宫颈机能不全指南解读.pptx

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,11/7/2009,#,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,2018/2/6,#,Cerclage,for the Management of Cervical,Insufficiency,Cervical insufficiency:definition,The 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 trimester,A short,cervical length in the second trimester,is,not sufficient for the,diagnosis.,Cervical conization,LEEP,Mechanical dilation,Obstetric lacerations,Congenital mllerian anomalies,Deficiencies in,cervical collagen and,elastin,Utero exposure,to,diethylstilbestrol,And so on.,Cervical insufficiency:etiology,Cervical insufficiency:diagnosis,Challenging because,of a lack of objective findings and clear diagnostic,criteria.,Diagnosis,is based on,history,Painless cervical dilation and expulsion,of the,pregnancy in,the second,trimester,Without contractions,or,labor,In the,absence of other clear,pathology,Can the identification,of cervical,shortening by TVS be an,ultrasonographic diagnostic,marker,of,cervical insufficiency?,Cervical insufficiency:diagnosis,Short cervical,length has been shown to be,a marker of preterm birth,in general rather than a specific marker of cervical insufficiency.,Diagnostic tests should not be used to diagnose cervical insufficiency.,Hysterosalpingography,Radiographic imaging,of balloon traction on the,cervix,Assessment of,the patulous cervix with Hegar or,Pratt dilators,Balloon elastance test,Cervical dilators,to calculate a cervical,resistance index,Cervical insufficiency:diagnosis,Cervical insufficiency:treatment options,Non-surgical treatment,Vaginal progesterone,Vaginal pessary,Activity restriction,Bed rest,Pelvic rest,Non-surgical,treatment,Transvaginal cervical cerclage:McDonald,procedure,and Shirodkar procedure,Transabdominal cervical,cerclage:laparotomy,laparoscopy and Robotic-assisted,Cervical insufficiency:treatment options,In which situations,should Transabdominal,cervical cerclage be considered?,Failed transvaginal cervical,cerclage procedures,history,（这个我持保留意见）,Transvaginal cervical,cerclage,procedures can not place because of,anatomical,limitations,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.,Cerclage should be limited to pregnancies in the second trimester before fetal viability has been achieved.,Cervical insufficiency:clinical considerations and recommendations,Indications for Cervical Cerclage in,Women With Singleton Pregnancies,Indications for Cervical Cerclage in,Women With Singleton Pregnancies,History-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 potential for associated maternal and perinatal morbidity.,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,:,Cerclage versus no cerclage in patients with short cervical length,Ultrasound-indicated cerclage,Questions 2:,Which patients should not be,considered candidates,for cerclage?,1.Short cervical,length,without history of prior,singleton pretermbirth.Vaginal 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.,Questions 3:,Is cerclage placement 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 reported.,4.Transabdominal cerclage,carries a much greater risk of hemorrhage,.,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,indication.,2.Further ultrasonographic,surveillance of cervical length after cerclage placement is not,necessary.,Utero exposure to diethylstilbestrol,Cervical insufficiency:thinking about transabdominal cerclage,Singleton pregnancy,Women With Singleton Pregnancies,Cerclage versus no cerclage in patients with short cervical length,Utero exposure to diethylstilbestrol,Ultrasound-indicated cerclage,Deficiencies in cervical collagen and elastin,Summary of Recommendations and Conclusions,Without contractions or labor,Activity restriction,The diagnosis of preterm labor may be more difficult in patients with cerclage.,Women With Singleton Pregnancies,Mechanical dilation,Activity restriction,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 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 cerclage in the office setting is,appropriate.,Indications for Cervical Cerclage in,(level B)麦当劳更简单一些。,排除同一医学中心既往发表的相同主题文献,Vaginal pessary,(level B)麦当劳更简单一些。,经腹宫颈环扎患者先兆早产的临床治疗策略？,Questions 7:Should cerclage be removed in women with preterm labor?,Balloon elastance test,Deficiencies in cervical collagen and elastin,Vaginal pessary,gestation in the cerclage group.,Cervical insufficiency:diagnosis,In patients elected cesarean delivery,remove cerclage at the time,Short cervical length has been shown to be a marker of preterm birth in general rather than a specific marker of cervical insufficiency.,Neither antibiotics nor prophylactic tocolytics has been shown to improve the efficacy of cerclage,regardless of timing or indication.,Questions 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 P,PROM,cannot be made,and either removal or retention is reasonable.,Regardless,if a cerclage remains in place with P,PROM,prolonged antibiotic prophylaxis beyond 7 days is not recommended.,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,or vaginal bleeding progress,cerclage removal is recommended.,Utero exposure to diethylstilbestrol,Utero exposure to diethylstilbestrol,In most cases,removal of a McDonald cerclage in the office setting is appropriate.,Cervical insufficiency:etiology,Neither antibiotics nor prophylactic tocolytics has been shown to improve the efficacy of cerclage,regardless of timing or indication.,Without contractions or labor,In patients planned vaginal delivery,remove cerclage before labor.,(level B)麦当劳更简单一些。,Without contractions or labor,Summary of Recommendations and Conclusions,(level A),Obstetric lacerations,Absence of the signs and symptoms,If cervical change,painful contractions,or vaginal bleeding progress,cerclage removal is recommended.,Cerclage may be considered in women with this combination of history and ultrasonographic findings.,Summary of Recommendations and Conclusions,Singleton pregnancy,Prior spontaneous,preterm birth,34 wks,Cervical length,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,),Summary of Recommendations 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 modifications 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。,Summary of Recommendations and Conclusions,Cerclage may increase the risk of preterm birth in women with a twin pregnancy and an ultrasonographically detected cervical length less than 25 mm and is not recommendedlevel 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。,Summary of 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 been achieved.,(,level C,),这个显然和临床有些不符合。,Summary 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,),这个也是有争议的。,In patients with no complications,transvaginal McDonald cerclage removal is recommended at 3637wks,of gestation.,(,level C,),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 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,),产科问题,产科、妇科,宫颈机能不全,Cervical insufficiency:thinking,about,transabdominal cerclage,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：-1-1至 -10-31,Cervical insufficiency:thinking,about,transabdominal cerclage,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,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,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,产科问题,产科、妇科,宫颈机能不全,Cervical insufficiency:thinking,about,transabdominal cerclage,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,