宫颈机能不全指南解读.ppt

CerclagefortheManagementofCervicalInsufficiency,Cervicalinsufficiency:definition,Theinabilityoftheuterinecervixtoretainapregnancyintheabsenceofthesignsandsymptomsofclinicalcontractions,orlabor,orbothinthesecondtrimester。,Uterinecervix,Absenceofthesignsandsymptoms,Secondtrimester,Ashortcervicallengthinthesecondtrimesterisnotsufficientforthediagnosis.,CervicalconizationLEEPMechanicaldilationObstetriclacerationsCongenitalmlleriananomaliesDeficienciesincervicalcollagenandelastinUteroexposuretodiethylstilbestrolAndsoon.,Cervicalinsufficiency:etiology,Cervicalinsufficiency:diagnosis,Challengingbecauseofalackofobjectivefindingsandcleardiagnosticcriteria.,DiagnosisisbasedonhistoryPainlesscervicaldilationandexpulsionofthepregnancyinthesecondtrimesterWithoutcontractionsorlaborIntheabsenceofotherclearpathology,CantheidentificationofcervicalshorteningbyTVSbeanultrasonographicdiagnosticmarkerofcervicalinsufficiency?,Cervicalinsufficiency:diagnosis,Shortcervicallengthhasbeenshowntobeamarkerofpretermbirthingeneralratherthanaspecificmarkerofcervicalinsufficiency.,Diagnostictestsshouldnotbeusedtodiagnosecervicalinsufficiency.HysterosalpingographyRadiographicimagingofballoontractiononthecervixAssessmentofthepatulouscervixwithHegarorPrattdilatorsBalloonelastancetestCervicaldilatorstocalculateacervicalresistanceindex,Cervicalinsufficiency:diagnosis,Cervicalinsufficiency:treatmentoptions,Non-surgicaltreatmentVaginalprogesteroneVaginalpessaryActivityrestrictionBedrestPelvicrest,Non-surgicaltreatmentTransvaginalcervicalcerclage:McDonaldprocedureandShirodkarprocedureTransabdominalcervicalcerclage:laparotomy,laparoscopyandRobotic-assisted,Cervicalinsufficiency:treatmentoptions,InwhichsituationsshouldTransabdominalcervicalcerclagebeconsidered?Failedtransvaginalcervicalcerclageprocedureshistory（这个我持保留意见）Transvaginalcervicalcerclageprocedurescannotplacebecauseofanatomicallimitations,Cerclageplacementmaybeindicatedbasedonahistoryofcervicalinsufficiency,physicalexaminationfindings,orahistoryofpretermbirthandcertainultrasonographicfindings.Cerclageshouldbelimitedtopregnanciesinthesecondtrimesterbeforefetalviabilityhasbeenachieved.,Cervicalinsufficiency:clinicalconsiderationsandrecommendations,IndicationsforCervicalCerclageinWomenWithSingletonPregnancies,IndicationsforCervicalCerclageinWomenWithSingletonPregnancies,History-IndicatedCerclage,OneinthreeRCTindicatedfewerdeliveriesbefore33weeksofgestationinthecerclagegroup.,PhysicalExamination-IndicatedCerclage,Giventhelackoflargerrandomizedtrialsthathavedemonstratedclearbenefit,womenshouldbecounseledaboutthepotentialforassociatedmaternalandperinatalmorbidity.,Questions1:Whatistheroleofultrasonographyinmanagingwomenwithahistoryofcervicalinsufficiency?,Tworecentsummariesoftheresultsofthesemultiplestudieshavedrawnthefollowingconclusions:,Cerclageversusnocerclageinpatientswithshortcervicallength,Ultrasound-indicatedcerclage,Questions2:Whichpatientsshouldnotbeconsideredcandidatesforcerclage?,1.Shortcervicallengthwithouthistoryofpriorsingletonpretermbirth.Vaginalprogesteroneisrecommendedtopreventcervicallength20mmbefore24wks.,2.Twinpregnancywithcervicallength25mm.,3.Evidenceislackingforthebenefitofcerclagesolelyforthefollowingindications:priorLEEP,conebiopsy,ormlleriananomaly.,Questions3:Iscerclageplacementassociatedwithanincreaseinmorbidity?,1.Lowriskofcomplicationswithcerclageplacement.,2.Incidenceofcomplicationsvarieswidelyinrelationtothetimingandindicationsforthecerclage.,3.Life-threateningcomplicationsofuterineruptureandmaternalsepticemiaarerarebuthavebeenreported.,4.Transabdominalcerclagecarriesamuchgreaterriskofhemorrhage.,Questions4:Istherearoleforadditionalperioperativeinterventionsandpostoperativeultrasonographicassessmentwithcerclageplacement?,1.Neitherantibioticsnorprophylactictocolyticshasbeenshowntoimprovetheefficacyofcerclage,regardlessoftimingorindication.,2.Furtherultrasonographicsurveillanceofcervicallengthaftercerclageplacementisnotnecessary.,Questions5:WhenisremovaloftransvaginalMcDonaldcerclageindicatedinpatientswithnocomplications,andwhatistheappropriatesettingforremoval?,Cerclageremovalisrecommendedat3637weeksofgestationinpatientswithnocomplications.,Inpatientsplannedvaginaldelivery,removecerclagebeforelabor.,Inpatientselectedcesareandelivery,removecerclageatthetimeofdelivery.,Inmostcases,removalofaMcDonaldcerclageintheofficesettingisappropriate.,Questions6:Howshouldwomenwithcerclageandpretermprematureruptureofmembranesbemanaged?,AfirmrecommendationonwhetheracerclageshouldberemovedafterPPROMcannotbemade,andeitherremovalorretentionisreasonable.,Regardless,ifacerclageremainsinplacewithPPROM,prolongedantibioticprophylaxisbeyond7daysisnotrecommended.,Questions7:Shouldcerclageberemovedinwomenwithpretermlabor?,Thediagnosisofpretermlabormaybemoredifficultinpatientswithcerclage.Inapatientwhopresentswithsymptomsofpretermlabor,clinicaljudgmentaboutcerclageremovalisadvised.,Ifcervicalchange,painfulcontractions,orvaginalbleedingprogress,cerclageremovalisrecommended.,SummaryofRecommendationsandConclusions,Singletonpregnancy,Priorspontaneouspretermbirth34wks,Cervicallength25mmbefore24wks,Cerclagemaybeconsideredinwomenwiththiscombinationofhistoryandultrasonographicfindings.(levelA),Cerclageisnotassociatedwithasignificantreductioninpretermbirthinpatentswithcervicallength25mmbefore24wksonly.(levelA),SummaryofRecommendationsandConclusions,Certainnonsurgicalapproaches,includingactivityrestriction,bedrest,andpelvicresthavenotbeenprovedtobeeffectiveforthetreatmentofcervicalinsufficiencyandtheiruseisdiscouraged.(levelB),ThestandardtransvaginalcerclagemethodscurrentlyusedincludemodificationsoftheMcDonaldandShirodkartechniques.Thesuperiorityofonesuturetypeorsurgicaltechniqueoveranotherhasnotbeenestablished.(levelB)麦当劳更简单一些。,SummaryofRecommendationsandConclusions,Cerclagemayincreasetheriskofpretermbirthinwomenwithatwinpregnancyandanultrasonographicallydetectedcervicallengthlessthan25mmandisnotrecommended.(levelB),Neitherantibioticsnorprophylactictocolyticshavebeenshowntoimprovetheefficacyofcerclage,regardlessoftimingorindication.(levelB)从一些新近的一些研究结果来看，目前尚有争议。,SummaryofRecommendationsandConclusions,Ahistory-indicatedcerclagecanbeconsideredinapatientwithahistoryofunexplainedsecond-trimesterdeliveryintheabsenceoflabororabruptioplacentae.(levelB),Cerclageshouldbelimitedtopregnanciesinthesecondtrimesterbeforefetalviabilityhasbeenachieved.(levelC)这个显然和临床有些不符合。,SummaryofRecommendationsandConclusions,Transabdominalcerclagegenerallyisreservedforpatientswithanatomicallimitations,orinthecaseoffailedtransvaginalcervicalcerclageproceduresthatresultedinsecond-trimesterpregnancyloss.(levelC)这个也是有争议的。,Inpatientswithnocomplications,transvaginalMcDonaldcerclageremovalisrecommendedat3637wksofgestation.(levelC),SummaryofRecommendationsandConclusions,Afterclinicalexaminationtoruleoututerineactivity,orintraamnioticinfection,orboth,physicalexamination-indicatedcerclageplacementinpatientswithsingletongestationswhohavecervicalchangeoftheinternalosmaybebeneficial.(levelC),Forpatientswhoelectcesareandeliveryatorbeyond39weeksofgestation,cerclageremovalatthetimeofdeliverymaybeperformed;however,thepossibilityofspontaneouslaborbetween37weeksand3