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Cervic