1、宫颈机能不全指南解读Cervical insufficiency:definitionThe inability of the uterine cervix to retain a pregnancy in the absence of the signs and symptoms of clinical contractions,or labor,or both in the second trimester。Uterine cervix Absence of the signs and symptoms Second trimesterA short cervical length in
2、the second trimester is not sufficient for the diagnosis.2宫颈机能不全指南解读Cervical conizationLEEPMechanical dilationObstetric lacerationsCongenital mllerian anomaliesDeficiencies in cervical collagen and elastinUtero exposure to diethylstilbestrolAnd so on.Cervical insufficiency:etiology3宫颈机能不全指南解读Cervica
3、l insufficiency:diagnosisChallenging because of a lack of objective findings and clear diagnostic criteria.Diagnosis is based on history1.Painless cervical dilation and expulsion of the pregnancy in the second trimester2.Without contractions or labor3.In the absence of other clear pathology4宫颈机能不全指南
4、解读Can the identification of cervical shortening by TVS be an ultrasonographic diagnostic marker of cervical insufficiency?Cervical insufficiency:diagnosisShort cervical length has been shown to be a marker of preterm birth in general rather than a specific marker of cervical insufficiency.5宫颈机能不全指南解
5、读Diagnostic tests should not be used to diagnose cervical insufficiency.a.Hysterosalpingographyb.Radiographic imaging of balloon traction on the cervixc.Assessment of the patulous cervix with Hegar or Pratt dilatorsd.Balloon elastance teste.Cervical dilators to calculate a cervical resistance indexC
6、ervical insufficiency:diagnosis6宫颈机能不全指南解读Cervical insufficiency:treatment optionsNon-surgical treatment1.Vaginal progesterone2.Vaginal pessary 3.Activity restriction 4.Bed rest 5.Pelvic rest Non-surgical treatment1.Transvaginal cervical cerclage:McDonald p r o c e d u r e a n d Shirodkar procedure2
7、.T r a n s a b d o m i n a l cervical cerclage:l a p a r o t o m y,l a p a r o s c o p y a n d Robotic-assisted7宫颈机能不全指南解读Cervical insufficiency:treatment optionsIn which situations should Transabdominal cervical cerclage be considered?1.Failed transvaginal cervical cerclage procedures history（这个我持保
8、留意见）2.Transvaginal cervical cerclage procedures can not place because of anatomical limitations8宫颈机能不全指南解读1.Cerclage placement may be indicated based on a history of cervical insufficiency,physical examination findings,or a history of preterm birth and certain ultrasonographic findings.2.Cerclage sh
9、ould be limited to pregnancies in the second trimester before fetal viability has been achieved.Cervical insufficiency:clinical considerations and recommendations 9宫颈机能不全指南解读Indications for Cervical Cerclage inWomen With Singleton Pregnancies10宫颈机能不全指南解读Indications for Cervical Cerclage inWomen With
10、 Singleton PregnanciesHistory-Indicated Cerclage One in three RCT indicated fewer deliveries before 33 weeks of gestation in the cerclage group.Physical Examination-Indicated Cerclage Given the lack of larger randomized trials that have demonstrated clear benefit,women should be counseled about the
11、potential for associated maternal and perinatal morbidity.11宫颈机能不全指南解读Questions 1:What is the role of ultrasonography in managing women with a history of cervical insufficiency?Two recent summaries of the results of these multiple studies have drawn the following conclusions:12宫颈机能不全指南解读Cerclage ver
12、sus no cerclage in patients with short cervical lengthUltrasound-indicated cerclage 13宫颈机能不全指南解读Questions 2:Which patients should not be considered candidates for cerclage?1.Short cervical length without history of prior singleton preterm birth.Vaginal progesterone is recommended to prevent cervical
13、 length 20mm before 24 wks.2.Twin pregnancy with cervical length 25 mm.3.Evidence is lacking for the benefit of cerclage solely for the following indications:prior LEEP,cone biopsy,or mllerian anomaly.14宫颈机能不全指南解读Questions 3:Is cerclage placement associated with an increase in morbidity?1.Low risk o
14、f complications with cerclage placement.2.Incidence of complications varies widely in relation to the timing and indications for the cerclage.3.Life-threatening complications of uterine rupture and maternal septicemia are rare but have been reported.4.Transabdominal cerclage carries a much greater r
15、isk of hemorrhage.15宫颈机能不全指南解读Questions 4:Is there a role for additional perioperative interventions and postoperative ultrasonographic assessment with cerclage placement?1.Neither antibiotics nor prophylactic tocolytics has been shown to improve the efficacy of cerclage,regardless of timing or indi
16、cation.2.Further ultrasonographic surveillance of cervical length after cerclage placement is not necessary.16宫颈机能不全指南解读Questions 5:When is removal of transvaginal McDonald cerclage indicated in patients with no complications,and what is the appropriate setting for removal?Cerclage removal is recomm
17、ended at 3637 weeks of gestation in patients with no complications.In patients planned vaginal delivery,remove cerclage before labor.In patients elected cesarean delivery,remove cerclage at the time of delivery.In most cases,removal of a McDonald cerclage in the office setting is appropriate.17宫颈机能不
18、全指南解读Questions 7:Should cerclage be removed in women with preterm labor?The diagnosis of preterm labor may be more difficult in patients with cerclage.In a patient who presents with symptoms of preterm labor,clinical judgment about cerclage removal is advised.If cervical change,painful contractions,
19、or vaginal bleeding progress,cerclage removal is recommended.19宫颈机能不全指南解读Summary of Recommendations and Conclusions Singleton pregnancyPrior spontaneous preterm birth 34 wksCervical length 25mm before 24 wks Cerclage may be considered in women with this combination of history and ultrasonographic fi
20、ndings.(level A)Cerclage is not associated with a significant reduction in preterm birth in patents with cervical length 25mm before 24 wks only.(level A)20宫颈机能不全指南解读Summary of Recommendations and Conclusions Certain nonsurgical approaches,including activity restriction,bed rest,and pelvic rest have
21、 not been proved to be effective for the treatment of cervical insufficiency and their use is discouraged.(level B)The standard transvaginal cerclage methods currently used include modifications of the McDonald and Shirodkar techniques.The superiority of one suture type or surgical technique over an
22、other has not been established.(level B)麦当劳更简单一些。21宫颈机能不全指南解读Summary of Recommendations and Conclusions Cerclage may increase the risk of preterm birth in wom e n wi t h a t wi n pre gna nc y a n d a n ultrasonographically detected cervical length less than 25 mm and is not recommended.(level B)Neit
23、her antibiotics nor prophylactic tocolytics have been shown to improve the efficacy of cerclage,regardless of timing or indication.(level B)从一些新近的一些研究结果来看，目前尚有争议。22宫颈机能不全指南解读Summary of Recommendations and Conclusions A history-indicated cerclage can be considered in a patient with a history of unexp
24、lained second-trimester delivery in the absence of labor or abruptio placentae.(level B)Cerclage should be limited to pregnancies in the second trimester before fetal viability has been achieved.(level C)这个显然和临床有些不符合。23宫颈机能不全指南解读Summary of Recommendations and Conclusions Transabdominal cerclage gene
25、rally is reserved for patients with anatomical limitations,or in the case of failed transvaginal cervical cerclage procedures that resulted in second-trimester pregnancy loss.(level C)这个也是有争议的。In patients with no complications,transvaginal McDonald cerclage removal is recommended at 3637 wks of gest
26、ation.(level C)24宫颈机能不全指南解读Summary of Recommendations and Conclusions After clinical examination to rule out uterine activity,or intraamniotic infection,or both,physical examination-indicated cerclage placement in patients with singleton gestations who have cervical change of the internal os may be
27、beneficial.(level C)For patients who elect cesarean delivery at or beyond 39 weeks of gestation,cerclage removal at the time of delivery may be performed;however,the possibility of spontaneous labor between 37 weeks and 39 weeks of gestation must be considered.(level C)25宫颈机能不全指南解读产科问题产科问题产科、妇科产科、妇科
28、宫颈机能不全宫颈机能不全Cervical insufficiency:thinking about transabdominal cerclage26宫颈机能不全指南解读 检索关键词 英文关键词：Laparoscopic cerclage 中文关键词：腹腔镜宫颈环扎 数据库 英文数据库：pubmed,Web Of Science,Scopus 中文数据库：万方、中国知网、中国生物医学文献数据库 文献类型：论著、病例报道 文献发表时间：2010-1-1至2016-10-31Cervical insufficiency:thinking about transabdominal cerclage2
29、7宫颈机能不全指南解读文献检索结果 web of science:26篇 pubmed:64篇 scopus:81篇 中国生物医学文献数据库：6篇 中国知网：21篇 万方数据库：29篇 共227例28宫颈机能不全指南解读文献筛选 排除重复文献 排除综述 排除非主题相关文献 排除不同语言发表的同一文献 排除同一医学中心既往发表的相同主题文献 排除不能获得全文文献29宫颈机能不全指南解读共34篇中英文文目前研究关注的是：环扎的成功率和手术相关的并发症。目前研究尚未关注的是：环扎后对产科的影响。Cervical insufficiency:thinking about transabdominal cerclage30宫颈机能不全指南解读产科问题产科问题产科、妇科产科、妇科宫颈机能不全宫颈机能不全Cervical insufficiency:thinking about transabdominal cerclage31宫颈机能不全指南解读Cervical insufficiency:thinking about transabdominal cerclage经腹宫颈环扎对剖宫产手术的影响？经腹宫颈环扎对中孕引产方式的影响？经腹宫颈环扎患者先兆早产的临床治疗策略？经腹宫颈环扎患者是否有必要进行促胎肺成熟？等等32宫颈机能不全指南解读
