宫颈机能不全指南解读-课件

1、Cerclage for the Management of Cervical InsufficiencyCerclage for the Management ofCervical 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 A

2、bsence of the signs and symptoms Second trimesterA short cervical length in the second trimester is not sufficient for the diagnosis. Cervical insufficiency: definiCervical conizationLEEPMechanical dilationObstetric lacerationsCongenital mllerian anomaliesDeficiencies in cervical collagen and elasti

3、nUtero exposure to diethylstilbestrolAnd so on.Cervical insufficiency: etiologyCervical conizationCervical inCervical insufficiency: diagnosisChallenging because of a lack of objective findings and clear diagnostic criteria. Diagnosis is based on historyPainless cervical dilation and expulsion of th

4、e pregnancy in the second trimesterWithout contractions or laborIn the absence of other clear pathologyCervical insufficiency: diagnoCan the identification of cervical shortening by TVS be an ultrasonographic diagnostic marker of cervical insufficiency?Cervical insufficiency: diagnosisShort cervical

5、 length has been shown to be a marker of preterm birth in general rather than a specific marker of cervical insufficiency.Can the identification of cervDiagnostic tests should not be used to diagnose cervical insufficiency.HysterosalpingographyRadiographic imaging of balloon traction on the cervixAs

6、sessment of the patulous cervix with Hegar or Pratt dilatorsBalloon elastance testCervical dilators to calculate a cervical resistance indexCervical insufficiency: diagnosisDiagnostic tests should not beCervical insufficiency: treatment optionsNon-surgical treatmentVaginal progesteroneVaginal pessar

7、y Activity restriction Bed rest Pelvic rest Non-surgical treatmentTransvaginal cervical cerclage: McDonald procedure and Shirodkar procedureTransabdominal cervical cerclage: laparotomy, laparoscopy and Robotic-assistedCervical insufficiency: treatmCervical insufficiency: treatment optionsIn which si

8、tuations 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 limitationsCervical insufficiency: treatmCerclage placement may be indicated based on a histo

9、ry 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 remendatio

10、ns Cerclage placement may be indiIndications for Cervical Cerclage inWomen With Singleton PregnanciesIndications for Cervical CerclIndications for Cervical Cerclage inWomen With Singleton PregnanciesHistory-Indicated Cerclage One in three RCT indicated fewer deliveries before 33 weeks of gestation i

11、n 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. Indications for Cervical CerclQuestions 1: What is the role of

12、 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:Questions 1: What is the role Cerclage versus no cerclage in patients with short cervical lengthUltrasound-indicated cerclag

13、e Cerclage versus no cerclage inQuestions 2: Which patients should not be considered candidates for cerclage?1. Short cervical length without history of prior singleton preterm birth. Vaginal progesterone is remended to prevent cervical length 20mm before 24 wks.2. Twin pregnancy with cervical lengt

14、h 25 mm.3. Evidence is lacking for the benefit of cerclage solely for the following indications: prior LEEP, cone biopsy, or mllerian anomaly. Questions 2: Which patients shQuestions 3: Is cerclage placement associated with an increase in morbidity?1. Low risk of plications with cerclage placement.

15、2. Incidence of plications varies widely in relation to the timing and indications for the cerclage.3. Life-threatening plications of uterine rupture and maternal septicemia are rare but have been reported.4.Transabdominal cerclage carries a much greater risk of hemorrhage .Questions 3: Is cerclage

16、placeQuestions 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 ult

17、rasonographic surveillance of cervical length after cerclage placement is not necessary.Questions 4: Is there a role fQuestions 5: When is removal of transvaginal McDonald cerclage indicated in patients with no plications, and what is the appropriate setting for removal?Cerclage removal is remended

18、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. Question

19、s 5: When is removal oQuestions 6: How should women with cerclage and preterm premature rupture of membranes be managed?A firm remendation on whether a cerclage should be removed after PPROM cannot be made, and either removal or retention is reasonable. Regardless, if a cerclage remains in place wit

20、h PPROM, prolonged antibiotic prophylaxis beyond 7 days is not remended. Questions 6: How should women 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 preter

21、m labor, clinical judgment about cerclage removal is advised. If cervical change, painful contractions, or vaginal bleeding progress, cerclage removal is remended. Questions 7: Should cerclage bSummary of Remendations and Conclusions Singleton pregnancyPrior spontaneous preterm birth 34 wksCervical

22、length 25mm before 24 wks Cerclage may be considered in women with this bination 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 Remendations and

23、CoSummary of Remendations 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 curre

24、ntly 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 Remendations and CoSummary of Remendations and Conclusions Cerclage may increase the risk of preterm

25、 birth in women with a twin pregnancy and an ultrasonographically detected cervical length less than 25 mm and is not remended. (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

26、前尚有争议。Summary of Remendations and CoSummary of Remendations 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 sec

27、ond trimester before fetal viability has been achieved. (level C) 这个显然和临床有些不符合。Summary of Remendations and CoSummary of Remendations and Conclusions Transabdominal cerclage generally is reserved for patients with anatomical limitations, or in the case of failed transvaginal cervical cerclage procedu

28、res that resulted in second-trimester pregnancy loss.(level C) 这个也是有争议的。In patients with no plications, transvaginal McDonald cerclage removal is recommended at 3637 wks of gestation. (level C)Summary of Remendations and CoSummary of Remendations and Conclusions After clinical examination to rule ou

29、t 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)Summa