, 45) significantly increase the risk of developing severe dysplasia and cervical cancer. Moreover, they are the main cause of the development of these diseases. 5) Oncogenic types of viruses do not cause the development of exophytic condylomas. They are integrated into the genome of epithelial cells and change their genetic properties, promoting gradual cancerous degeneration. 6) Exophytic condylomas of large sizes, as a rule, must be removed (for example, using electrocoagulation, laser, podophyllotoxin preparations, etc.). 7) To date, there are no systemic medications that can reliably cure the papilloma virus. Detection of long-term persistence (preservation in the body) of oncogenic type papilloma viruses is the main risk factor for the development of severe degrees of dysplasia and cervical cancer, therefore, in this case, a particularly thorough and frequent examination of the cervix is ​​required in order to detect the disease in time and adequately treat it.
4. Cervical intraepithelial neoplasia (dysplasia) . This term (CIN) is used to refer to disorders of the maturation and structure of stratified squamous epithelium. Changes are assessed by cytological examination of cell scrapings from the surface of the neck and/or by histological examination of biopsy material. This pathology is associated with impaired cellular differentiation and maturation. There are three degrees of dysplasia: CIN I, CIN II, CIN III. With mild dysplasia (CIN I), cell maturation is impaired in the lower third of the epithelial layer. The top two thirds look typical. With the second and third degrees of dysplasia (CIN II, CIN III), cell maturation is impaired, respectively, in 2/3 or throughout the entire thickness of the epithelium. The next most severe cellular and tissue changes are carcinoma in situ, which translates as cancer “in place,” that is, within the epithelial layer, without growing into the underlying tissue of the cervix.

In turn, CIGN is an analogue of CIN, but refers to columnar epithelium. CIGN is judged by cellular atypia of the epithelial layer. Accordingly, adenocarcinoma in situ is distinguished as the most severe dysplasia. Cells of altered tissue (both squamous and cylindrical epithelium) look atypical, which is confirmed by cytological examination of scrapings from the surface of the cervix (Papanicolau smear). In them, the nucleus is enlarged, it has a lighter color, and the content of cytoplasm in the cell is reduced. In addition to the changes described, blood vessels also acquire a special structure: they come close to the surface, arranged in the form of loops, spirals and other elaborate shapes. This helps distinguish healthy tissue from pathological tissue during colposcopic examination of the cervix.

I. Exo- and endocervicitis

This is an inflammation of the mucous membrane of the exocervix and endocervix, which can be caused by both opportunistic microflora (streptococci, staphylococci, E. coli) and urogenital infection (myco-, ureaplasmosis, trichomoniasis, chlamydia, viral infections).
There are no specific clinical symptoms of inflammation; most often the disease is manifested by the appearance of more abundant discharge from the genital tract (leucorrhoea), very rarely dull pain in the lower abdomen, associated mainly with concomitant diseases (urethritis, cystitis).

Diagnostics

A gynecological examination reveals hyperemia around the external pharynx, mucous or purulent discharge.

Colposcopy helps not only to diagnose cervicitis, but sometimes to clarify its etiology.

So, according to the colposcopic picture, it is possible to differentiate inflammation of chlamydial, viral, candidiasis and trichomonas etiology.

With trichomanasic cervicitis, the so-called “strawberry cervix” symptom is observed, when small petechial hemorrhages are visualized on the cervix during colposcopy.

Trichomonas diffuse cervicitis

Candidal cervicitis is accompanied by an alternation of “rough” zones with a “varnished” surface, as well as the appearance of typical cheesy discharge on the cervix and vaginal walls.

Candidiasis cervicitis

A typical symptom of viral cervicitis is the symptom of “large erosion,” when the entire surface of the cervix is ​​bright red with ulcers.

Chlamydial cervicitis is accompanied by swelling of the ectopic columnar epithelium, foci of necrosis and ulceration, and mucopurulent discharge.

To clarify the etiology of inflammation, it is also necessary to take a smear for flora, a culture tank and sensitivity to antibiotics from the cervical canal, a scraping for urogenital infection using the PCR method and a PAP test to exclude background and precancerous diseases.

Treatment depends on the pathogen that caused the inflammation and its sensitivity to antibiotics.

Considering that most often the cause is several pathogens, local drugs with anti-inflammatory, antibacterial and antifungal effects are used in treatment (Polygynax, Terzhinan, Klion-D, Betadine).

For gonorrheal, trichomonas, herpetic etiology of cervicitis, oral antibacterial or antiviral drugs are used in combination.

What can happen to dysplasia if it is not treated?

57% of CIN I spontaneously regress (“go away on their own”), 32% persist as CIN I for a long time, 11% progress to CIN II, CIN III, and only 0.5% progress to invasive carcinoma. Unlike mild dysplasia, CIN III turns into invasive cancer in 12% of cases within 2 years, and regresses quite rarely.

Is it possible to suspect the presence of CIN before visiting a gynecologist?

As a rule, no. CIN and CIGN have virtually no clinical manifestations. Therefore, you need to visit your doctor regularly (at least once a year) , even if there is absolutely nothing bothering you. The appearance of bloody discharge during sexual intercourse deserves special attention. If the cervix bleeds, this can be a very serious symptom, indicating a pronounced pathological process, including cancer. Other causes of bleeding after sexual intercourse may be inflammation, atrophy of the vaginal mucosa (for example, in postmenopausal women), and pathology of the uterine body. In women taking microdose hormonal contraceptives, this can be observed, among other things, due to thinning of the endometrium against the background of weak hormonal stimulation. All these reasons are temporary, harmless and easily removable. But, to exclude the most serious of them - cervical diseases, all women with spotting after sexual intercourse are advised to immediately visit a gynecologist.

Cervical cancer . This is a dangerous malignant disease. Every year, about 400,000 are detected worldwide. new cases of cervical cancer, of which about 200,000 are fatal. Cervical cancer ranks third among cancer pathologies in women, second only to breast and uterine cancer. Squamous cell carcinoma develops from squamous epithelium, and adenocarcinoma, which has a high degree of malignancy (tendency to rapid growth and metastasis), develops from cylindrical epithelium.

The average age for the onset of squamous cell carcinoma is 46 years, for adenocarcinoma - 35 years. Often, malignant pathology of the cervix in women at risk develops even earlier - at the age of 24 years. According to the degree of invasion (germination of layers located under the epithelium), cancer is divided into carcinoma in situ, minimally invasive, and invasive cancer. Invasive cancer has 4 stages, depending on invasion into neighboring organs, involvement of regional lymph nodes and the presence of distant metastases (bones, liver, brain). The 5-year survival rate for the first stage is 85%, with 4 - 5%. Given the questionable prognosis and complex combination treatment of invasive cancer, the primary focus of public health in developed countries is on the early diagnosis of precancerous lesions and carcinoma in situ. In particular, in the USA, since 1960, it has now been possible to reduce mortality from cervical cancer by 87%, thanks to an established screening system (see the services section). If you want to protect yourself from developing incurable stages of cervical cancer, visit your gynecologist annually and undergo a special examination!

Mansoura nomogram for determining the size of the cervix during normal pregnancy

Table 9.

Cervical thickness, mm, in the group of high-risk pregnant women before and after cerclage.

*

P(W) before and after cerclage, statistically significant (

Table 10.

Thickness of the anterior wall of the lower segment of the uterus, mm, in the group of high-risk pregnant women before and after cerclage.

Table 11.

The magnitude of the posterior cervical angle in the group of high-risk pregnant women before and after cerclage.

Rice. 6.

Cervical length in a group of high-risk pregnant women before and after cerclage.

Rice. 7.

Diameter of the internal os before and after cerclage.

Rice. 8.

The magnitude of the posterior cervical angle in the group of high-risk pregnant women before and after cerclage.

The incidence of membrane protrusion in patients in high-risk cases was 6 cases (6%), of which there were 2 cases of termination of pregnancy, 2 cases of premature birth, and 2 cases of timely delivery.

Diagnostic criteria for assessing pharynx incompetence

As a result of conducting a discriminant analysis of the obtained indicators of healthy pregnant women and pregnant women at high risk (Tables 12-14), we determined the following ultrasound criteria for pharynx failure (threshold values): cervical length 6 mm. The predictive value of these indicators for a normal cervix in our study (negative prognosis for the development of cervical incompetence) is 86.4%, as shown in Table. 12-14.

Table 12.

Discriminant function coefficient for determining cervical incompetence.

Table 13.

Coefficient of the discriminant function for determining cervical incompetence after excluding the influence of pregnancy and childbirth.

Table 14.

Classification resulting from discriminant analysis.

Note:

percentage of correctly classified groups - 88%; predictive value of normal pregnancy - 88.9% (192 cases out of 216); the predictive value of pregnancy at risk is 86.4% (76 cases out of 88).

Discussion

Nomogram of cervical size

As previously stated, many authors have provided nomograms for cervical size under physiological conditions and have suggested that each institution establish its own diagnostic criteria for cervical incompetence (Ludmir, 1988 and Barth, 1994). In the present study, the mean values ​​and standard deviations for ultrasound measurements of cervical length, internal os diameter, membrane protrusion, cervical thickness, anterior wall thickness of the lower segment of the uterus and posterior cervical angle were assessed during a prospective longitudinal comparative study of women in Mansoura. who were admitted to the Mansoura University Hospital.

Cervical length

The average length of the cervix in the 10-14th week of normal pregnancy (35.4±5.1 mm) increased significantly, reaching a maximum (41±4.3 mm) by 24-29 weeks of pregnancy, then decreased significantly with maturation and cervical dilatation, which occurs after 34 weeks of pregnancy (average 36.4±3.7 mm).

There is no consensus in the literature about the dynamics of cervical length during normal pregnancy when examined using TVUS. Most cases show lengthening mid-gestation followed by shortening (Kushnir et al., 1990), but some authors report no significant change in length (Smith et al., 1992 and Zorzoli et al., 1994). Kushnir et al. (1990) studied 166 women with normal pregnancy using TVUS. Studies were carried out every 4 weeks from 8 to 37 weeks of pregnancy. They found that cervical length increased progressively until 20–25 weeks of gestation, reaching a maximum of 48 mm. In addition, Klejewski et al. (1994) examined 127 women with normal pregnancies using TVUS from 14 to 37 weeks and found that cervical length increased during pregnancy (P

Smith et al. (1992) in a study using transvaginal ultrasonography noted that cervical length was constant, averaging 37 mm until the end of the third trimester. Also Zorzoli et al. (1994) in a study of 154 women who underwent TVUS between 12 and 31 weeks of pregnancy, found that the average cervical length (43 mm) did not change significantly. We agree with the observations of many authors (Ayers et al., 1988; Anderson, 1990; Kushnier et al., 1990) that cervical length decreases significantly only at the end of the third trimester.

Like many authors (eg Varma et al. 1986; Ayers et al. 1988; Kushnir et al. 1990), we found that cervical length is not influenced by previous pregnancy or childbirth. In contrast, Zorzoli et al. (1994) noted that multiparous women had longer cervixes than women with a first pregnancy or previous caesarean section and suggested that mechanical rather than hormonal factors had a greater effect on cervical length.

In high-risk pregnant women, the average cervical length was 28.7 ± 5.4 mm before cerclage, which is significantly shorter compared with women with normal pregnancies at the same stage of pregnancy (average 35.4 ± 5.1 mm ) (R

Diameter of internal throat

The diameter of the internal os is the most important indicator for predicting cervical incompetence (Rumack et al., 1991). The decision to perform cervical cerclage must be made on a case-by-case basis, depending on changes in cervical dilatation (Campbell, 1993).

In the present study, the average diameter of the internal os at 10-14 weeks of normal pregnancy was 3.8 ± 0.9 mm and remained more or less constant until the end of the 30th week of pregnancy, when it increased significantly to 5.4 ± 1 mm (P

According to Varma et al. (1986) and Rodobnik et al. (1988), the average width of the internal os does not change significantly from the 10th to the 36th week of pregnancy. However, these authors who used TAUS in their study used a full bladder technique. Bladder distension is known to distort the shape of the cervix, making it appear longer and narrower and therefore camouflaging an incompetent cervix.

In high-risk cases, the diameter of the internal os before cerclage was on average significantly higher than that in healthy pregnant women at the same stage of pregnancy and decreased significantly after cerclage (P

Protrusion of membranes

Protrusion of the membranes through a partially dilated cervical canal, although a late symptom, is probably the most reliable ultrasound sign of developed cervical incompetence. Ultrasound examination may show early bulging of the meninges in association with an unchanged external os before changes in the cervix can be detected by digital examination or speculum (Rumack et al., 1991 and Campbell et al., 1993).

In our study, no protrusion of the membranes was found in women with normal pregnancy, but in the high-risk group, 6 cases of protrusion of the membranes were identified in women who underwent cerclage. Of these, in 2 cases the pregnancy was terminated, in 2 cases premature birth occurred and in 2 cases the pregnancy ended in delivery at term.

Vaulamo et al. (1983) made the decision to perform cerclage only on the basis of protrusion of the membranes with a partially dilated internal os and reported favorable pregnancy outcomes. On the other hand, Varma et al. (1986) described 8 patients who had normal clinical parameters, but ultrasound examination revealed hernial protrusion of the membranes into the cervical canal. In 5 of these women, the pregnancy was terminated and in 3, delivery occurred before 34 weeks.

The size of the posterior angle of the cervix

An assessment of the posterior angle of the cervix during normal pregnancy showed that it averages less than 80° until 30-34 weeks, when the angle increases until the onset of labor (P

Neck thickness

The average thickness of the cervix at the level of the internal os was 29±2.8 mm in the early stages of normal pregnancy (10-14 weeks) with a significant progressive increase during pregnancy. This is consistent with Smith et al. (1992), who found an increase in cervical thickness at the level of the internal os during pregnancy (P

In high-risk pregnancies, the cervical thickness before cerclage is on average significantly greater than in normal pregnancies (P

Thickness of the anterior wall of the lower segment of the uterus

The average thickness of the anterior wall of the lower segment of the uterus at the 15-19th week of normal pregnancy is 10.1 ± 1.2 mm, and significantly decreases by the 25-29th week (P 0.05).

Thinning of the anterior wall of the lower segment of the uterus of less than 6 mm has been described in patients at risk of cervical incompetence (O'Leary et al., 1986). In addition, according to Podobnik et al. (1988), in patients at risk of cervical incompetence, the thickness of the anterior wall of the lower uterine segment is more than 7 mm, and the absence of protrusion of the membranes was an indicator of a good prognosis.

Our diagnostic criteria for pharynx incompetence

There have been no prospective studies using transvaginal ultrasound criteria for the diagnosis and treatment of pharyngeal incompetence to evaluate its diagnostic value compared with traditional methods (Joffe et al., 1992). Using the statistical method of discriminant analysis to identify differences between TVUS indicators, we determined the following list of discriminant coefficients (in order of decreasing significance) (see Table 13):

• bulging of shells - 1.448154;
• cervical length - 0.844060 E-2;
• cervical width - 0.3564436 E-2;
• thickness of the lower segment of the uterus - 0.3320329;
• posterior angle of the cervix - 0.3239718 E-21;
• diameter of the internal throat - 0.2056026.

Because bulging of the membranes is rare and its appearance is a late sign, found in only a small percentage of cases, and is itself considered a pathognomonic sign of cervical incompetence, it has been excluded from routine selection criteria. Lower uterine segment and cervical thickness are not often used in studies due to poor reproducibility. Although the posterior cervical angle is also often not considered an indicator of os failure, we suggest that it be considered in the selection of patients for cerclage because it can be easily measured, has good reproducibility, and has a higher discriminant coefficient than the internal os index. Thus, we have 3 parameters in order of decreasing importance: the length of the cervix, the posterior angle of the cervix and the diameter of the internal os. As shown above, we offer a complex of 3 parameters: cervical length 6 mm and posterior cervical angle > 90°. The presence of at least 2 parameters out of 3 is a selection criterion for performing cerclage. Our selection criteria are more stringent than those proposed by Ludmir (1988) [use of TAUS, cervical length 30 mm, internal os diameter > 8 mm] because we used TVUS.

Literature

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Who is at risk for developing dysplasia and cervical cancer?

• Carriers of HPV oncogenic serotypes (16, 18, 31, 45, and about a dozen intermediate-risk viruses)
• Long-term persistence of oncogenic types of virus (more than 2 years)
• High “viral load”, i.e. a large number of serotypes and their high concentration in tissues at the same time.
• Early onset of sexual activity
• Many sexual partners throughout life
• Smoking

Endometriosis of the cervix . Genital endometriosis is an extremely common disease in women of reproductive age. The most common locations of the lesion are the body of the uterus, ovaries, pelvic peritoneum, and uterosacral ligaments. The cervix accounts for only an extremely small percentage of endometrioid heterotopias. The cause of endometriotic lesions of the cervix is ​​diathermocoagulation of ectopia, damage during surgical abortion, childbirth. On the relatively deep wound surface, pieces of endometrial tissue, released during the next menstruation, attach and “take root.” Cervical endometriosis usually manifests itself in the form of bleeding on the eve of menstruation. Diagnosis is carried out on the basis of a visual gynecological examination and colposcopy. Treatment is surgical and is necessary only for large heterotopias and in the presence of clinical manifestations. To remove heterotopias, their laser vaporization is used.

Polyps and fibroids of the cervical canal . The reasons for the appearance of polyps are not completely clear. Their structure is characterized by a central connecting stalk, covered with either stratified squamous or columnar epithelium. Most often, polyps are an accidental finding during a regular gynecological examination. If they are large, they can bleed easily. Polyps are a benign disease. However, sometimes cancer (especially adenocarcinoma) can have the appearance of a polyp. Such a polyp, as a rule, has an unevenly colored bumpy surface and bleeds easily. The presence of a polyp is an indication for its removal, followed by diagnostic curettage of the cervical canal and uterine cavity. Histological examination of the obtained material is important. Often, at the same time as a polyp of the cervical canal, a polyp or endometrial hyperplasia is detected.

Fibroids (myomatous nodes) of the cervix are less common than in the body of the uterus (see section “uterine fibroids”). They can also be subserous, intramural and submucosal. The presence of cervical fibroids in the vast majority of cases is an indication for surgical treatment. In the case of submucosal nodes, they are removed (with a scalpel or an electrocoagulator). Large intramural and subserous nodes quickly disrupt the anatomy and function of adjacent organs (bladder, ureters, rectum), and therefore are also an indication for one or another operation (conservative myomectomy, hysterectomy). The latter can be performed using either abdominal or vaginal access.

Symptoms

Cervical erosion is characterized by an asymptomatic and painless course. Most often it is discovered by a gynecologist during a routine examination.

In some cases, erosion may be accompanied by nonspecific symptoms such as heavy mucous discharge (clear or yellowish), pain during or after intercourse, pain during or after cervical screening, bloody discharge from the genital tract outside of menstruation (after intercourse). act or gynecological examination, during physical activity), pain in the pelvic area.

Attention : symptoms such as post-coital bleeding, pain in the pelvis, unusual discharge may indicate the development of pathology (cervicitis, cervical polyps, endometriosis, malignant process). Be sure to consult a gynecologist to determine the cause. The doctor will conduct all the necessary examinations and differential diagnostics to rule out the disease or prescribe the necessary treatment.

Where to go for diagnosis and treatment of cervical diseases?

The medical institution to which you should contact must have an adequate diagnostic base. All types of cytological and histological studies should be available here. A highly qualified pathologist (histologist) must be well versed in all types of epithelial lesions, from the most minor and benign, to precancerous (such as CIN) and malignant. The institution must have PCR diagnostics available (including for detecting papillomavirus infection and its typing), there must be all the necessary instruments for high-quality collection of materials for research (special disposable brushes, spatulas), there must be special standard instruments for cervical biopsy uterus, there must be electrosurgical equipment for conization of the cervix. The gynecologist must have a high-quality colposcope and be fully proficient in the techniques and methods of colposcopy. Doctors at a clinic specializing in the treatment of cervical diseases must have access to and master methods of excision and destruction of affected tissue (electrocoagulation and excision, laser coagulation or evaporation, cryodestruction). If necessary, doctors must also perform surgical excision (“cold knife”) of the affected tissue with the application of cosmetic sutures. Ideally, the medical institution you choose should have sufficient administrative and computer facilities to track and monitor patients at high risk for developing cervical cancer. Remember that the widespread introduction in developed Western countries of preventive cytological examinations of cervical smears stained with Papanicolaou, as well as other components of the treatment and preventive program for cervical diseases, has reduced the incidence of cervical cancer by 87%. THIS IS THE BASIS OF THE SIGNIFICANT INCREASE (BY 15 YEARS) IN THE AVERAGE LIFE EXPECTATION OF WOMEN IN WESTERN EUROPEAN COUNTRIES, JAPAN AND THE USA IN RECENT YEARS.