宫颈机能不全是否可以保守治疗讲义

1、宫颈机能不全是否可以保守治疗讲义Incompetent CervixCharactersPainless cervical dilatation in second trimester or perhaps early in the third trimesterWith prolapse and ballooning of membranes into the vaginaFollowed by rupture of membranes and expulwion of an immatrue fetusUnless effectively treated, this sequence te

2、nds to repeat in each pregnancyDiagnosis ?EffectiveTreatments ?22宫颈机能不全定义：在没有宫缩的情况下，子宫颈由于解剖或功能缺陷不能维持妊娠至足月诊断：病史：妊娠中期反复自然流产、早产史非孕期诊断:（争议）8号扩张器探宫颈内口无阻力子宫输卵管碘油造影宫颈内口宽度6mm孕期：经阴道超声测宫颈内口宽度/宫颈长度孕期宫颈管测量的困惑 ？3Ultrasonic measurement of cervical length: (transvaginal) The mean cervical length at 24 weeks was ab

3、out 35 mm China: transvaginal(abdominal) 30mmReliable predictor low riskAsymptomatic cervical dilatation:After midpregnancy has gained attention as a risk factor for preterm deliveryBetween 28 and 34 weeks, dilatation 1 cm or effacement of more than 30% risk Cervical examination4Ultrasonic measureme

4、nt(transvaginal)5孕期宫颈管测量正常妊娠14-30周宫颈长度是35-40mm，第10百分位数是25mm；宫颈长度的临界值定25mm正常孕妇孕30周前宫颈长度稳定，孕晚期宫颈进行性缩短即使宫颈机能不全者，孕16周前宫颈长度常正常孕产次似乎不影响宫颈长度宫颈缩短或漏斗形成常见于18-22周高危病人宫颈长度监测：孕14-16周开始，次/2周6孕期宫颈管测量方法排空膀胱，获取宫颈矢状影像，并显示宫颈黏膜的长轴，沿宫颈管测量宫颈内外口的长度测定3次宫颈管闭合部分长度，以mm记录最短数据宫底加压15s记录宫颈长度和漏斗的变化四种字型()描述超所见的宫颈管变化如果宫颈管是关闭的，只需测量CL

5、宫颈管通常有弯曲，缩短的宫颈大都是直的，弯曲的宫颈通常意味着CL25mm7孕期宫颈管测量的评估内口扩张者形成漏斗（）测量宫颈计算Funneling%=漏斗长度/( 漏斗长度 + 宫颈闭合部分长度) 中孕期超声-预测早产风险宫颈内口宽度(内口直径)15mmFunneling% 25%宫颈机能不全诊断要点CL缩短；宫颈内口宽度15mm；宫颈管宽度 6mm;羊膜囊向宫颈管内突入8宫颈缩短者宫颈环扎？Berghella（2010）-A meta-analysis分析宫颈环扎术是否降低早产率单胎、CL 25 mm随机分组有早产史者：降低 2.5 cm UC 2.5 cm UC 2.5 cm UC 2.5

6、 cm 宫缩抑制剂糖皮质激素抗生素?无需治疗监测无需治疗监测32周门诊入院监测糖皮质激素孕酮预防早产预防宫颈长度较短孕妇的临床研究 *Fonseca EB（2007），RCT，413例孕22-25周宫颈长度测定15mm者纳入研究治疗组（天然黄体酮200mg，PV，QN，从24周至34周） 治疗组小于34周的早产率明显降低预防有自发性早产史的孕妇的临床研究 *孕酮预防双胎妊娠孕妇的临床研究 *并不降低多胎孕妇的早产再发率孕酮预防早产安全性说明书局限于早孕安胎1717Preterm deliveryPreterm labourLow birth weight (2,500gr) 12340.50.

7、30.1Keirse, M. Progestogen administration in pregnancy may prevent preterm delivery?, Br. J. Obstet. Gynaecol., 97: 149-54, 1990. Is there scientific evidencefor progesterone?早产的预防-减少子宫收缩早产高危孕妇（142例）-黄体酮，100mg，PV，Qd 早产发生率降低50%异常子宫活动：每小时子宫收缩4次da Fonseca EB, Am J Obstet Gynecol. 2003异常子宫活动37周前早产34周前早产

8、 黄体酮(N=72) 安慰剂(N=70)阴道应用孕酮对33周早产的作用CONCLUSION: Vaginal progesterone administration to asymptomatic women with a sonographic short cervix reduces the risk of preterm birth and neonatal morbidity and mortality. Romero R et al. Am J Obstet Gynecol 2012Vaginal progesterone in women with an asymptomatic

9、short cervix in the midtrimester ultrasound decrease PTD (N=775)Romero et al. AJOG. 2012.Short cervical lengthPreterm birth 33 weeksPlaceboVaginal ProgesteroneRR (95% CI)Twins 44.8% (13/29)30.4%(7/23)0.70 (0.34-1.44)Romero R, Nicolaides K, Conde-Agudelo A, Tabor A, OBrien J, Cetingoz E, DA Fonseca E

10、, Creasy G, Klein K, Rode L, Soma-Pillay P, Fusey S, Cam C, Alfirevic Z, Hassan S Am J Obstet Gynecol 2011;12:003阴道应用孕酮对双胎早产的作用23孕酮预防早产Cervical cerclage pessary25Guidelines for the management of spontaneous preterm labor:identification of spontaneous preterm labor, diagnosis of pretermpremature rupture of membranes, and preventive tools for preterm birthThe Journal of Maternal-Fetal and Neonatal Medicine, May 2011; 24(5): 659667Cervical cerclage pessary预防效果有争议：Hui SY（香港中大）一项随机对照研究4438名低危单胎妇女，20-