宫颈机能不全指南解读培训课件.ppt

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1、宫颈机能不全指南解读,宫颈机能不全指南解读,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 c

2、ervical length in the second trimester is not sufficient for the diagnosis.,2,宫颈机能不全指南解读,Cervical insufficiency: defini,Cervical conizationLEEPMechanical dilationObstetric lacerationsCongenital mllerian anomaliesDeficiencies in cervical collagen and elastinUtero exposure to diethylstilbestrolAnd so

3、on.,Cervical insufficiency: etiology,3,宫颈机能不全指南解读,Cervical conizationCervical in,Cervical insufficiency: diagnosis,Challenging because of a lack of objective findings and clear diagnostic criteria.,Diagnosis is based on historyPainless cervical dilation and expulsion of the pregnancy in the second t

4、rimesterWithout contractions or laborIn the absence of other clear pathology,4,宫颈机能不全指南解读,Cervical insufficiency: diagno,Can the identification of cervical shortening by TVS be an ultrasonographic diagnostic marker of cervical insufficiency?,Cervical insufficiency: diagnosis,Short cervical length ha

5、s been shown to be a marker of preterm birth in general rather than a specific marker of cervical insufficiency.,5,宫颈机能不全指南解读,Can the identification of cerv,Diagnostic tests should not be used to diagnose cervical insufficiency.HysterosalpingographyRadiographic imaging of balloon traction on the cer

6、vixAssessment of the patulous cervix with Hegar or Pratt dilatorsBalloon elastance testCervical dilators to calculate a cervical resistance index,Cervical insufficiency: diagnosis,6,宫颈机能不全指南解读,Diagnostic tests should not be,Cervical insufficiency: treatment options,Non-surgical treatmentVaginal prog

7、esteroneVaginal pessary Activity restriction Bed rest Pelvic rest,Non-surgical treatmentTransvaginal cervical cerclage: McDonald procedure and Shirodkar procedureTransabdominal cervical cerclage: laparotomy, laparoscopy and Robotic-assisted,7,宫颈机能不全指南解读,Cervical insufficiency: treatm,Cervical insuff

8、iciency: 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,8,宫颈机能不全指南解读,Cervical insufficiency: treatm

9、,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

10、insufficiency: clinical considerations and recommendations,9,宫颈机能不全指南解读,Cerclage placement may be indi,Indications for Cervical Cerclage inWomen With Singleton Pregnancies,10,宫颈机能不全指南解读,Indications for Cervical Cercl,Indications for Cervical Cerclage inWomen With Singleton Pregnancies,History-Indica

11、ted 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

12、and perinatal morbidity.,11,宫颈机能不全指南解读,Indications for Cervical Cercl,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:,12,宫颈机能不全指南解读,Questio

13、ns 1: What is the role,Cerclage versus no cerclage in patients with short cervical length,Ultrasound-indicated cerclage,13,宫颈机能不全指南解读,Cerclage versus no cerclage in,Questions 2: Which patients should not be considered candidates for cerclage?,1. Short cervical length without history of prior singlet

14、on preterm birth. 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.,14,宫颈机能不全指南解读,Ques

15、tions 2: Which patients sh,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 u

16、terine rupture and maternal septicemia are rare but have been reported.,4.Transabdominal cerclage carries a much greater risk of hemorrhage .,15,宫颈机能不全指南解读,Questions 3: Is cerclage place,Questions 4: Is there a role for additional perioperative interventions and postoperative ultrasonographic assess

17、ment 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.,16,宫颈机能不全指南解读,Questions 4: I

18、s there a role f,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 deli

19、very, 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.,17,宫颈机能不全指南解读,Questions 5: When is removal o,宫颈机能不全指南解读培训课件,Questions 7: Should cerclage be removed

20、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

21、 removal is recommended.,19,宫颈机能不全指南解读,Questions 7: Should cerclage b,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 fin

22、dings. (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),20,宫颈机能不全指南解读,Summary of Recommendations and,Summary of Recommendations and Conclusions,Certain nonsurgical approaches, including activity rest

23、riction, 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

24、 suture type or surgical technique over another has not been established. (level B) 麦当劳更简单一些。,21,宫颈机能不全指南解读,Summary of Recommendations and,Summary of Recommendations and Conclusions,Cerclage may increase the risk of preterm birth in women with a twin pregnancy and an ultrasonographically detected ce

25、rvical length less than 25 mm and is not recommended. (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，目前尚有争议。,22,宫颈机能不全指南解读,Summary of Recommendations and,Summary of Recommenda

26、tions 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 achieve

27、d. (level C) 这个显然和临床有些不符合。,23,宫颈机能不全指南解读,Summary of Recommendations and,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-trimes

28、ter pregnancy loss.(level C) 这个也是有争议的。,In patients with no complications, transvaginal McDonald cerclage removal is recommended at 3637 wks of gestation. (level C),24,宫颈机能不全指南解读,Summary of Recommendations and,Summary of Recommendations and Conclusions,After clinical examination to rule out uterine a

29、ctivity, 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

30、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),25,宫颈机能不全指南解读,Summary of Recommendations and,产科问题,产科、妇科,宫颈机能不全,Cervical insufficiency: thinking about transabdominal cerclage,26,宫颈机能不全指南解读

31、,产科问题产科、妇科宫颈机能不全Cervical insuff,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：2010-1-1至2016-10-31,Cervical insufficiency: thinking about transabdominal cerclage,27,宫颈机能不全指南解读,检索关键词Cervical insufficiency: t,文献检索结果,web

32、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,28,宫颈机能不全指南解读,文献检索结果web of science:26篇28宫颈机能,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,29,宫颈机能不全指南解读,文献筛选排除重复文献29宫颈机能不全指南解读,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: t

33、hinking about transabdominal cerclage,30,宫颈机能不全指南解读,共34篇中英文文Cervical insufficiency,产科问题,产科、妇科,宫颈机能不全,Cervical insufficiency: thinking about transabdominal cerclage,31,宫颈机能不全指南解读,产科问题产科、妇科宫颈机能不全Cervical insuff,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,32,宫颈机能不全指南解读,Cervical insufficiency: thinki,