宫颈机能不全指南解读课件

CerclagefortheManagementofCervicalInsufficiency.CerclagefortheManagementof1Cervicalinsufficiency:definitionTheinabilityoftheuterinecervixtoretainapregnancyintheabsenceofthesignsandsymptomsofclinicalcontractions,orlabor,orbothinthesecondtrimester。UterinecervixAbsenceofthesignsandsymptomsSecondtrimesterAshortcervicallengthinthesecondtrimesterisnotsufficientforthediagnosis..Cervicalinsufficiency:defini2CervicalconizationLEEPMechanicaldilationObstetriclacerationsCongenitalmülleriananomaliesDeficienciesincervicalcollagenandelastinUteroexposuretodiethylstilbestrolAndsoon.Cervicalinsufficiency:etiology.CervicalconizationCervicalin3Cervicalinsufficiency:diagnosisChallengingbecauseofalackofobjectivefindingsandcleardiagnosticcriteria.DiagnosisisbasedonhistoryPainlesscervicaldilationandexpulsionofthepregnancyinthesecondtrimesterWithoutcontractionsorlaborIntheabsenceofotherclearpathology.Cervicalinsufficiency:diagno4CantheidentificationofcervicalshorteningbyTVSbeanultrasonographicdiagnosticmarkerofcervicalinsufficiency?Cervicalinsufficiency:diagnosisShortcervicallengthhasbeenshowntobeamarkerofpretermbirthingeneralratherthanaspecificmarkerofcervicalinsufficiency..Cantheidentificationofcerv5Diagnostictestsshouldnotbeusedtodiagnosecervicalinsufficiency.HysterosalpingographyRadiographicimagingofballoontractiononthecervixAssessmentofthepatulouscervixwithHegarorPrattdilatorsBalloonelastancetestCervicaldilatorstocalculateacervicalresistanceindexCervicalinsufficiency:diagnosis.Diagnostictestsshouldnotbe6Cervicalinsufficiency:treatmentoptionsNon-surgicaltreatmentVaginalprogesteroneVaginalpessaryActivityrestrictionBedrestPelvicrestNon-surgicaltreatmentTransvaginalcervicalcerclage:McDonaldprocedureandShirodkarprocedureTransabdominalcervicalcerclage:laparotomy,laparoscopyandRobotic-assisted.Cervicalinsufficiency:treatm7Cervicalinsufficiency:treatmentoptionsInwhichsituationsshouldTransabdominalcervicalcerclagebeconsidered?Failedtransvaginalcervicalcerclageprocedureshistory（这个我持保留意见）Transvaginalcervicalcerclageprocedurescannotplacebecauseofanatomicallimitations.Cervicalinsufficiency:treatm8Cerclageplacementmaybeindicatedbasedonahistoryofcervicalinsufficiency,physicalexaminationfindings,orahistoryofpretermbirthandcertainultrasonographicfindings.Cerclageshouldbelimitedtopregnanciesinthesecondtrimesterbeforefetalviabilityhasbeenachieved.Cervicalinsufficiency:clinicalconsiderationsandrecommendations.Cerclageplacementmaybeindi9IndicationsforCervicalCerclageinWomenWithSingletonPregnancies.IndicationsforCervicalCercl10IndicationsforCervicalCerclageinWomenWithSingletonPregnanciesHistory-IndicatedCerclageOneinthreeRCTindicatedfewerdeliveriesbefore33weeksofgestationinthecerclagegroup.PhysicalExamination-IndicatedCerclageGiventhelackoflargerrandomizedtrialsthathavedemonstratedclearbenefit,womenshouldbecounseledaboutthepotentialforassociatedmaternalandperinatalmorbidity..IndicationsforCervicalCercl11Questions1:Whatistheroleofultrasonographyinmanagingwomenwithahistoryofcervicalinsufficiency?Tworecentsummariesoftheresultsofthesemultiplestudieshavedrawnthefollowingconclusions:.Questions1:Whatistherole12CerclageversusnocerclageinpatientswithshortcervicallengthUltrasound-indicatedcerclage.Cerclageversusnocerclagein13Questions2:Whichpatientsshouldnotbeconsideredcandidatesforcerclage?1.Shortcervicallengthwithouthistoryofpriorsingletonpretermbirth.Vaginalprogesteroneisrecommendedtopreventcervicallength≤20mmbefore24wks.2.Twinpregnancywithcervicallength≤25mm.3.Evidenceislackingforthebenefitofcerclagesolelyforthefollowingindications:priorLEEP,conebiopsy,ormülleriananomaly..Questions2:Whichpatientssh14Questions3:Iscerclageplacementassociatedwithanincreaseinmorbidity?1.Lowriskofcomplicationswithcerclageplacement.2.Incidenceofcomplicationsvarieswidelyinrelationtothetimingandindicationsforthecerclage.3.Life-threateningcomplicationsofuterineruptureandmaternalsepticemiaarerarebuthavebeenreported.4.Transabdominalcerclagecarriesamuchgreaterriskofhemorrhage..Questions3:Iscerclageplace15Questions4:Istherearoleforadditionalperioperativeinterventionsandpostoperativeultrasonographicassessmentwithcerclageplacement?1.Neitherantibioticsnorprophylactictocolyticshasbeenshowntoimprovetheefficacyofcerclage,regardlessoftimingorindication.2.Furtherultrasonographicsurveillanceofcervicallengthaftercerclageplacementisnotnecessary..Questions4:Istherearolef16Questions5:WhenisremovaloftransvaginalMcDonaldcerclageindicatedinpatientswithnocomplications,andwhatistheappropriatesettingforremoval?Cerclageremovalisrecommendedat36–37weeksofgestationinpatientswithnocomplications.Inpatientsplannedvaginaldelivery,removecerclagebeforelabor.Inpatientselectedcesareandelivery,removecerclageatthetimeofdelivery.Inmostcases,removalofaMcDonaldcerclageintheofficesettingisappropriate..Questions5:Whenisremovalo17Questions6:Howshouldwomenwithcerclageandpretermprematureruptureofmembranesbemanaged?AfirmrecommendationonwhetheracerclageshouldberemovedafterPPROMcannotbemade,andeitherremovalorretentionisreasonable.Regardless,ifacerclageremainsinplacewithPPROM,prolongedantibioticprophylaxisbeyond7daysisnotrecommended..Questions6:Howshouldwomen18Questions7:Shouldcerclageberemovedinwomenwithpretermlabor?Thediagnosisofpretermlabormaybemoredifficultinpatientswithcerclage.Inapatientwhopresentswithsymptomsofpretermlabor,clinicaljudgmentaboutcerclageremovalisadvised.Ifcervicalchange,painfulcontractions,orvaginalbleedingprogress,cerclageremovalisrecommended..Questions7:Shouldcerclageb19SummaryofRecommendationsandConclusionsSingletonpregnancyPriorspontaneouspretermbirth＜34wksCervicallength≤25mmbefore24wksCerclagemaybeconsideredinwomenwiththiscombinationofhistoryandultrasonographicfindings.(levelA)Cerclageisnotassociatedwithasignificantreductioninpretermbirthinpatentswithcervicallength≤25mmbefore24wksonly.(levelA).SummaryofRecommendationsand20SummaryofRecommendationsandConclusionsCertainnonsurgicalapproaches,includingactivityrestriction,bedrest,andpelvicresthavenotbeenprovedtobeeffectiveforthetreatmentofcervicalinsufficiencyandtheiruseisdiscouraged.(levelB)ThestandardtransvaginalcerclagemethodscurrentlyusedincludemodificationsoftheMcDonaldandShirodkartechniques.Thesuperiorityofonesuturetypeorsurgicaltechniqueoveranotherhasnotbeenestablished.(levelB)麦当劳更简单一些。.SummaryofRecommendationsand21SummaryofRecommendationsandConclusionsCerclagemayincreasetheriskofpretermbirthinwomenwithatwinpregnancyandanultrasonographicallydetectedcervicallengthlessthan25mmandisnotrecommended.(levelB)Neitherantibioticsnorprophylactictocolyticshavebeenshowntoimprovetheefficacyofcerclage,regardlessoftimingorindication.(levelB)从一些新近的一些研究结果来看，目前尚有争议。.SummaryofRecommendationsand22SummaryofRecommendationsandConclusionsAhistory-indicatedcerclagecanbeconsideredinapatientwithahistoryofunexplainedsecond-trimesterdeliveryintheabsenceoflabororabruptioplacentae.(levelB)Cerclageshouldbelimitedtopregnanciesinthesecondtrimesterbeforefetalviabilityhasbeenachieved.(levelC)这个显然和临床有些不符合。.SummaryofRecommendationsand23SummaryofRecommendationsandConclusionsTransabdominalcerclagegenerallyisreservedforpatientswithanatomicallimitations,orinthecaseoffailedtransvaginalcervicalcerclageproceduresthatresultedinsecond-trimesterpregnancyloss.(levelC)这个也是有争议的。Inpatientswithnocomplications,transvaginalMcDonaldcerclageremovalisrecommendedat36–37wksofgestation.(levelC).SummaryofRecommendationsand24SummaryofRecommendationsandConclusionsAfterclinicalexaminationtoruleoututerineactivity,orintraamnioticinfection,orboth,physicalexamination-indicatedcerclageplacementinpatientswithsingletongestationswhohavecervicalchangeoftheinternalosmaybebeneficial.(levelC)Forpatientswhoelectcesareandeliveryatorbeyond39weeksofgestation,cerclageremovalatthetimeofdeliverymaybeperformed;however,thepossibilityofspontaneouslaborbetween37weeksand39weeksofgestationmustbeconsidered.(levelC).SummaryofRecommendationsand25产科问题产科、妇科宫颈机能不全Cervicalinsufficiency:thinkingabouttransabdominalcerclage.产科问题产科、妇科宫颈机能不全Cervicalinsuff26检索关键词英文关键词：Laparoscopiccerclage中文关键词：腹腔镜宫颈环扎数据库英文数据库：pubmed,WebOfScience,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2016-10-31Cervicalinsufficiency:thinkingabouttransabdominalcerclage.检索关键词Cervicalinsufficiency:t27文献检索结果webofscience: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.文献检索结果webofscience:26篇.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.文献筛选排除重复文献.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。Cervicalinsufficiency:thinkingabouttransabdominalcerclage.共34篇中英文文Cervicalinsufficiency30产科问题产科、妇科宫颈机能不全Cervicalinsufficiency:thinkingabouttransabdominalcerclage.产科问题产科、妇科宫颈机能不全Cervicalinsuff31Cervicalinsufficiency:thinkingabouttransabdominalcerclage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.Cervicalinsufficiency:thinki32CerclagefortheManagementofCervicalInsufficiency.CerclagefortheManagementof33Cervicalinsufficiency:definitionTheinabilityoftheuterinecervixtoretainapregnancyintheabsenceofthesignsandsymptomsofclinicalcontractions,orlabor,orbothinthesecondtrimester。UterinecervixAbsenceofthesignsandsymptomsSecondtrimesterAshortcervicallengthinthesecondtrimesterisnotsufficientforthediagnosis..Cervicalinsufficiency:defini34CervicalconizationLEEPMechanicaldilationObstetriclacerationsCongenitalmülleriananomaliesDeficienciesincervicalcollagenandelastinUteroexposuretodiethylstilbestrolAndsoon.Cervicalinsufficiency:etiology.CervicalconizationCervicalin35Cervicalinsufficiency:diagnosisChallengingbecauseofalackofobjectivefindingsandcleardiagnosticcriteria.DiagnosisisbasedonhistoryPainlesscervicaldilationandexpulsionofthepregnancyinthesecondtrimesterWithoutcontractionsorlaborIntheabsenceofotherclearpathology.Cervicalinsufficiency:diagno36CantheidentificationofcervicalshorteningbyTVSbeanultrasonographicdiagnosticmarkerofcervicalinsufficiency?Cervicalinsufficiency:diagnosisShortcervicallengthhasbeenshowntobeamarkerofpretermbirthingeneralratherthanaspecificmarkerofcervicalinsufficiency..Cantheidentificationofcerv37Diagnostictestsshouldnotbeusedtodiagnosecervicalinsufficiency.HysterosalpingographyRadiographicimagingofballoontractiononthecervixAssessmentofthepatulouscervixwithHegarorPrattdilatorsBalloonelastancetestCervicaldilatorstocalculateacervicalresistanceindexCervicalinsufficiency:diagnosis.Diagnostictestsshouldnotbe38Cervicalinsufficiency:treatmentoptionsNon-surgicaltreatmentVaginalprogesteroneVaginalpessaryActivityrestrictionBedrestPelvicrestNon-surgicaltreatmentTransvaginalcervicalcerclage:McDonaldprocedureandShirodkarprocedureTransabdominalcervicalcerclage:laparotomy,laparoscopyandRobotic-assisted.Cervicalinsufficiency:treatm39Cervicalinsufficiency:treatmentoptionsInwhichsituationsshouldTransabdominalcervicalcerclagebeconsidered?Failedtransvaginalcervicalcerclageprocedureshistory（这个我持保留意见）Transvaginalcervicalcerclageprocedurescannotplacebecauseofanatomicallimitations.Cervicalinsufficiency:treatm40Cerclageplacementmaybeindicatedbasedonahistoryofcervicalinsufficiency,physicalexaminationfindings,orahistoryofpretermbirthandcertainultrasonographicfindings.Cerclageshouldbelimitedtopregnanciesinthesecondtrimesterbeforefetalviabilityhasbeenachieved.Cervicalinsufficiency:clinicalconsiderationsandrecommendations.Cerclageplacementmaybeindi41IndicationsforCervicalCerclageinWomenWithSingletonPregnancies.IndicationsforCervicalCercl42IndicationsforCervicalCerclageinWomenWithSingletonPregnanciesHistory-IndicatedCerclageOneinthreeRCTindicatedfewerdeliveriesbefore33weeksofgestationinthecerclagegroup.PhysicalExamination-IndicatedCerclageGiventhelackoflargerrandomizedtrialsthathavedemonstratedclearbenefit,womenshouldbecounseledaboutthepotentialforassociatedmaternalandperinatalmorbidity..IndicationsforCervicalCercl43Questions1:Whatistheroleofultrasonographyinmanagingwomenwithahistoryofcervicalinsufficiency?Tworecentsummariesoftheresultsofthesemultiplestudieshavedrawnthefollowingconclusions:.Questions1:Whatistherole44CerclageversusnocerclageinpatientswithshortcervicallengthUltrasound-indicatedcerclage.Cerclageversusnocerclagein45Questions2:Whichpatientsshouldnotbeconsideredcandidatesforcerclage?1.Shortcervicallengthwithouthistoryofpriorsingletonpretermbirth.Vaginalprogesteroneisrecommendedtopreventcervicallength≤20mmbefore24wks.2.Twinpregnancywithcervicallength≤25mm.3.Evidenceislackingforthebenefitofcerclagesolelyforthefollowingindications:priorLEEP,conebiopsy,ormülleriananomaly..Questions2:Whichpatientssh46Questions3:Iscerclageplacementassociatedwithanincreaseinmorbidity?1.Lowriskofcomplicationswithcerclageplacement.2.Incidenceofcomplicationsvarieswidelyinrelationtothetimingandindicationsforthecerclage.3.Life-threateningcomplicationsofuterineruptureandmaternalsepticemiaarerarebuthavebeenreported.4.Transabdominalcerclagecarriesamuchgreaterriskofhemorrhage..Questions3:Iscerclageplace47Questions4:Istherearoleforadditionalperioperativeinterventionsandpostoperativeultrasonographicassessmentwithcerclageplacement?1.Neitherantibioticsnorprophylactictocolyticshasbeenshowntoimprovetheefficacyofcerclage,regardlessoftimingorindication.2.Furtherultrasonographicsurveillanceofcervicallengthaftercerclageplacementisnotnecessary..Questions4:Istherearolef48Questions5:WhenisremovaloftransvaginalMcDonaldcerclageindicatedinpatientswithnocomplications,andwhatistheappropriatesettingforremoval?Cerclageremovalisrecommendedat36–37weeksofgestationinpatientswithnocomplications.Inpatientsplannedvaginaldelivery,removecerclagebeforelabor.Inpatientselectedcesareandelivery,removecerclageatthetimeofdelivery.Inmostcases,removalofaMcDonaldcerclageintheofficesettingisappropriate..Questions5:Whenisremovalo49Questions6:Howshouldwomenwithcerclageandpretermprematureruptureofmembranesbemanaged?AfirmrecommendationonwhetheracerclageshouldberemovedafterPPROMcannotbemade,andeitherremovalorretentionisreasonable.Regardless,ifacerclageremainsinplacewithPPROM,prolongedantibioticprophylaxisbeyond7daysisnotrecommended..Questions6:Howshouldwomen50Questions7:Shouldcerclageberemovedinwomenwithpretermlabor?Thediagnosisofpretermlabormaybemoredifficultinpatientswithcerclage.Inapatientwhopresentswithsymptomsofpretermlabor,clinicaljudgmentaboutcerclageremovalisadvised.Ifcervicalchange,painfulcontractions,orvaginalbleedingprogress,cerclageremovalisrecommended..Questions7:Shouldcerclageb51SummaryofRecommendationsandConclusionsSingletonpregnancyPriorspontaneouspretermbirth＜34wksCervicallength≤25mmbefore24wksCerclagemaybeconsideredinwomenwiththiscombinationofhistoryandultrasonographicfindings.(levelA)Cerclageisnotassociatedwithasignificantreductioninpretermbirthinpatentswithcervicallength≤25mmbefore24wksonly.(levelA).SummaryofRecommendationsand52SummaryofRecommendationsandConclusionsCertainnonsurgicalapproaches,includingactivityrestriction,bedrest,andpelvicresthavenotbeenprovedtobeeffectiveforthetreatmentofcervicalinsufficiencyandtheiruseisdiscouraged.(levelB)ThestandardtransvaginalcerclagemethodscurrentlyusedincludemodificationsoftheMcDonaldandShirodkartechniques.Thesuperiorityofonesuturetypeorsurgicaltechniqueoveranotherhasnotbeenestablished.(levelB)麦当劳更简单一些。.SummaryofRecommendationsand53SummaryofRecommendationsandConclusionsCerclagemayincreasetheriskofpretermbirthinwomenwithatwinpregnancyandanultrasonographicallydetectedcervicallengthlessthan25mmandisnotrecommended.(levelB)Neitherantibioticsnorprophylactictocolyticshavebeenshowntoimprovetheefficacyofcerclage,regardlessoftimingorindication.(levelB)从一些新近的一些研究结果来看，目前尚有争议。.SummaryofRecommendationsand54SummaryofRecommendationsandConclusionsAhistory-indicatedcerclagecanbeconsideredinapatientwithahistoryofunexplainedsecond-trimesterdeliveryintheabsenceoflabororabruptioplacentae.(levelB)Cerclageshouldbelimitedtopregnanciesinthesecondtrimesterbeforefetalviabilityhasbeenachieved.(levelC)这个显然和临床有些不符合。.SummaryofRecommendationsand55SummaryofRecommen