1、Cerclage for the Management of Cervical Insufficiency宫颈机能不全指南解读1Cervical 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 an
2、d symptoms Second trimesterA short cervical length in the second trimester is not sufficient for the diagnosis.宫颈机能不全指南解读2Cervical conizationLEEPMechanical dilationObstetric lacerationsCongenital mllerian anomaliesDeficiencies in cervical collagen and elastinUtero exposure to diethylstilbestrolAnd s
3、o on.Cervical insufficiency:etiology宫颈机能不全指南解读3Cervical 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 l
4、abor3.In the absence of other clear pathology宫颈机能不全指南解读4Can 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
5、a specific marker of cervical insufficiency.宫颈机能不全指南解读5Diagnostic 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.Cervi
6、cal dilators to calculate a cervical resistance indexCervical insufficiency:diagnosis宫颈机能不全指南解读6Cervical insufficiency:treatment optionsNon-surgical treatment1.Vaginal progesterone2.Vaginal pessary 3.Activity restriction 4.Bed rest 5.Pelvic rest Non-surgical treatment1.Transvaginal cervical cerclage
7、:McDonald p r o c e d u r e a n d Shirodkar procedure2.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-assisted宫颈机能不全指南解读7Cervical insufficiency:treatment optionsIn which situations should Transabdominal cervical cerclage be considered?1.Failed t
8、ransvaginal cervical cerclage procedures history（这个我持保留意见）2.Transvaginal cervical cerclage procedures can not place because of anatomical limitations宫颈机能不全指南解读81.Cerclage placement may be indicated based on a history of cervical insufficiency,physical examination findings,or a history of preterm bir
9、th and certain ultrasonographic findings.2.Cerclage should be limited to pregnancies in the second trimester before fetal viability has been achieved.Cervical insufficiency:clinical considerations and recommendations 宫颈机能不全指南解读9Indications for Cervical Cerclage inWomen With Singleton Pregnancies宫颈机能
10、不全指南解读10Indications for Cervical Cerclage inWomen With 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 demonstra
11、ted clear benefit,women should be counseled about the potential for associated maternal and perinatal morbidity.宫颈机能不全指南解读11Questions 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 dr
12、awn the following conclusions:宫颈机能不全指南解读12Cerclage versus no cerclage in patients with short cervical lengthUltrasound-indicated cerclage 宫颈机能不全指南解读13Questions 2:Which patients should not be considered candidates for cerclage?1.Short cervical length without history of prior singleton preterm birth.V
13、aginal progesterone is recommended to prevent cervical 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.宫颈机能不全指南解读14Questions 3:Is cerclage placement
14、 associated with an increase in morbidity?1.Low risk of 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 repor
15、ted.4.Transabdominal cerclage carries a much greater risk of hemorrhage.宫颈机能不全指南解读15Questions 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
16、 the efficacy of cerclage,regardless of timing or indication.2.Further ultrasonographic surveillance of cervical length after cerclage placement is not necessary.宫颈机能不全指南解读16Questions 5:When is removal of transvaginal McDonald cerclage indicated in patients with no complications,and what is the appr
17、opriate setting for removal?Cerclage removal is recommended 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
18、 cerclage in the office setting is appropriate.宫颈机能不全指南解读17Questions 6:How should women with cerclage and preterm premature rupture of membranes be managed?A firm recommendation on whether a cerclage should be removed after PPROM cannot be made,and either removal or retention is reasonable.Regardles
19、s,if a cerclage remains in place with PPROM,prolonged antibiotic prophylaxis beyond 7 days is not recommended.宫颈机能不全指南解读18Questions 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 s
20、ymptoms of preterm labor,clinical judgment about cerclage removal is advised.If cervical change,painful contractions,or vaginal bleeding progress,cerclage removal is recommended.宫颈机能不全指南解读19Summary of Recommendations and Conclusions Singleton pregnancyPrior spontaneous preterm birth 34 wksCervical l
21、ength 25mm before 24 wks Cerclage may be considered in women with this combination of history and ultrasonographic findings.(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)宫颈机能不全指南解读20Summary of Recomm
22、endations and Conclusions Certain nonsurgical approaches,including activity restriction,bed rest,and pelvic rest have 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 mo
23、difications of the McDonald and Shirodkar techniques.The superiority of one suture type or surgical technique over another has not been established.(level B)麦当劳更简单一些。宫颈机能不全指南解读21Summary of Recommendations and Conclusions Cerclage may increase the risk of preterm birth in wom e n wi t h a t wi n pre
24、gna nc y a n d a n ultrasonographically detected cervical length less than 25 mm and is not recommended.(level B)Neither 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。宫颈机能不全指南解读22Summary o
25、f Recommendations and Conclusions A history-indicated cerclage can be considered in a patient with a history of unexplained 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 be
26、en achieved.(level C)这个显然和临床有些不符合。宫颈机能不全指南解读23Summary of Recommendations and Conclusions Transabdominal cerclage generally 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
27、)这个也是有争议的。In patients with no complications,transvaginal McDonald cerclage removal is recommended at 3637 wks of gestation.(level C)宫颈机能不全指南解读24Summary of Recommendations and Conclusions After clinical examination to rule out uterine activity,or intraamniotic infection,or both,physical examination-i
28、ndicated cerclage placement in patients with singleton gestations who have cervical change of the internal os may be 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 sp
29、ontaneous labor between 37 weeks and 39 weeks of gestation must be considered.(level C)宫颈机能不全指南解读25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 cerclage宫颈机能不全指南解读26 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
30、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 cerclage宫颈机能不全指南解读27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例宫颈机能不全指南解读28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宫颈
31、机能不全指南解读29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 cerclage宫颈机能不全指南解读30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 cerclage宫颈机能不全指南解读31Cervical 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？等等宫颈机能不全指南解读32
